Monday, December 16, 2013

Guest Blogger: Day 8

Dr. Terri-Ann Bennett, writing from Korle Bu Teaching Hospital in Accra, Ghana. She contemplates some of the differences in obstetrics between the US and Ghana, and encounters her first DOA patient: Day 8

Guest Blogger: Terri-Ann Bennett

Dr. Terri-Ann Bennett, a chief resident in Obstetrics & Gynecology at NYU, went to Ghana recently and had her own blog. It was insightful and well-written, and I want to share it here.

Here is her first post, in which she reviews her first few days on service at Korle Bu Teaching Hospital: The Introduction

Tuesday, July 9, 2013

How To Clean Your Vag

This post is going to be exactly what it sounds like. If that grosses you out, click to somewhere else.

In the office, I get a lot of questions about how to clean "down there." There are a lot of cultural influences that lead us to think of vaginas as unclean. Feminine hygiene products are marketed to women in a way that lead us to assume that we are inherently unclean. So many religions and cultures have mythology surrounding menstruation and women's bodies that imply a contamination or lack of cleanliness. Meanwhile, where are the testicular hygiene products?

Many of my patients come in thinking that any discharge means they have bacterial vaginosis (BV), a bacterial overgrowth that can lead to odor. While BV does exist, in my opinion* it is wildly overdiagnosed and overtreated, especially given that its presence has almost no spontaneous adverse consquences**. It can be very annoying, but it's not dangerous. It's not like Chlamydia, or HIV. It's not even as painful as a yeast infection. If you have BV or think you do, it's important to confirm it with a doctor, and not just assume you need antibiotics over and over. Those antibiotics can actually lead to a yeast infection, so be cautious.

First, a terminology clarification:
The outside female genitalia is called the vulva. The inside female genitalia is called the vagina. So even though we use vagina as a general term to refer to the entire female genitalia, the medical term only refers to the inside.

So what is the truth about the cleanliness of vaginas? 
First of all, yes, the vagina is full of bacteria. It needs to have that bacteria in order to stay healthy - they are the "good" bacteria. When you eliminate the bacteria (by taking antibiotics, for example), that allows overgrowth of other things, like yeast. Yeast can exist in the vagina, but when they grow too much, they can cause itching, burning, pain with sex, redness, or odor. There are certain bacteria that shouldn't be in the vagina - like Chlamydia (a sexually transmitted infection), or E. coli (a bacteria found in stool). Another bacteria that can exist in the vagina, Group B Strep (GBS), does nothing to the woman, but can cause a serious infection in infants, so if a pregnant woman has it, we give her Penicillin in labor to get rid of it before the baby comes out.

Should you clean your vagina?
Bottom line: not really. Most women have a small amount of daily mucous discharge. That discharge is produced by glands in the vagina. That mucous traps any untoward elements, and pushes them out. That's why the vagina is "self-cleaning." An increase in the amount of discharge isn't very concerning - usually it is related to the hormonal cycle, or random chance. A change in the color of the discharge can sometimes come with an infection, so you should see your doctor in that case. But using a douche doesn't really help. It pushes things up when you really want things to come down. And what is up? Your uterus and cervix. If there is anything dangerous in the vagina, you would be pushing it up toward your uterus, and potentially your fallopian tubes. That means that if there is "bad" bacteria in there, like Chlamydia or Gonorrhea, that bacteria would then be pushed upward into a sterile area, and cause Pelvic Inflammatory Disease, which can cause tubal scarring and infertility.

Should you clean your vulva?
Yes, this is OK. The vulva are on the outside, and so have the tougher external skin that covers most of our bodies. However, I have found that the vulvar skin, being hidden from the outside world most of the time, is more sensitive than the skin on your arms or legs. It can often become very irritated by shaving/waxing, or the detergent in soap, which strips off the natural oils. This can cause a vulvar dermatitis, which can be extremely itchy, and looks like dry patches of a lighter color than the rest of the skin. When this happens, I advise women to stop using soap or removing hair at least temporarily, and I usually prescribe a cream to help with inflammation. If you think you have vulvar dermatitis,  see your gynecologist. If you want to stop using soap on the vulva, I recommend washing with water and a washcloth. This can remove the dirt/discharge without irritating the sensitive vulvar skin.

Should you shave your vulva?
Meh. You can, if you want to, but stop if it causes problems. Hair removal pulls the hair from the shaft, and can introduce bacteria into the hair follicle. When this happens, a woman can get folliculitis, which looks like a small pimple, and is painful. If this happens, I advise women to stop hair removal at least in that area. It's important to remember that hair removal is entirely cosmetic, and has no medical benefits, so if it's causing irritation, it's time to stop, at least temporarily. Not every culture thinks women should be hairless.
One potential alternative is trimming the hair instead. This can avoid the folliculitis complication while still feeling neat/clean.

What should you do for the occasional itch?
If you are having persistent itch or pain, you can try an over-the-counter yeast cream, or see a gynecologist. But if you get the occasional itch down there, and you are pretty sure it's nothing, I recommend a cream like Vagisil (or its generic alternative "Vaginal Anti-Itch Cream"). It has a pain reliever and a soothing ointment, and can take care of the occasional itch, or pain from folliculitis. If it doesn't help, see a doctor.

How do you know if you need to see a doctor?
Occasional mild symptoms, like itching or odor, can arise with changes in cycle, especially around the time of menses. Something that does away quickly on its own, especially once your period is over, is usually no big deal. Symptoms that are severe, or that are constant and persistent, mean that you should be evaluated by a doctor.

These recommendations are not hard and fast rules. They're just my attempt to answer questions that it seems like all women have. Feel free to leave questions in the comments section, and I'll try to address them.

*This is my opinion, based on my professional experience, not a scientific statement. Others would disagree with me, but they can write their own damn blog.

**BV has been associated with some negative outcomes, like preterm birth or infection after surgery, but attempts at prevention and treatment have been mixed or have often failed, and it's unclear whether it's a cause or an association.

Thursday, February 21, 2013

Your Birth Control Should Be Free

Do you get prescription birth control - the pill, the patch, or the vaginal ring?
If so, make sure that you are not charged a copay when you pick it up at the pharmacy. Many people are still being charged erroneously - I was, until I complained to my insurance company.

Under the Affordable Care Act, women no longer have to pay a copay for prescription birth control. (I wish it didn't require a prescription, but that's a whole different rant). This change officially took place on January 1, 2013.

When I picked up my birth control last month, I realized I was still being charged a copay, and I wasn't sure when I was supposed to stop. I asked the pharmacist, and he told me that about 80% of women at his pharmacy are no longer paying a copay, and I shouldn't be either. (My pharmacist rocks.) He advised me to contact my insurance company to find out what was going on.

That day, I called the company. The representative had no idea what I was talking about. When I explained that under the ACA, I should not be paying a copay, he scanned through my information on his computer screen, and said "I don't see anything about that in your account."

"It's not in my account," I said, "it's the Affordable Care Act. It's a law."

He was totally clueless. He kept scanning through my account. I asked to speak to a supervisor and, not surprisingly, he stalled me, and kept insisting that "my account" shows nothing about eliminating the copay. "Look, I'm a doctor, I know what I'm talking about," I told him. HELLO.  It didn't help. He played dumb.

Frustrated, I gave up. I thought about complaining - maybe to the Better Business Bureau, or maybe the ACA has a provision for insurance companies playing dirty tricks? But first I tried one more time. I called again later that day, and spoke to a woman, who knew exactly what I was talking about. She agreed that I should not be paying a copay, and that, in fact, I should be reimbursed for the 2 copays I had already paid since January 1. She was very helpful, and very apologetic. She said she would register a complaint and it should be fixed within 3 business days. She took my phone number - my cell number, which I never give out - and my email, and assured me someone would contact me.

Two days later, I got 2 telemarketing calls to my private, unregistered cell phone, and several spam emails to my email account that rarely gets spam. Thanks, insurance company. I sent them an angry email, and got an autoreply informing me how I can look up their privacy policies. pbbbtth.

An entire month went by, and it was time to pick up the next prescription before I realized I had never heard back about the copay. I called again, and the person said that my account now shows that I do not need to pay copays (yay), but said nothing about being reimbursed. He submitted another ticket, told me I would hear back within 3 business days, and asked for my phone number. I told him Hell No You People Sold My Number Last Time. He claimed that they don't do that, and I called bullshit. I said I would call them back, even though it means going through that awful robot lady who can't understand anything I say and yet insists on requiring voice commands instead of numerical options until I end up yelling "I WANT TO SPEAK TO A %&#@$ HUMAN BEING" and then I finally get transferred to an agent.

In summary, if you pick up your birth control at a pharmacy, you should NOT be paying a copay.
If you are paying a copay, call your insurance company immediately, and demand that they fix it, and that they reimburse you for ones you have already paid.
If they try to give you a line about your plan being "grandfathered in," do the research yourself and verify whether or not this is true - it may be a stalling tactic.

Here's the government website where you can read about the ACA.
Here's information on how the ACA improves access to preventive care services for women, and makes many of them free.
Here's the information about grandfathered health plans.
Here's the consumer assistance program.

Sunday, January 27, 2013

What Happened to Lady Sybil on Downton Abbey?

(WARNING: This entire post is a spoiler if you are not watching Downton as it airs in the US)


On tonight's Downton Abbey, Lady Sybil died of toxemia of pregnancy. What does this mean?

Toxemia is the older name for a disease now known as preeclampsia/ eclampsia. Sybil felt unwell, and complained of headaches and swollen ankles. Sometimes this happens in normal pregnancies, so it can be hard to differentiate between disease and normal. She also looked pale and uncomfortable, which had me nervous from the beginning of the episode.

At one point in the episode, Dr. Clarkson can be seen checking her blood pressure. The illness usually first starts with elevating blood pressure. A normal blood pressure in pregnancy generally ranges around 100-120/60-80, and can be as low as 90/50. When it gets above 140/90, that is when disease is present. It can get even higher, above 160/110, and the higher it gets, the more the danger. It's not clear whether the blood pressure connection was known in the era of Downton, as none of the doctors mention it.

Dr. Clarkson also mentions that Sybil's baby seems small. In toxemia, or preeclampsia, there is an abnormal placental attachment - the arteries of the placenta and uterus don't adapt in a normal way to pregnancy, and there is increased resistance to blood flow. When this happens, the baby doesn't get quite enough nutrition and oxygen, and might be growth restricted. It would be born small, even at full term (9 months).

During Sybil's labor, Dr. Clarkson insists on checking Sybil's urine for albumin, or protein. The phenomenon of preeclampsia is now known to manifest first in elevated blood pressure plus protein in the urine. This combination makes the diagnosis, and often predicts the poor outcomes associated. Women with preeclampsia are at risk of seizure, stroke, fetal death, and maternal death.
Dr. Clarkson insists on bringing Sybil to the hospital for a cesarean because the only known cure for toxemia (preeclampsia) is delivery. That remains true today - delivery is the only cure. However, we have another tool in our arsenal these days, which is the administration of a high dose of magnesium sulfate, an electrolyte. It's not know why, but magnesium is extremely effective at preventing the seizures associated with preeclampsia. It doesn't cure the problem, nor prevent the other outcomes like stroke or fetal death, but it makes a huge difference in preventing seizure. It can also be rapidly administered at the time of an eclamptic seizure to stop the seizure and save the woman.

Sadly, it seems that the benefits of magnesium sulfate were not known during the era of Downton, because once Sybil begins to seize, Dr. Clarkson says that there is nothing he can do. When seizing starts, the disease is called eclampsia - the combination of elevated blood pressure, proteinuria, and seizure. Sybil seizes to death in a matter of minutes. The scene was devastatingly accurate, and horrifying.

In the United States, we still see a lot of preeclampsia, but very little eclampsia. That's because we are able to detect the warning signs - elevated blood pressure and proteinuria - and give magnesium and induce labor before the dangerous outcomes occur. Intervening in preeclampsia is one of the most important developments of modern obstetrics.

In developing countries, preeclampsia/eclampsia is one of the most common causes of death. As was noted by the downstairs Downton staff, many women before Sybil have died in childbirth. We still haven't eliminated this problem. I was gratified to see it portrayed in such a popular show. Although it meant losing one of my favorite characters, it is important to highlight this tragically common problem.

Wednesday, November 14, 2012

No Excuse

If you haven't read about the death of this woman, you should:

Woman "Denied A Termination" Dies in Hospital

A 31-year-old woman presented to a hospital in Ireland in pain, and was diagnosed with a miscarriage in progress (what we call inevitable abortion - "abortion" being the medical term for any pregnancy that ends before viability). There was no doubt that she was going to lose the fetus. Nonetheless, the doctors were barred by law from removing the fetus or inducing labor because the fetus still had a heartbeat. The woman suffered for 2.5 days, and then died of sepsis.

Non-medical people might wonder whether this outcome might just be a rare, unexpected outcome. You might wonder whether the doctors could have known what would happen.

So, let me be clear: this outcome was entirely preventable. This woman should not have died. Her risk of sepsis was well-known, and predictable. Women who have spontaneous miscarriages are at risk of infection, and the longer the miscarriage goes on, the higher the risk. Women in second trimester (which she was, at 17 weeks) are at even higher risk, because the cervix has to dilate more, and because the reason for the miscarriage could easily be an infected pregnancy. Pregnant women are highly susceptible to infection, and less able to fight it because their immune systems are suppressed. When a woman comes in with a miscarriage that doesn't end spontaneously within 1-2 hours, we evacuate the uterus to prevent the development of complications - specifically, hemorrhage and sepsis.

Her death is not a mystery, and it is not surprising. It's hard to blame the doctors, as their hands were tied by law and they risked losing their license to practice, or going to jail, by intervening. The doctors were prevented from providing adequate medical care by the law. The people responsible for the law are the Irish lawmakers who created it.

If they had done their jobs, the lawmakers who created this law would have looked at the implications of it. They would have learned that the law would inevitably cause the deaths of women. (Who knows how many others have died that we haven't heard about?) In fact, women die every day as a result of pregnancy and of lack of access to safe abortion. Anti-choice individuals who argue that such outcomes are rare, people such as our recent nominee for vice-president, are lying, or they are speaking ignorantly. I think it's the former, because if you spend 1 minute googling maternal mortality, you can easily see that 800 women die every day in pregnancy from preventable causes.

When lawmakers dictate what physicians can and cannot do, they are presuming that they can practice medicine better than doctors can. If they want to pass laws dictating medical practice, then they should take responsibility for these patients' lives. Lawmakers who pass laws that prevent abortion even when the pregnancy is a threat to the mother's health or life are knowingly causing the deaths of pregnant women. This is murder, and should be prosecuted as such. There is no excuse for having a law like this.

Sunday, November 4, 2012

Unsung Heroes

I have been helping out with disaster relief the last 5 days, and working hard. The last 3 days, I was working with M├ędecins Sans Frontieres (MSF), and finding myself astounded to be doing MSF work in my own city.
I have gotten a lot of moral support from everyone, and I am grateful for that. But while I think I have done some good and helped some people, I actually think that my contribution has been minimal in comparison with some of the other people out there that get less attention. I want to take a minute to highlight these ordinary people being heroic in a time of need.

1. Sanitation Workers
The city is a mess, and can't become functional until it is cleaned up. Sanitation workers are working long hours of backbreaking work to get New York back in shape. I saw sanitation workers lifting up huge pieces of furniture all over the place, and somehow getting all of it into their trucks. They were in the Rockaways today, on the streets that are covered in piles of sand and broken crap, hauling it all away.

2. Social Workers
Everyone realizes that doctors and nurses would be needed in a crisis, but few appreciate the desperate need for social workers. These amazing people can do everything from therapy to logistics to coordination. I had social workers tracking down people's insurance information to get them emergency prescription refills, comforting people with anxiety and depression that was worsened by losing their homes and being trapped in chaotic shelters, replacing broken eyeglasses for people without insurance, and basically doing everything they were asked. One of the days I was in a shelter, I was exploding with stress until a wonderful social worker arrived on the scene, and took some of the work out of my hands, handling everything with grace and perseverance.

3. Pharmacists
So many people have chronic conditions now, and many people did not expect the storm to be what it was. They brought only a few pills with them, or they didn't refill the prescription before the storm hit, and now they're stuck with no meds. Their pharmacies and doctors' offices are under water, and their insurance information is lost in the flood. Pharmacies all over the city are accommodating the need for emergency meds by urgently refilling meds, delivering to shelters, accepting partial insurance info and figuring out the rest later, waiving copays and offering 3-day emergency refills without any insurance information whatsoever. One pharmacist, when he realized how much need we had at a shelter, drove over in his car (kids in tow) to drop off not only prescriptions, but soap, lotion and other toiletries he thought people might need.

4. Nursing Home Staff
Several nursing homes and assisted living facilities were located in areas that were evacuated. These facilities had to move all of their residents, many elderly and with chronic medical and/or psychiatric conditions, into shelters. Some of the staff from these facilities worked 12-18 hour days in the shelters to stay with the patients they know, and make sure they get the meds they need in the middle of a chaotic situation. Without the staff from these facilities, caring for these patients would have been nearly impossible.

5. Home Health Aides
In the shelters I worked in, there were home health aides staying on a cot in the shelter (sharing a room with 20-100 other people) to care for their patients - changing their diapers, checking for bedsores, requesting wheelchairs, giving them medications and staying with their patients 24/7 to make sure they were well cared for.

6. Community Organizations
In many of these communities, we are outsiders; unfamiliar with the surroundings and the people. Preexisting community organizations stepped in to collect, organize and distribute donations, as well as information about where to get food, shelter and medical care. In the Rockaways, a youth organization became a hub for donations, and got so many donations (and needy people looking for donations) that they started distributing to other donation sites. These inspiring young people (in their early 20s) were the most organized and efficient group that I saw in this entire experience.

7. Good Samaritans
People came out in droves to help. Many were turned away from several sites, only to keep traveling to other ones until they found a place to help. These volunteers became essential, and many found a very specific task that they became very good at, and helped bring a chaotic situation more under control. Most were working outside their comfort zone, or even below their level of expertise. But no one balked, everyone pitched in to do whatever was necessary. Some people triaged medical patients; others climbed epic flights of stairs to knock on doors and bring water and food to trapped people; others still cared for patients in shelters too sick or old or incapacitated to fully care for themselves.

The aftermath of this storm has made me realize how much we need everyone in our city and our community to pitch in. But it also made me realize that there are people out there who do really good, hard  things every single day, who deserve our appreciation. Please take a moment to thank them.