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.

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)

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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.

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.

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 Médecins 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.

Human Papillomavirus (HPV)

Question:
I have HPV. Is my life over?

No, your life is not over. It will be OK.
Human Papillomavirus (HPV) is an extremely common sexually transmitted infection. There are dozens of forms of HPV, but not all of them cause disease. Some forms of HPV cause cervical cancer, and some forms cause genital warts. Other forms seem to cause no disease at all.

Why is HPV important?
HPV causes almost 100% of cervical cancer. If we can prevent HPV, we can prevent cervical cancer.

How did I get diagnosed with HPV?
Most likely, the diagnosis occurred during a Pap smear.

For years, we have known that cervical cancer is almost entirely preventable. When a woman has HPV, it takes years to cause problems, and if caught before becoming actual cancer, it can be treated. That's why we do Pap smears regularly. Pap smears are a light scraping of the cervix that gently brushes off some of the cells. Those cells are examined by a pathologist to determine if they are abnormal or normal. If normal, the woman can continue her regular screening. If abnormal, they must be investigated further.

How do I know if my cervix has abnormal cells?
The abnormal readings that predict cervical cancer are called cervical dysplasia, meaning that the cells of the cervix have been altered by the presence of HPV. These readings can be either LGSIL (low-grade squamous intraepithelial lesions) or HGSIL (high-grade squamous intraepithelial lesions). The higher the grade, the more abnormal the cells, and the closer to cancer it is. However, these LGSIL and HGSIL do not mean that cancer is present, only that abnormalities are present that may lead to cancer. When a pap test shows LGSIL or HGSIL, this means that HPV is definitely present, so there is no need to do a specific HPV test. (More on abnormal Pap testing in a later blog post).

HPV --> LGSIL (low grade) --> HGSIL (high grade) --> Cancer

A third abnormal finding that may occur is called ASCUS (atypical squamous cells of undetermined significance). This means that the cells looked a little abnormal, but not quite LGSIL or HGSIL, and it was hard to tell whether their appearance indicated dysplasia or not. Until HPV testing, it was very hard to know what to do with ASCUS pap readings. Nowadays, we can test for HPV in the settings of ASCUS. If HPV is positive, then we know that there may be precancerous changes, and so we should treat that as an abnormal pap. If HPV is negative, then the woman cannot have dysplasia, and we can treat that as a normal pap.

Sometimes HPV testing can be done even when the Pap smear is negative. This is one possible method of screening available to women who are 30 years of age and older. You can talk to your doctor about what screening method is right for you.

Do I have an STD for life now?
Not necessarily. In some people, the HPV sticks around for years, and that's how it creates abnormal cells. However, many people, especially young people, acquire and eliminate HPV rapidly before it causes any damage. That's why HPV testing is not as useful in women under 30 - because they can acquire and eliminate HPV so quickly that a positive test doesn't mean much. However, in all women, including women under 30, cervical dysplasia does not disappear quickly, and does need to be followed up. That's why Pap smears are done in even young women.

Can I prevent HPV?
Yes. HPV is sexually transmitted, so the only thing that puts you at risk is having sex. The best protection is abstinence, but if you are sexually active, using condoms is the best way to prevent HPV. HPV is not usually acquired outside of sexual intercourse, so you can't get it from a toilet seat (which people often wonder).
Since men are not tested for HPV, routine STD testing will not identify whether your male partner has HPV. Therefore, it's important to always get pap smears, even if you are monogamous and/or have only had 1 partner.
There is also a vaccine against HPV. It is only partially effective, which means that you still need pap smears, but your risk of having an abnormal Pap smear is much lower, and that's great. Women aged 26 and younger are eligible for the HPV vaccine. (There's a good reason for that. I'll address it in a future post).

Red and Black

This question is from a reader. Feel free to contact me with questions!


Question:
My menstrual blood is sometimes brown instead of red. Is there something wrong with me?

Answer:
No, you're fine.

Blood is bright red when it is oxygenated. Blood has hemoglobin, which can bind oxygen molecules. In the lungs, oxygen is passed from the lungs into the blood, turning it bright red. As the blood is transported through the body, its oxygen is transferred to the organs it passes through, and the blood becomes darker (dark red, bluish). By the time it reaches the veins (which bring blood back to the heart), much of the oxygen content has reduced.

During menstruation, blood is shed by the lining of the uterus, and that is usually bright red blood. The blood does not always come out immediately. It can sit in the uterus, cervix or vagina for some time before the woman sees the blood. In that time, the blood can be oxidized (which is different from oxygenated) - it involves a transfer of electrons, rather than just binding of oxygen to hemoglobin. When blood is oxidized, it turns brownish or black.

Therefore, brownish period blood is merely blood that has been sitting around for a while. All blood, after being exposed to air, will eventually turn brown or black.

(Incidentally, this is why stool can sometimes be black - because there is gastrointestinal bleeding. If you have black stools, see your doctor)

Irregular Periods

Question: 
My periods are irregular and infrequent. Is that OK?

No, there may be a problem.

Regular menstruation usually occurs monthly. For most women, this is highly predictable, and comes every 28-30 days. Other women might have shorter or longer cycles (26 or 32 days apart, for example), or variable cycles, but they will still have a monthly period. These women all have regular menstruation.

When the period is irregular, meaning it does not come reliably every month, there is a problem. Most of the time, the problem is that the body is not ovulating, also known as anovulation.
Here is a nice video from womenshealth.gov showing the process of menstruation.

To understand why anovulation happens, it is important to understand how the female hormones work.
Estrogen and progesterone are the most commonly known female hormones. They are very important in controlling the normal function of a woman's reproductive system.

This graph shows the hormonal fluctuations that are needed to have a normal menstrual cycle:

Source: DevBio

Estrogen (blue) causes the uterine lining (the endometrium) to thicken in preparation for ovulation. Progesterone (purple) stabilizes the endometrium, preventing the blood from spilling out. Just before menstruation, both estrogen and progesterone drop quickly (see day 28), and the loss of progesterone allows the thickened uterine lining to bleed out.

Two other hormones that are less well-known also play a role. Follicle-stimulating hormone (FSH, orange) causes the ovaries to develop an egg, and lutenizing hormone (LH, red) peaks and causes the ovary to release that egg (ovulation).

When these four hormones do not fluctuate they way they're supposed to, normal ovulation and menstruation don't happen. Without the increase in LH, the body doesn't know to release the egg. And without the decrease in progesterone, the uterus doesn't shed its lining.

In many women with irregular menstruation, the periods come infrequently, and they can go several months without bleeding. When the period does come, it can be heavy because of the heavy buildup of the uterine lining, and it often lasts longer because there is no hormonal input telling the uterus to stop bleeding.

Why are the hormones abnormal?
It's not entirely clear why this happens. Many women who have anovulation also have a syndrome called polycystic ovary syndrome (PCOS). Its name comes from the fact that many women with PCOS develop multiple small cysts on their ovaries, although women can have PCOS without actually having cysts. In addition to infrequent menstruation, women with PCOS may be overweight, and may have unusual hair growth (on the chin or chest) and acne. About 5-10% of women have PCOS.

In PCOS, there is more estrogen than progesterone. In women who are overweight, the fat in the body converts some of the other body hormones to estrogen, and this leads to menstrual problems. When the women with PCOS lose weight, the PCOS sometimes gets better. However, PCOS can also exist in women who are not overweight, and in these women it is not clear why the hormones are abnormal.

There are reasons other than PCOS that a woman might not get her period. PCOS is most typical in women whose periods have always been irregular, rather than a new change. There are other causes or infrequent periods, like being underweight, thyroid disorder, high prolactin levels, kidney failure, breastfeeding, and certain medications, among others. It's important to be evaluated by a doctor to determine why your periods are irregular.

OK, my hormones don't work. But why is anovulation a problem? Isn't it lucky to not bleed every month?
When the endometrium is exposed to estrogen without the benefit of enough progesterone to match, it becomes very thick, and over many years, the cells in the endometrium can become abnormal, and eventually become cancerous.
Women who have untreated irregular periods for many years are at high risk of having endometrial (uterine) cancer. For that reason, it's important for women with irregular periods to see a gynecologist for evaluation. (There are other less common reasons why periods can be irregular, so it's important to have a full evaluation by a doctor.)

Can I get pregnant?
Women with anovulation often have infertility because they do not ovulate regularly. They may require medications like clomiphene citrate to provoke their ovaries to ovulate, and they may need to see an infertility specialist. However, it is impossible to know whether a woman is fertile before she tries to get pregnant.

What should I do about it?
In order to protect against cancer, women with anovulation or PCOS who are not actively trying to get pregnant should be on some form of hormonal birth control to balance out the estrogen and progesterone levels, and keep the uterine lining thin.
There are several forms of birth control that can protect against cancer.
The birth control pill is extremely effective. It contains estrogen and progesterone, and it replaces the body's production of those hormones. On the pill, level of hormones does not fluctuate over the month, which prevents ovulation, but the estrogen and progesterone are well matched, preventing cancer. Periods will become regular, monthly.
Ortho Evra, the contraceptive patch, and NuvaRing, the contraceptive vaginal ring, work very similarly to the pill, but are easier to use.
Depo provera, or the shot, is a large dose of progesterone that is given every 3 months. The progesterone provides a good match for the excess estrogen, and also prevents ovulation. Many women on depo provera do not menstruate, which is fine as long as the uterine lining is kept thin by the progesterone.
The Mirena IUD, which contains tiny amounts of progesterone, also provides a match for the excess estrogen in the body, and keeps the uterine lining thin. It lasts for 5 years.
The implant, which is now known as Nexplanon, is a small rod that is placed in the upper arm, and contains progesterone.
Women with anovulation or PCOS should talk to their doctor about which method is right for them.

In addition, aerobic exercise and weight loss in women with PCOS often helps improve hormonal function. Women with PCOS may also have diabetes or pre-diabetes, and may benefit from a diabetes medication called metformin. Evaluation by a doctor is the first step in determining whether infrequent periods are a sign of PCOS or another cause.

Here is more information about PCOS from womenshealth.gov