We just got back from vacation to the East Coast with our five boys, ages 9,7,5, 2 1/2, and 5 months old….driving 17 hours straight through on the way there…uh, yeah.  The idea was that it would be way cheaper than flying since that would be 6 airfares plus whatever highway robbery for luggage; we were gone 10 days so that’s a lot of clothes.  Plus once there, we would have had to rent a large SUV and hassle with car seats, which the rental places never have enough or the right ones, so drive it was!  Now my favorite thing is not driving through the mountains of West Virginia at 4 o-clock in the morning negotiating one narrow lane due to construction, but since everyone was asleep, it was manageable.  On the way home, we started from Pittsburgh which shortened the trip down to 12 hours, but all during daylight.  Highlights included a baby who screamed anytime he was strapped into his carseat, various fights over DVD choice, PSPs and DSi’s, Snapple bottles doubling as pee containers, a child with a completely filthy shirt from sleeping on the floor, and yes, the inevitable, “are we there yet?”  All things considered, it wasn’t terrible although my husband did swear not to do it again until the baby was forward-facing…and talking.

During this time, I had time to catch up on some reading.  A good friend had sent me a book for the birth of the baby entitled “Didn’t I Feed You Yesterday?  A Mother’s Guide to Sanity in Stilettos” by Laura Bennett.  My limited TV watching usually involves Discovery Health or the Food Network (I know, boring, right) and I have never watched Project Runway, but Ms. Bennett was brought to fame by being a contestant on the show, while pregnant with her 5th boy.  She actually has 6 children, the oldest a daughter away at college, and she lives with these 5 boys and her husband, get this, in Manhatten.  Part of our vacation was visiting Manhatten with our 5 boys and I have to say that anyone who could raise 5 boys in that city deserves to win a reality show, at the least (she didn’t actually win, but she should have just on principle).  Don’t get me wrong, I absolutely love New York, but believe me when I say that the next time I go, it will be sans children.  Whereas my children’s idea of a good time was to go to the multistory M&M store in Times Square and try to find the nearest Dave and Buster’s, mine would involve a nice little bistro with the hubby or a Broadway show.  My darling sister-in-law volunteered my brother to babysit the boys one night so we could sneak off.  Only problem was one of the children decided to hide in the shower, setting off a small panic for my as-yet childless SIL.  We were trying to stay relatively close since I didn’t have any pumped milk should the sleeping baby wake up so when we returned at 2 am, the two oldest children said, “We watched you go into Birdland (a jazz club across the street)” so I know they didn’t fall asleep like normal kids.  I’m sure my brother and SIL were like, “note to selves:  no more volunteering to babysit.”

Anyway, back to the book.  Now naturally you’re thinking, 5 kids in Manhatten, this woman must be filthy rich, which she appears to be as her husband is a world-renowned architect and she has an expensively-garaged Porsche 911.  And her staff of four: two nannies, a mannie and a  full-time housekeeper.  But wait…SHE’S also an architect, and now a fashion-designer since the show.  As much as you might love to hate her with all these benefits, you have to love a woman who you would for all intents and purposes presume to be an uppity socialite, has actually given birth to six kids, and breastfed them, and oh, one of them is special needs.  I am officially in love with her.  And since, as my friend who gave me the book indicated, we are in a special sorority of mothers-of-five-boys, her rollicking, witty, tongue-in-cheek-while-brutally-honest unbelievable story is one I can really relate to (minus the high society).  Those of us who would actually pursue this life, well, we have to be kind of crazy and Ms. Bennett describes her particular brand of crazy with highlights of her beautiful furniture being systematically dismantled, coordinating all the different activites and doctor’s appointments with the skill of an air-traffic controller, writing, sewing, and partying, all the while looking fabulous in her Manolo Blahniks.  Although this is where she and I part ways (sorry, will never own a pair of $800 shoes), I appreciate her ability to give attention to detail in her appearance and dress DESPITE having a brood.  Certainly, I don’t relate to everything she does, e.g. chewing nicotine gum for energy and to stay slim, but most of all that is simply style differences.  But let’s just say, the very idea of a woman doing what she’s doing, is just wonderful…exhausting, but wonderful.

My favorite part of the book is her disdain for this current generation of over-protective, controlling, helicopter parents who don’t hesitate to criticize YOUR parenting choices, all the while turning parenthood into some sort of sentence in an un-funny, neurotic prison.  In one chapter, she describes hearing a recently divorced woman complaining about how awful her ex-husband was being:

“‘What did he do?’ I had to ask…It’s all in good fun, but I imagined that this mom’s problems must have something to do with Ecstasy pills rolling out of the girlfriend’s slack mouth, or her pole-dancing friends coming over for a weekend performance.  Something juicy, or half naked at the very least.  ‘Well’-she sniffed, half angry, half distraught-’he packed their lunches with Cheetos, Go-Gurts, and bologna sandwiches on white bread.’ She sat back, satisfied.  My mouth fell open, so she continued.  “Do you have any idea how dangerous high-fructose corn syrup is?  It is in every single one of those products!  And the cheese single must have been made out of milk from cows who have been given hormones and antibiotics.  When the children are in my care, I poach Amish-raised, grass-fed, free-range chicken breasts and stuff them into whole-grain pitas with hydroponic tomatoes and micro-greens that we grow in our own kitchen.  How could he possibly endanger them in this way?’…But as I sat there…I couldn’t help thinking that perhaps it was this woman’s husband who should be pursuing custody change.  Her reaction was maniacally disproportionate….soon (her children) would be boosting Twinkies from the corner bodega, a behavior that can only lead to smoking pot and much higher crimes.”

While laughing at this story, I have to confess that I too have found myself in the gripes of self-righteous indigination at how poorly members of my family sometimes operate.  I did at one time put a moratorium on sugar in the house…after putting up with never-ending forlorn looks, stashes of hidden candy and outright rebellion, I had to concede that the only sure-fire way to get my kids to eat right was to do my best, and that to completely restrict anything would immediately make it desirable and tantilizing to them, leading to all sorts of nefarious, secretive attempts to consume the forbidden fruit.  Looking back at how I was when I only had one child, I thank God that he managed to turn out pretty well despite my anal first-time parenting rigidity.  I still remember a car trip with our first child where I was balancing precariously in the backseat giving passing cars a peep show, while I breastfed my baby in his carseat, because I simply couldn’t bear to take him out while the car was moving.  This trip, not so much…I had no problem taking him out and nursing him…I AM NOT RECOMMENDING THIS…but as a mom of 5 boys, you gotta do what you gotta do.

Lest you think her’s is not a “real” household, Ms. Bennett tells how in addition to all the “man smell,” she also houses a hamster, a rabbit, a tortoise, and multiple finches.  As she recounts the story of her son mistaking rabbit droppings for Cocoa Puffs, I am reminded of how much the animal life at our house has only added to the “testosterone drama.”  We have two cats, but we didn’t name one of them because all the other ones were eaten.  In addition to fish in a pond and a tank, we have four huge dogs:  a German Shepherd, a Neopolitan mastiff, a Bull Mastiff/Pit Bull mix (my husband’s “hood” dog), and an American bulldog.  They have essentially destroyed the front of my house so that it looks like Beirut, and they frequently get into bloody fights such that now several of them limp…this is not my idea of fun.  But once again, I have to remind myself that the enjoyment of the children’s (and animals’) escapades is what life is all about.  If I have learned anything being a mom of five boys, it is not to take myself too seriously, not to yell ALL the time, and appreciate all the funny moments before they are gone.  Although we are unlike the author in that we try to teach our kids NOT to cuss, my husband and I were rolling with laughter when my 5 year old came into our adjoining hotel room in NYC and sleepily said, “I had to come in here because the volume on that cartoon was just too damn loud.”

To find out more about Laura Bennett, visit her website www.didntifeedyouyesterday.com.

The advent of social media has provided a sounding board for people behind the comfort, and sometimes anonymity, of a computer screen.  It’s kind of nice to have something on your mind, shoot it off on Facebook or Twitter, maybe it lands, maybe it doesn’t.  Life goes on, right?  Well, I have noticed a disturbing trend on these formats that highlights the cons of an open platform.  Apparently, some people don’t like it when other people disagree with them.  We actually have new verbs that have entered our lexicon:  Unfriend and Unfollow.  And the old and newly abused verb, Block.  Now I certainly don’t think that people should ever put up with any sort of verbal abuse on social media, and I think that’s why unfriend, unfollow and block exist.  But what I see now is people doing this to each other just for DISAGREEING about one topic or another.  Hello!  We are all different;  who knows what combination of genetics, personal experiences, worldview, trials and difficulties have worked together to form the opinions we hold.  Last I checked, clones have not fully integrated our society, and so we continue to be unique individuals;  isn’t diversity supposed to be the point? 

This issue really came into focus when @antitheistangie live-tweeted her abortion on Twitter.   People who know me and read my stuff, know that I am pro-life.  It’s not a secret, and yet I don’t make a habit of bashing people over the head with it.  Because, uh, that sort of defeats the purpose…unfortunately, there are many pro-life head-bashers who I think really end up disservicing the whole movement, giving all of us a bad name and making people think we are all hateful, judgemental accusers.  While I think it is appalling to live-tweet an abortion, I would NEVER berate, accuse, castigate, name-call or attempt to guilt-trip someone who did so.  In fact, I tweeted to @antitheistangie that I was praying for her and her family (which I was and did) and left it at that.  Do those people who sent her hatemail really think they were doing something positive?  It seems to me, all it would do would be to further cement her position that pro-lifers are mean nutjobs who disdain her.  Their disturbing behavior is a poor reflection of those loving, heartfelt, passionate people who believe in perserving the sanctity of life.  Another dear woman is going through a traumatic experience and was discussing her torment online about whether to seek a termination for her child’s severe medical condition.  Instead of information and support, what she has been getting is hatefulness, rudeness, and judgement, adding monumental stress and angst to an already horribly difficult situation.

Apparently, if you associate yourself with a particular movement or ideology (breastfeeding, birth activism, granola), you have to sign a petition that you will believe THIS way about each individual issue to be accepted within said movement.  I read one woman’s blog who actually said that pro-life women have NO RIGHT to be birth advocates because they do not support abortion….oookkkaaayyy….that makes zero sense to me, beyond the sheer arrogance that this person’s point of view was the only acceptable one.  Seems somewhat narrow-minded to me.  But again, members of a movement who say and do stupid and insulting things, give the whole movement a bad name.  I know some people who won’t follow, friend or “like” someone or a blog or page because of some particular belief that person has with which they don’t agree, even if they have other things in common.  So if someone isn’t exactly like you in every thought and deed, you can’t learn anything from them?  Hogwash.  It’s called common ground people, and we could all learn from one another if we would set aside differences and agree on those things we can, well, “agree” on.

I had one friend who threatened to stop being my friend over an email about abortion that I had widely sent out to a group of people.  Instead of her saying, hey we disagree on this one, don’t send me any more emails about this subject and we’ll just agree to disagree, she actually was willing to totally sacrifice our friendship for this ONE issue.  WOW!  I can understand it if there was some kind of personal attack taking place…but I’m sorry, it would take A LOT for me to stop being friends with someone over a ideological, political, spiritual or social position.  To me, I am secure enough in my own positions that I can listen to other’s points-of-view without feeling personally outraged or threatened by their disagreement.  This is one of the reasons I blog:  I was complaining to my mentor, Lauren Plante, about some issue within the birthing community, and she said, “Well, why don’t you just blog about it?”  Lauren and I disagree on lots of stuff, but we are the best of friends;  she knows how I feel, I respect her viewpoint and we meet in the middle on those things on which we do agree.  The point is, if it’s someone’s blog or Facebook page or Twitterfeed, it is their opinion, which even if I disagree with them, I will “defend to the death their right to say it.”  Free speech is quickly going out of style, just ask Lierre Keith.  When her book, “The Vegetarian Myth,” came out, she was physically attacked by some vegans-gone-wild.  Do I think these deranged individuals represent vegans at large?  Of course not, but as Tom Naughton blogs, you have to wonder why people would react so violently to a different point of view.

When I come across a status update with which I disagree or don’t like, I read it and move on.  So what if I don’t agree with some statement or other?  That does not nullify that a person may have other valuable things to say.  I think political correctness HAS run amuk in many public forums, with the most disturbing trend to try to silence or shut down people who are saying “controversial” things.  Grow up people!  Be an adult, instead of a rude, immature hater!  I had a woman “Unlike” my Facebook page because I posted something about a medical benefit of circumcision, stating she could no longer “like” me if I advocated “cutting up little boys’ penises.”    Well, OK then, move on, if you don’t like it, then only be friends with people who are uncircumcised, life goes on!

I also see that within the birthing community, some people’s bad experiences with the medical establishment has shifted them so far in the other direction that they can’t seem to be positive about ANY aspect of mainstream medicine and won’t support a woman who has a hospital birth, C-section, AROM or an epidural.  Danielle Elwood just posted an excellent blog about this topic.  Every woman is not going to have the same belief systems, expectations, education or understanding as someone else that has led to their own personal birth philosophy.  And that’s OK!  I heard some women ridiculing a birth center birth video because the mom had her membranes artifically ruptured.  But when you compare this birth to most hospital births, it was beautiful, affirming and the mother was obviously very happy!  Please, don’t throw the baby out with the bathwater.  Appreciate those things which are positive, even if YOU would have done this, that or another a different way.  We all have reasons for doing things the way we do them.  Maybe if we took the time to understand why a person arrives at their particular decision, it would help us to problem-solve and network together in a more positive way.  In reading @antitheistangie’s backstory, she had a very difficult upbringing with, ironically, a grandmother who did homebirths and had some very bizarre religious beliefs.  So I can understand why she may have certain viewpoints, even if I don’t personally believe that way.  I think ultimately, we would all get more accomplished if we don’t bash, accuse or ridicule someone with a different opinion.  I hope that the online community will start to demonstrate more maturity, dignity and respect so we can all continue to learn from one another.

I have always enjoyed the full support of my husband for breastfeeding, which I have tried not to take for granted.  Breastfeeding requires committment and is often not easy, so a supportive partner can help you navigate “booby traps.”  But not everyone has a partner that supports nursing; in fact, some partners are actively opposed to it.  With their permission, I am writing about two friends and their experiences with unsupportive partners, so that maybe someone who has similar opposition can have some insight into how to respond.  I was also interested in exploring whether this opposition had any cultural basis;  as it happens, both of these partners were African-American.  My husband is also African-American, and I talked with him about his perceptions toward breastfeeding growing up.  He does not remember ever seeing anyone nursing a baby and felt like most women in his family and neighborhood saw bottle-feeding as more convenient.  Now, he is a physician and understands the health benefits of nursing, but as he grew up, he just had the sense that nursing was better so he said he had two requirements for his future wife, that she would want to breastfeed and that she didn’t smoke (future lung doctor even then).  His mother seemed very uncomfortable with me nursing our first son and asked me when I was going to stop nursing and give the baby a bottle.  I restrained myself and simply answered that I wanted to nurse the baby as long as possible.

My first friend was separated from her husband from 7 months pregnant until her daughter was 6 months old.  She had always wanted to nurse and so breastfeeding was already established when she and her husband reconciled.  No one in her family had breastfed, but she knew the benefits from her own reading.  When her husband returned to the household, he said that he felt that the baby was too attached to her and that he felt helpless at not being able to feed her.  My friend was pumping bottles but she thinks that when the baby was crying and she would nurse her, he felt distanced from them.  Although her husband was against it and she was a very busy student teacher at the time, she states that she was “determined to breastfeed,” and felt that if she gave up, she was a quitter.  Perservering, she nursed for 13 months until she became pregnant with her second daughter.  With this baby, her husband said, “You breastfed one, let’s try bottlefeeding,” and the common, “I was bottle-fed and I turned out OK.”  Again, my friend pressed on with her desire to nurse and he backed off although he did not want her to breastfeed in public.  Interestingly, although her husband and his brother (who lived with them for a short time) were both opposed to nursing, their mother, who was very involved in her grandchildren’s lives, was supportive even though she never nursed.   My friend nursed for 15 months until becoming pregnant with her third child, a boy.  Her husband was much more forceful that he did not want his son breastfed.  This time, she felt that there was an element of sexualizing of her breasts, which was not discussed as an issue with the girls, to the point that she always had a shirt on whenever they were intimate.  Despite the stronger opposition, she nursed her son the longest, 16 months.   Her husband told her that he felt feeding decisions should be made by both parents and that she was going against his wishes.  She remembers a particular episode when she was in the shower and the baby was screaming, and her husband again told her he felt helpless to soothe the baby.  This couple has since divorced.

My second friend had her first two children with a partner that was supportive of breastfeeding, although he did not want her to nurse in public.  Although he never saw anyone in his family breastfeed, it was something he actually encouraged her to do.  She also never saw anyone in her circle nurse, but had a lactation consultant in the hospital who educated and encouraged her.  She nursed for 8 months with her first child, but only 4 months with her second because she went to work at a nursing home, which did not provide breaks or a place to pump.  After being walked in on while pumping, but not getting to pump frequently enough, her milk dried up.  She broke up with this partner and when she became pregnant with her current husband, she found him to be adamantly against breastfeeding.  Starting during the pregnancy, he stated that he couldn’t feed the baby and that nobody else could keep the baby if she nursed.  She also felt that he was conflicted by viewing the breasts from a sexual context.  Since she didn’t have much support around her and didn’t own a breast pump, she felt it was easier not to have constant confrontation and she exclusively bottle-fed her third child.  She states that she was “trying to please him,” a decision she now regrets.  She says she did feel closer to her oldest child, due to the bond of nursing him the most.  Her youngest child had lots of gas and reflux problems, which she would remind her husband the oldest children did not have.  Although she had a tubal after her last birth, she says that if she were to have another child, she would “just do it” now as she feels stronger in herself and more understanding of the benefits plus she would have the support of friends who have nursed.

Certainly back in the 50s, moms were made to feel “poor” or of low-status if they did not bottle-feed; after all, it was the “modern” way to nourish your baby.  The natural childbirth movement helped breastfeeding to resurface, but the practice lapsed again in the 80s-90s, mostly due to successful advertising by formula companies and their invasion of hospitals.  Even today, as breastfeeding rates are higher (although still not sustained in large numbers), the number of breastfeeding-focused hospitals are few and far between, and many, mine included, do not even have a lactation consultant.  Add in a partner who has no frame of reference for nursing, 90:10 baby shows with bottles rather than breasts featured, and breastfeeding in public under attack, is it no surprise that women are not breastfeeding in appreciable numbers?  Although these examples are anecdotal, I think it gives some insight into what some women face when it comes to the breast vs. bottle debate.  Whether there are true cultural differences in different communities, or whether it is just a matter of exposure and education, I don’t know.  I suspect that ALL communities would benefit from removing obstacles at hospitals, active support in the early days of nursing, and recognizing that a family environment ultimately is something that we don’t always understand as a breastfeeding activists.  Let’s reach out to our sisters instead of assuming we understand their daily reality.

As I type, I look over at my one-week old baby zonked out in his cradle swing and am in awe at how awesome his arrival was.  Instead of having my third c-section as scheduled, I went into labor on my own (first time in 5 tries) and delivered him (precipitously in fact), one hour before I was to arrive at the hospital for my surgery.  I find this wonderful and quite ironic in light of the recent NIH VBAC conference in Bethesda, MD;  I had just downloaded the consensus statement and was digesting it while awaiting my baby’s arrival (more on that later).

In order to tell the story of how I ended up with a surprise VBAC, I have to start at the beginning of my long and adventurous reproductive journey.  My first pregnancy ended in the first trimester with a miscarriage and heavy bleeding requiring a D&C to stop it.  I was a OB/Gyn resident at the time and was surrounded by high risk OB patients every day.  I trained in downtown Philadelphia where an addicted mom with no prenatal care could deliver on one end of the hall, while a high risk IVFer from the Main Line might be delivering on the other end.  Although we worked side by side with midwives, we only became involved if their patients developed complications or needed a C-section.  Needless to say, like most OB residents, my experience with normal, low-risk physiological birth was minimal.  Being pregnant in this environment and then losing the baby certainly colored my perspective.  Like any mom who loses a first baby, I was troubled with the worry that I wouldn’t be able to have another baby, so that when I did become pregnant again, I embraced the “we have to be very careful and be supervised very closely with this one” approach.  I worked up until term, 36 hr shifts, 100 hr work-weeks, having to turn sideways at the operating table at the end, and then it was decided that I should be induced at 39 weeks due to gestational hypertension.  There were no signs of pre-eclampsia and the pressures were not sky-high, but at the time, I fell into the “you’re term, what’s the need to take a chance” mentality and was scheduled for an induction.  I went in at night for prostaglandin gel due to an unripe cervix (should have known better) followed by Pitocin the next morning.  I labored all day, getting the obligatory epidural that a Pitocin induction necessitates, finally getting to complete around 8 pm.  I pushed for 2 1/2 hrs, I used the bar, the sheet, everything the hospital approach has to offer…but the baby was OP and would not rotate with “all” of our maneuvers and so I received a C-section for “arrest of descent.”  Happy as I was with my new son, everyone who has labored and then had surgery, knows the pain that you are in for.  I wasn’t disappointed in the C-section because at that time, I was still fully entrenched in the “at least I have a healthy baby” mindset.

Despite that experience, I always wanted to have a vaginal birth and since most university hospitals were still doing them regularly (’03), I chose a new doctor whose obstetrical/surgical skills I trusted who would support by desire for VBAC.  My pressures started acting up again so I was slated for induction, although this time my cervix was riper and I went right in for Pitocin.  They did one of the most inhumane things which was to artifically rupture my membranes on Pitocin in the active phase of labor.  Needless to say, an epidural was imperative but I almost couldn’t sit for it due to the pain.  This time I pushed for 3 hours, hard pushing, hands and knees at one point (I must have learned something from the midwives), and ended up with a vacuum extraction and a fractured coccyx, from a 7#14oz baby.  He had jaundice and a cephalohematoma but hey, I got my VBAC.  He today is honored to say, “I broke mom’s butt when I was born.”

Baby number 3 was an easier pregnancy although this time I added on gestational diabetes so that plus the usual spike in blood pressures brought us back to induction.  Although he was my smallest baby, 7#, he still was delivered by vacuum although my butt remained intact.  With baby number 4, I figured another VBAC was practically guaranteed so I didn’t resist the induction assuming the last birth meant smoother sailing now.  This time they decided to start the Pitocin the night before, but instead of staying at a low dose overnight, the nurse kept coming in and increasing the dosage.  I knew I wasn’t progressing because I was not in active labor, so I questioned her about the dose, reminding her that I did have a scarred uterus.  She responded that everything looked fine but she would stop until morning.  Morning arrived with the usual course of epidural, AROM and increasing Pitocin.  When it came time to push, within 20 minutes, I knew something was wrong.  Despite the epidural, I could tell he wasn’t coming down with my pushing and by the frazzled looks of everyone in the room, I knew the heart tones were dropping.  I looked at my husband and told him we needed to stop.  By the time they got down to the uterus in the OR, it became clear that if we wouldn’t have stopped, I would have had a uterine rupture.  As it was, I had what is called a uterine window, they were able to see the baby’s hair through a very thin lower uterine segment.

Finally, I made the connection between the induction and the narrow avoidance of catastrophe.   So with baby number five, I knew I did not want another induction.  Interestingly, this pregnancy was also my healthiest.  I had made a concentrated effort before becoming pregnant to address my diet and treat my vitamin deficiencies, so I had no blood sugar or blood pressure problems, kept my weight gain to 15 pounds and did not have any obstetric problems other than being an advanced maternal age grandmultipara with a history of 2 c-sections!  Knowing that I had never gone into spontaneous labor, I felt the safest route was to do a scheduled repeat C-section at 40 weeks.  I did put it into God’s hands and had been in prayer that I was open to the baby coming forth in whatever way he was supposed to…and so I went into spontaneous labor at 2 am, the morning of surgery, got to the hospital at 4:30 and was 9 cm dilated.  The staff asked me what I wanted to do and I said, “I’m going to have him!”  They also offered me an epidural (too late for that) and IV pain meds (I certainly didn’t want a narced up baby), so unmedicated it was, and he was born at 5:13 AM, a beautiful, alert 7#11oz baby boy who latched right on and has been peaceful ever since.  Not having to recover from an extensive surgery was a gift for which I continue to be amazed and grateful.

Reflecting back over my journey, I see how much the field of obstetrics has managed to contribute and sometimes outright cause complications, all the while assuming they are just keeping everyone safer.  And I see how much fear has overtaken the natural birthing process.  I’ve said before that shows like Deliver Me, A Baby Story, and Birth Day should be renamed “Fear Factor” because they play on a woman’s often natural concerns about the birth by portraying the whole process as highly dramatic, with a woman strapped down and hooked up, by a doctor gowned and gloved like an alien visitor and often highlighting very anxious family members.  Sure a woman has fear, fear that something is going to happen to her or the baby, fear of pain, fear of failure, that she just won’t be able to “do it.”  Add in snarky, cynical nurses and doctors who ridicule anyone who seems to want to be in charge of her birth (after all we’re the experts)…limited labor support or assistance in the form of doulas or labor coaches except in certain areas…restricted mobility, food and drink…and almost endless interventions and you have potential for trouble.  We have cultivated an environment that this is normal, and somehow now some women even find value in being “risky.”  My mentor, Dr. Lauren Plante, a maternal-fetal medicine specialist who had two midwife-attended home births, wrote about this in an essay entitled “Mommy, what did you do in the industrial revolution?”  Meditations on the rising cesarean rate:  “Although the inherent literal meaning of the high-risk pregnancy is one that entails a higher risk of a poor outcome (for mother or baby), the sub-text seems to be that high-risk equals high-value…is it the Disneyfication of a primal human endeavor, longing for the synthetic and dramatized in preference to the authentic?”  In other words, do we have more regard for the Main-Liner’s IVF-achieved pregnancy who has an elective c-section over the addicted mother’s unmedicated spontaneous birth?

All of the repeat C-sections and almost extinction of VBAC, have not really prevented poor outcomes as revealed by the NIH VBAC conference.  Women who have a trial of labor after a previous cesarean have a lower risk of maternal mortality compared to those who have a repeat cesarean.  Although there is a higher risk of uterine rupture with trial of labor, spontaneous labor versus induction has the lowest risk.  And there have been no reports of maternal mortality due to uterine rupture (we were constantly told…mother and baby could die with VBAC).  Repeat C-sections are also associated with an increased risk of abnormal placental position and growth in subsequent pregnancies, which also increases risk of cesarean hysterectomy.  Although there is an increased risk of perinatal mortality with trial of labor, the risk is small and not that different from a laboring woman with her first pregnancy.  Issues related to medical liability are a big concern for many practitioners, a fact that could be alleviated or helped by tort reform and hospitals assuming some malpractice costs up front.  In our local hospital, although the hospital allows VBACs, there is at least one doctor who simply doesn’t want to take any risk and personally won’t do VBACs.  This approach is unfortunate since the overall finding of the NIH conference is that trial of labor is a safe option for many women and that women should be fully informed so that they may make the best decision for them.  ACOG certainly needs to revise its mandate that anesthesia and c-section should be available immediately so that more rural hospitals can still offer VBAC to their patients without feeling they are not within standard of care.  Can you imagine if I had been in a VBAC-banned hospital and been forced to have surgery at 9 cm dilated?  Can you imagine how that would have increased my potential for morbidity and even mortality?  Should everyone have a VBAC?  No, but every woman should still have the opportunity to discuss her personal issues and whether it could be an option for her, and she should be not be forced to have surgery against her will due to a medically-unsubstantiated VBAC ban.  We should continue to make efforts to reduce medically unnecessary inductions for mom and baby’s well-being, we should attempt to humanize cesareans for moms who need to have them, we should properly evaluate and assess each VBAC individually to decrease risk, and we should place natural labor and birth back into the realm of the norm, with the interventions and surgeries reserved for the truly high-risk.

I haven’t posted a blog in a bit, waiting for inspiration to strike…rather than following the “how to be a successful blogger” advice, which is to produce a little bit, very frequently.  I have to say, I would rather wait between posts and give you something that I think could really be useful than some of the hastily thrown together blogs I have seen around.

Anyway, since it’s January, I thought it would be a good time to address that ever-present January topic:  dieting.  I have decided to relegate all dieting to the ash-heap since even the very word makes me cringe.  You could say I have been around the dieting block many times in my life, and I finally feel that things may broken through on this particular obstacle in my life, so naturally I want to share it with you. 

As some of you know, I was raised on the hippie organic gardening homestead with no TV and definitely no TV dinners, sodas or junk food (except for rare birthday or vacation binges).  Probably this is when the sense of deprivation set in, because not only did I want to live in the suburbs, but of course, I would have readily traded in my whole wheat bread for the white bread bologna sandwiches in the Donny & Marie lunchboxes of my friends at school.  Sigh, the grass is always greener.  I was a normal size all the way through school, although like many women growing up in America, I thought I was fat.  Add in my odd name, odd parents, smart but not beautiful self-perception, and I had a minimal dating experience and a classically cultivated case of low self-esteem. 

In college, of course, your new-found freedom often results in choices that can be destructive whether it be through excessive alcohol consumption, poor food choices or crappy relationships, all of which I can say I whole-heartedly embraced.  It’s nice to be able to reinvent yourself, “where nobody knows your name;” it’s actually a good thing to make good grades, and you are exposed to a broad variety of people compared to the rather homogenous small town from which I came.  The freshman fifteen shortly followed although at that point, it was still shed easily enough.  Unfortunately it was the beginning of the yo-yo cycle, gain and lose a million times until your poor body finally gives up and starts really putting the breaks on easy weight loss.

In the late 90s, I discovered the low carb approach and successfully lost weight on the Atkins diet.  It made sense that sugar, bread and potatoes were the enemy and at that time, artificial sweeteners were the panacea of low-carbers and thus started a wicked diet soft drink addiction.  After all, you were skipping the sugar and calories, all must be well with the world.  During this time, I also had a love-hate relationship with exercise.  Whoever decided to replace natural activity exercise with gym memberships, aerobics classes and endless running, I think still needs to be taken out back and well, whatever.

About that time Ob/Gyn residency struck.  You have to understand that most ob/gyn residents are overachiever adrenaline junkies with bad attitudes from chronic sleep deprivation.  The problem is we are led to believe this is normal in order to be successful in a truly toxic profession.  Everything is “emergency, danger, stat section, hemorrhage” coupled with 100 hour work weeks (this was before they dropped it to a mere 80 hrs).  When you have had 2 hrs of sleep and you’re drinking your 5th Diet Coke and grabbing “crap of the day” from the cafeteria, is it any wonder that I totally derailed my physical health, burned my adrenals like there was no tomorrow, and gained more weight than ever in my life?  Now that I understand the complexity of issues I was torturing my body with, it all makes sense.  At the time, I just felt like a drained, fat failure.  However, I did manage to meet my husband and conceive a baby and breastfeed him through all this mess, but that, of course, was yet another drain on my poor hormonal system.

Having seen the toll it was taking on our family, as my husband was, wait for it, an INTENSIVE CARE fellow, we made the decision that I would stay home for the year he was finishing up before we were to move to start our “real jobs.”  I felt it was only fair to our oldest son since I had had him smack in the middle of that tortuous situation.  There was some amount of recovery during this time since I was getting more regular sleep and had at that time been turned on to Diana Schwazbein, MD, who happened to have been Suzanne Somer’s endocrinologist.  Her book, “The Schwarzbein Principle,” made the most sense of any diet book I had read at the time (and believe me, I read them all).  Her focus was that you should a variety of real, whole food in order to heal your body.  And in the midst of all this recovery, I got pregnant again.  Both of those first two pregnancies, I had flunked my first glucose tolerance test but passed the second (blood sugar reading 1 hr after the nasty, sugary glucola has to be less than 140).    I  had absorbed enough low carb knowledge to understand that this was not a good sign.

Once we moved to start our careers, we made the decision that I would not immediately go back to obstetrics since we now had two small children and he had the privilege of being the only pulmonary/critical care doctor in our area (translation: long hours/bad schedule).  We didn’t want to subject our children to both of us being gone all the time, so I set up my outpatient gynecology practice.  Not delivering babies enabled me to have more time to read and study and thus began my journey into bioidentical hormones.  From there I naturally embraced the concepts of healing and nutrition, supplements and balance rather than symptom control and disease management.

Through all this I was still having trouble with my weight and finally got fed up and joined Weight Watchers.  My grandmother had been a life-time member of WW, and me and my mom have always dabbled in it (can you say generational curse).  I was successful and lost about 30 pounds.  It did bother me that in order to achieve the “points” you were allowed, you ended up consuming a lot of Frankenfoods/diet this or diet that and that I was usually hungry, making me once again, obsessed with food.  Wow, with WW, you could work in ice cream cones and all sorts of other crap as long as you stayed in your points.  The other program, core, was supposed to be the healthy one, except that you couldn’t have any fat or protein;  flavorless and you’re still hungry.  So what happened?  Naturally, I got pregnant!  Great, I figured, I just lost the weight, this pregnancy should be a breeze.  Except that I was diagnosed, full on this time, with gestational diabetes!  I was shocked and dismayed, and although I never had to take insulin and actually had my smallest baby (7 pounds even), I could not believe the ominous implications this had for my future glucose tolerance.

During this time, I was really seeking healing from the Lord and I think if it had not been for Him, I would have given up.  After all, here I was dispensing medical advice and couldn’t seem to get any breakthrough with myself.  Fast forward through two hellacious years of stress and yup, another baby, and I was really at my wit’s end.  I just kept praying for a breakthrough, and God told me two things.  The first thing He said was “homeostasis,” which I thought was odd because I hadn’t really thought about this concept since some of my basic science days.  Homeostasis is when the body self-regulates and auto-adjusts itself to maintain the status quo, medically-speaking.  The second thing He said was, “Do what you would do for your patients.”

The first concept I had observed in my practice.  I had some patients who were obese and had medical problems and yet their weight stayed the same, year to year.  I also had observed the patients who were “doing everything right,” dieting and exercising, sometimes every day, and yet their weight stayed the same, much to their frustration.  The second concept I readily embraced.  I had been testing my hormones for awhile but this time I did everything I could get my hands on, and what do you know?  I was deficient in a lot of things, vitamins, minerals as well as still having adrenal issues.  So I started really upping my intake of vitamins/supplements according to the problems I uncovered.  It was at this time, that for the first time ever, I was able to kick my addiction to diet soda.  I wasn’t a purist, I would have one every once in awhile, but it really amazed me that I could truly be satisfied with other things, especially water.  I also noticed that my sugar cravings were really improving.  I had always been a chocoholic (although I did prefer dark chocolate) and so this was surprising.

Also about this time, on one of the low carb blogs I read, I ran across Matt Stone, a nutritional researcher and all-around sarcastic non-conformist.  Except what he was saying made sense to me and harkened me back to the words of Dr. Schwarzbein…heal your body with real food.  One of his comments on the low carb boards piqued my interest because he was making the point that rather than making carbs be the bad guy, why don’t we fix the metabolism so that it works with ANY type of food.  After all the Japanese eat prodigious amounts of carbs and are thin…at least they were until introduced to a Westernized diet.  He also was a proponent of the High Everything Diet (aka HED).  His thesis was in order to heal the metabolism you actually needed to eat a high calorie, high fat diet (natural fats, not the crap fake hydrogenated fats made by man), dumping sugar, but especially fructose, which he and other researchers were beginning to see was actually inducing insulin resistance, Type II diabetes, and obesity.  I also believe this is a key to the “homeostasis” theory:  without real whole food, basic hormonal balance, adrenal health, vitamin/nutrient sufficiency, and thyroid support, the body is literally in stasis and won’t budge until these areas are addressed.  Ignore every person who tells you, “Eat less and exercise more.”

Also about this time, my husband and I started a series on a talk show through our church called the Bible Medicine series.  The idea is that you use Biblically-based concepts for approaching medical conditions and ailments.  When you look at the diet of the Bible, of course, there was nothing else but whole, natural foods.  Then man got involved and started creating foods chemically, start mass-producing food using tons of pesticides, fertilizers and genetically modified plants.  Yes, God created sugar cane but the process of turning it into the refined, addictive white powder was a “man-plan.”  God created corn but it took man to turn it into high fructose corn syrup, which may be one of the single most metabolically destructive products on the market today.  In addition, you cannot ignore spiritual or emotional factors that can lead to overeating or other eating disorders.  I had to pursue my healing for those feelings of rejection and inadequacy that had plagued me for much of my life.  Some people have been physically or sexually abused which is a root cause for their eating issues.  Sometimes comments by friends or families can trigger significant psychological barriers.  Maybe you had a terrible trauma happen in your life and eating problems followed suit.  I know that nutrition can only get you so far.  I don’t believe you can divide the mind, soul, body or spirit and with any medical problem, you must seek healing on all these levels.  Rejection, fear of man, fear of failure, fear of abandonment, trauma, abuse, all can fuel addictive behavior and impede physical health and wellness.  Pursue inner healing so that your physical person can follow suit.

So what did I do?  I pursued my complete healing, and gave my body what it needed to function according to the way it was created.  The “homeostasis” concept was that if you did not give your body what it needed in terms of whole, natural food and treatment of deficiencies or beat it like a dead horse with excessive exercise, it would not work to do what you wanted it to do, it would only do what it could to “maintain” and survive.  The diet part?  I started eating more, more food in its natural, whole form, especially a lot of natural fats like butter and coconut oil.  I dumped sugar, hydrogenated fats, anything artificial that I knew Jesus wasn’t eating…and I embraced that food was my friend, not my enemy.  And once I did that, the pressure was immediately off.  I didn’t think about food all the time, I enjoyed my food when I had it, I was not constantly scrounging around for a snack because I was satisfied with my food.  I have embraced the slow food, local food, support of small farmers movement because I think that is how we are intended to eat.  We had a garden this year, the hen-house is built, we know enough farmers to buy grass-fed beef in bulk.  We are the process of de-sugarizing the house and gently letting the kids know that sweets are to be rare, rather than regular.  And with 8 weeks to go in this pregnancy, I have only gained 9 pounds, rather than my usual 30 (while eating all the time), and my 1 hr post-prandial blood sugar this time was an incredible 87!  I am not some bastion of willpower, but rather I finally started giving my body what it needed the whole time, and the results are truly rewarding.  I know that when the baby comes, I will focus on nourshing myself so my baby has the best breastmilk he can have, and not worry about some crazy crash diet or ridiculous exercise program to lose weight.  So maybe you will join me in dumping dieting, and pursue your complete wholeness and wellness for 2010.

For help in these areas:  I recommend Matt Stone’s website and blog, www.180degreehealth.com, www.180degreehealth.blogspot.com, as well as www.schwarzbeinprinciple.com, www.westonaprice.org, www.jordanrubin.com

For Christian counseling/understanding spiritual roots of disease:  “The Bondage Breaker” by Neil Anderson, “A More Excellent Way” by Henry Wright

Allopathic programs train you to look askance at anything that could be construed as a natural therapy.  “We have a drug for that” is a mantra that is entrenched, at least in clinical rotations, but, by golly, they made the mistake of teaching me biochemistry, pharmacology and physiology first.  Some of that, more than I anticipated, came flooding back at the most appropriate times, such as when the Women’s Health Initiative Study came out.  I was beyond dismayed by this study and vowed not to prescribe synthetic hormones.  Shelving hormone therapy in favor of, I shudder to admit, anti-depressants, supplements, and soy (shudder again), it didn’t take long for this gynecologist to discover, duh, women need hormones.  However, my quest to bring real answers to real clinical problems forced me to return to the basic sciences, in search of a more excellent way.  As with anything worth doing, it brings its share of naysayers, to which I say, bring them on, I love bio-identicals and I’m never going back!

1.  Hormones are all the same. – I love this one!  Especially since we bend over backwards to differentiate between things like Human insulin and Bovine insulin.  No, I’m sorry, synthetic hormones are not the same as bio-identical ones (the same chemical structure as in the human body), although the naysayers want to quibble about the term “bio-identical”.  They want to do that because everyone knows what “synthetic” means and if given a choice, most would choose a therapy that is NOT synthetic.  Now, that doesn’t mean it is not manufactured.  No, you cannot rub a yam on your arm and get hormones.  Hormones must be extracted in a lab, even the bio-identical ones.  But this process does not warrant the conspiracy theory that “bio-identical” is not an accurate term.  The fact is, Big Pharma/ACOG/NAMS are all scared of this term so they figure if they throw up a big hand-waving smoke screen about the name, people will start to doubt its value.  Too late people, the cat is out of the bag!  A hormone fits in a receptor and that receptor responds to a hormone that it recognizes better than one that it doesn’t.  My favorite example:  synthetic progestins (most commonly Provera, medroxy progesterone acetate) while they may stop bleeding, and “stabilize the endometrium,” that’s where any similarity ends.  Progestins make people feel bad, moody, anxious, etc.  Natural progesterone is the “mood-stabilizer” hormone.  Progestins are pregnancy category X (causes birth defects), while natural progesterone is a PRO-GESTATION agent, without which a normal pregnancy cannot progress.  And jumping ahead to Number 2:  BIG LIE that came out of WHI:  these results should be applied to natural hormones, to the extent that the FDA actually put the same risks identified for Prempro (heart attack, blood clot, stroke, breast cancer) on Prometrium, micronized bioidentical progesterone.  INSANE!

2.  All hormones have the same risks:  Uh, yeah, how many times do we have to say this?  Natural progesterone has no pro-clotting properties.  Oral estrogens and some types of synthetic progestins can cause very serious clotting problems.  Oral estrogens (even bioidentical estrogen) have to be metabolized by the liver, which is where clotting and inflammatory factors are made.   Numerous journal articles back this up, but it is physiology not rocket science.  Since transdermal estrogen bypasses the liver, there is no increased clotting risk.  Don’t believe me?  Read the ESTHER trial.  This study (which naturally was not conducted in the US) followed women who had a VTE (venous thromboembolism/blood clot), for the types of subsequent HRT they took.  Those women who took transdermal estrogen (in this study, patches) and/or bio-identical progesterone did not have an increased risk of subsequent VTE. 

3.  Transdermal hormones are not absorbed well.  I don’t really get this one either.  Apparently the people saying this don’t understand physiology very well.  Oral administration of hormones requires that the hormones make it through the GI tract and are metabolized by the liver (first pass effect) which is why the doses have to be so much higher.  Transdermal absorption is much better (think low dose hydrocortisone cream) and bypasses the liver, which is helpful for those with elevated liver enzymes, high risk for clotting because of smoking, obesity or family history, those with GI problems like gastric bypass, malabsorption, chronic bowel problems.  For some reason, most people have no trouble accepting excellent transdermal absorption of estrogen, but they don’t think progesterone creams are absorbed well.  Wrong!  It has been wonderful to see just how low dose we can get hormones and still get a clinical effect, just by utilizing the proper routes of administration.  Doctors have routinely used vaginal progesterone to support early pregnancies because it is quickly absorbed into the uterus.

4.  Bio-identical hormones are very expensive (only Suzanne Somers can afford them).  Many insurances do pay for hormones if you have a compounding pharmacy which files with insurance for compounded preparations.  They’ve been paying for compounded vaginal progesterone suppositories in early pregnancy for a long time (and these are way cheaper compounded than the retail products).  If your insurance does not cover compounds, the average monthly price with the pharmacies I use is around $40-$45, which usually is for multiple hormones.  Not bad for hormone balance!

5.  Patients do not require customized hormone therapy.  The American College of OB/GYN wants to make it very clear to you.  WOMEN DO NOT REQUIRE CUSTOMIZED HORMONE THERAPY.  Do you hear that!?!   Women are all the same, the only distinction you need to make is, do you have a uterus or not?  Beyond that, listen you women, THERE IS NO NEED TO “INDIVIDUALIZE, TAYLOR OR CUSTOMIZE” THERAPY!  See, the modern approach to hormone therapy is based upon guessing, mono-therapy if you’ve had a hysterectomy because “all you need is estrogen,” synthetic progestins if you have a uterus, no options for testosterone, and no attention paid to your diet, your supplements, your metabolic status, your thyroid and adrenal function, etc.  And that’s the way ACOG intends it to stay, no matter how many women Suzanne Somers tries to convince to demand otherwise.

6.  Compounded hormones are not effective.  Yes, which is why women drive sometimes more than 2-3 hours to find someone who will prescribe them.  If they didn’t work, this whole thing would have fizzled on its own by now.  The FDA tried to discredit compounders by stating that certain batches of hormones at some pharmacies were not potent.  My advice is to only use a compounding pharmacy who is a member of the International Academy of Compounding Pharmacists (who oversee and randomly test products for potency) and the Professional Compounding Centers of America (which supply rigorously tested high potency ingredients for compounds).

7.  There is no scientific evidence to support their use.  As one “expert,” stated, bioidenticals are “data-free.”  Which is false.  First of all, there are lots of journal articles about bioidentical estrogen patches/gel/spray and bioidentical micronized progesterone which are available through retail pharmacies; see this wonderful review for literature support of bioidenticals.   As for compounds, the data is limited but promising, see here and here.  Clinically speaking, compounds have completely transformed my practice in terms of the positive impact they have made on my patients’ lives. 

8.  They are not FDA-approved.  We’ve established that even if you don’t want to use compounds, there are still plenty of FDA-approved bio-identical products currently on the market:  Climara estrogen patch, Vivelle Dot estrogen patch (one of my favorites), Evamist estrogen spray, Estrogel, Estrasorb, Prometrium (oral natural progesterone), Crinone (natural vaginal progesterone gel), oral estradiol (I avoid oral estrogen if I can, even bioidentical), Androgel (natural testosterone, for men only).  However, compounds cannot be FDA approved because they are individually prepared for each patient.  But the INGREDIENTS that are used in compounds are FDA approved because they have what is called a USP (United States Pharmacopia) monograph.  That means they are registered as able to be prescribed by doctors and taken by patients.  The whole FDA push to make the weak naturally occuring estrogen estriol a big bad hormone target, was simply to try to strengthen their attack on compounding pharmacies which in turn was only done as an orchestrated attack by then-pharmaceutical giant Wyeth in response to their plummeting Premarin/Prempro sales in the wake of WHI.  And don’t forget how Wyeth paid money to Wulf Utian, the head of the North American Menopause Society, which then put out their recommendations to continue using synthetics for ob/gyns to follow (like lemmings over the cliff).  I’ve got a whole blog brewing on Dr. Utian and how he’s in bed with the pharmaceutical industry.  He’s since dropped his affiliation with Wyeth/Pfizer like a hot potato but it doesn’t take much research into his past to find it.

9.  Saliva testing to determine what a patient needs hormonally is not valid or reliable.  Yes, we know this is the mantra of mainstream Ob/Gyn.  But the real point in all this is how they do not care about the science.   Actually, if you listen closely, you will hear them say things like, “It’s not reliable due to time of cycle, time of day, what you ate, etc., etc.”  All true, hormone levels are influenced by these factors, which is why, in a cycling woman, hormones are tested on Day 20, fasting first thing in the morning.  A post-menopausal woman doesn’t have the same fluctuations as a pre-menopausal woman, so she can test anytime, as long as it is morning and fasting.  Serum hormone testing measures bound (to protein carriers and thus inactive) and unbound hormones (free or active).  Bound hormones cannot pass through cell membranes into saliva like small free hormones can, thus saliva is reflective of the free or active level of hormones in the body.  When a woman is using transdermal hormones, the hormones quickly exit the bloodstream and are deposited into target tissues.  Thus they are not accurately measurable in serum, but are detectable in saliva.  Saliva can be more problematic in a woman with irregular cycles.  However, we are testing women using a standardized process, the ranges of normal are based on averages of women with no hormonal symptoms and regular cycles, and it is a tool that is used in conjunction with clinical assessment.  Saliva testing is not perfect, but when it is used as an adjunctive tool, it is certainly superior to guessing.  And in the post-menopausal woman, it is very reliable.  It is interesting that Dr. David Zava, the founder of ZRT labs, tried to present his data to Dr. Leon Speroff, well-known leader in the OB/GYN world, author of the hormone bible “Clinical Gynecologic Endocrinology and Infertility,” and out-spoken defender of synthetic hormones (as well as recepient of Big Pharma dollars).  Dr. Speroff, who up to then had been quite friendly, simply did not want to hear any of the scientific evidence.  Why?  Well, because, it would change everything.  See, it’s easier for these guys to say, “Oh, that doesn’t work,” rather than to actually find out if it does.  They have no incentive and they have a lot of power so if they say it doesn’t work, then all the other people under them (the lemmings), will just parrot what they said.  You know, if Drs. Speroff and Utian said it, it must be true.  Except maybe people should question their patently obvious financial conflicts of interest.

10.  Bioidenticals are really just on the fringe of medicine and can be ignored.  We have Oprah, Dr. Phil, and Suzanne Somers to thank for blowing this myth to bits.  As much as Big Pharma/FDA/NAMS/ACOG wish the “bioidentical” problem would just die off and go away, they KNOW it is not.  Demand is higher than ever (it’s not just my phone is ringing off the hook for women seeking this therapy).  Add in organizations like Women in Balance, BodyLogicMD and excellent well-trained docs like Erika Schwartz, Christine Northrup, David Brownstein, Kent Holtorf, Kenna Stephenson, Rebecca Glaser, and many more who have been helping women hormonally, and you begin to see that bioidenticals have become an established presence in medicine, and much to many women’s relief, is not going away any time soon.

I thought I would interject a post on the subject of the prenatal vitamin, spurred by a Twitter feed from a Canadian birthing magazine, called, natch, “Birthing.”  Since I have been browsing through the different birthing groups on Twitter, I’ve noticed this magazine seems to be very open to birthing options, avoiding unnecessary cesearean sections, promoting breastfeeding, etc., all topics in which I am interested.  So this is by no means a bash on their magazine.  But they wrote a short article about the prenatal vitamin (PNV), promoting the top three as they see it:  folic acid, calcium, and iron.   While clearly not meant to a scholarly article,  I think it represents mainstream information about the PNV which is, in my opinion, woefully inadequate.

Certainly, most people are aware of the need to take vitamins during pregnancy, and many of them who do not care to remember to take supplements when not pregnant, suddenly realize they are in the process of growing another human being and get on the PNV train.  Great!  Some vitamins are probably better than no vitamins, so it’s a good start (although Dr. Wiseman points out your average cheap vitamins often contain petroleum by-products, ground rocks and fillers).  However, there is growing concern that there are multiple areas of vitamin/mineral deficiencies that are affecting the non-pregnant female, which then becomes a bigger problem for the developing baby when she becomes pregnant.

Since I routinely test for vitamin and mineral deficiencies in women of childbearing age, I know how widespread such deficiencies really are.  In fact, the reason I do routine testing is because I was missing so much by not doing so.  Ob/Gyns are not really trained to practice preventative medicine, so these were lessons I learned in private practice.  But it wasn’t until I saw a Vitamin D level of 6 in a healthy 25 year old patient, that it began to hit home that I needed to be testing everybody (most experts recommend a Vitamin D level above 30, although optimal is more like 50, significantly deficient is less than 20).  Before I jump into Vitamin D again (admittedly one of my favorite subjects), I’ll start with the other elements mentioned in the article.

FOLIC ACID:  Most people have an awareness of the importance of this vitamin in pregnancy, even if they may not understand why.  Folic acid, also know as folate, is important for any developing cells so the rapid growth of a baby is dependent upon adequate levels of folate.  However, the biggest concern is in the prevention of neural tube defects like spina bifida and anencephaly.  What most people don’t know is, there is a very small window of time when folate supplementation can make a difference with these significant birth defects.  The neural tube (an embryonic structure that grows into the brain and spinal cord) is generally closed by the 52nd day of pregnancy…many women don’t even find out they are pregnant until they are past this point.  Intake of folic acid is actually more important in the pre-conception period, so that when the neural tube starts develping shortly after implantation of the embryo in the uterus, there are already high levels of folate, rather than deficiency, going in.   While different food products like flour have been fortified with folic acid, there is still far too many women who are deficient when they become pregnant.  Although the standard recommendation for women of child-bearing age is to have an intake of 400 mcg daily, this goal is clearly not being achieved.  Some experts believe that the problem is that there is not high enough levels of folate fortification to prevent even more NTDs than the drop that has already occurred.  As this article suggests, and as we are now seeing again with the ascendency of Vitamin D as death defying, cancer-fighting essential element and its acompanying naysayers, you will always see those scientists who oppose new recommendations without providing reasonable alternatives.  Though masking B12 deficiency by taking too much folate is what concerns most physicians, I have no problem recommending 1 mg of folate to my non-pregnant patients because I routinely test their Vitamin B12 levels.   And I also have no problem recommending higher than 1 mg intake of folate during pregnancy (previously only recommended to women with a previous NTD), for the same reason.

IRON:  You’re not going to get much argument from me about the importance of iron supplementation in pregnancy.  Many women become anemic in pregnancy as the developing baby will steal this essential nutrient from mom.  Women undergoing cesearean delivery in particular need to be closely monitored for iron-deficiency anemia, although you can easily lose a large amount of blood at a vaginal birth, so this advice is good for any pregnant woman, unless you have hemochromatosis.

CALCIUM:  Certainly the baby is going to take this important nutrient from mom to help with its own bone mineralization, so calcium intake is very important in pregnancy.  And there is some evidence that optimal calcium levels may decrease the risk for pre-eclampsia, although this is not a straight-forward association.   Most experts agree that pregnant woman need 1500 mg calcium, yet most prenatal vitamins contain only 200 to 300 mg, as cited in the Birthing article.  So unless a pregnant woman is getting a tremendous amount of calcium in her diet (or popping Tums for heartburn), she should take an additional calcium supplement.   However, without adequate Vitamin D, absorption of calcium is limited.  As I have alluded to, Vitamin D deficiency in child-bearing women is widespread.

VITAMIN D:  Readers of this blog will be familiar with my Vitamin D rants!  But it is frustrating to continue to see the evidence of how important this vitamin is, how easy it is to test for and supplement, and how it is still not getting the attention that it deserves.  The Birthing article put forth the obligatory recommendation of 400 IU of Vitamin D in the prenatal vitamin, which is just not enough, period.  I receive initial resistance in some of my patients for Vitamin D testing because they feel very secure in the 400 IU that their Caltrate contains.  When I educate them about how many people I see who are taking exactly what they are taking and are extremely Vitamin D deficient, most of them are surprised, and some of them are mad!  After all, they are doing everything they are supposed to be doing.  I sympathize.  It is hard to keep up with medical advances, and hard not to come across a food that is contaminated with Salmonella, pesticides or mercury, or feel the need to come in with a suitcase of supplements.  Here is a great summary article about the inadequacy of Vitamin D in prenatal vitamins and the multiple medical outcomes that are impacted by low Vitamin D in the woman, then pregnant woman, then baby.  Bottom line is, don’t take a chance, test every pregnant woman for Vitamin D.  There is no documented evidence that raising a woman’s Vitamin D level to a normal level during pregnancy has anything but advantages for the growing baby, but I would certainly only recommend natural Vitamin D3 rather than synthetic D2 be the preferred supplement.

VITAMIN B12:  Cell formation, DNA synthesis, and neurological development and function are all dependent upon Vitamin B12.  I hate to sound like a broken record, but just ask my office staff, we give B12 injections all day long and not just because everyone’s fatigued.  We test everyone and many are deficient.  The miniscule amount in prenatal vitamins may, and I emphasize MAY, be able to maintain someone with a good B12 level (greater than 400 pg/mL, but I would consider sufficiency greater than 600), but I would still think the easiest way to know, is not to guess!  Test!  This vitamin is too important for you and your baby’s neurological system to ignore.  Since meat and dairy products are the most common dietary sources for this vitamin, vegetarian and vegan moms must have their B12 levels monitored.

IODINE:  This particular article did not cite iodine at all in their prenatal recommendations which is a travesty.  The RDA for iodine for non-pregnant women in 150 micrograms a day, for a pregnant woman 220 micrograms a day, and 290 micrograms a day for a breastfeeding woman.  So why are there still prenatal vitamins manufactured without any iodine or inadequate levels?   Dr. Brownstein wants to know why too.  Iodine deficiency can cause hypothyroidism, miscarriage, stillbirth, preterm delivery, congenital abnormalties in the baby.  It can affect brain development, IQ, and behavior.  According to the International Council on for the Control of Iodine Deficiency Disorders (ICCIDD), iodine deficiency is the single most common preventable cause of mental retardation and brain damage in the world.  The only way to know for sure about iodine levels is to have the urinary iodine excretion test done, please read my iodine post for more on this.

OMEGA 3s:  Although there is no mention of Omega 3s in the Birthing article, we’ve seen the arrival of newer prenatal vitamins on the market that have added in essential fatty acids, typically DHA, as a result of research showing that omega 3 intake in pregnant moms can improve infant development and augments IQ.  It stands to reason that all the benefits to mom in terms of reducing inflammation in the body, improving lipid profiles, and augmenting the immune system, will translate into higher levels in Omega 3s in baby, which has been documented in the literature.  The main concern, of course, is purity of the omega 3 source, since we don’t want to trade one problem for another, namely mercury toxicity.  So the pregnant woman in particular must be sure that she is taking a highly purified toxin-free form of fish oil or choose vegetarian source, flaxseed, although you also have to be careful with this one because it goes rancid as soon as it is exposed to light.  Bottom line:  spend a little more, get small, fresh quantities and use them quickly.  My office staff laughs when I give my “Your $3.95 jumbo jar of fish oil from Wal-Mart is not going to cut it!” speech.  Carlson labs has very purified fish oil, including one especially for pregnancy, called Mother’s DHA.

Overall, relying  on just one prenatal vitamin to supply all your needs in pregnancy is not adequate, especially if you are starting out deficient or don’t have a good diet.  I am currently pregnant and even though I take a whole-food based prenatal vitamin from Innate Response, I take additional folate, Vitamin D, iodine, Vitamin B12 and chelated iron.  I have my blood work monitored to know what my levels are, especially vitamin D, since these have been low in the past.  In addition, I try to eat as much organic whole food as possible.  Then once the baby’s born and I’m breastfeeding, it’s even more important that I keep my vitamins on board to give my baby a great start!

I attended the 35th Annual Symbosium on Obstetrics & Gynecology on October 29-30th at Washington University in St. Louis, MO.  Learning new things is always exciting and it’s good to go to these programs to try to keep some pace with the rapid advancements in medicine.  Wash U is considering a bastion of higher education and high quality medical treatment.  Having been trained at a university hospital, I appreciate the level of consideration that goes into medical decision making, i.e. evidence-based medicine, that you sometimes don’t get in a rural community-hospital setting.  That being said, since my pursuit of a more wholistic approach has been so rewarding, I can see how sometimes the most medically respected minds can be in an ivory tower of isolation, that is sometimes altogether different than everyday practice.  So here’s my take on the topics discussed at the symposium.  Warning:  this is a lengthy post, so unless you are an ob/gyn geek like me, you might want to skim through to find a topic you like!

CONTROVERSIES IN SCREENING & TREATING FOR THROMBOPHILIAS IN PREGNANCY   David Stamilio, MD, Maternal Fetal Medicine Specialist at Wash U, STL

This is a very important topic as I see a surprising number of women who have had a venous thromboembolism (VTE), or blood clot, at some point in their lives.  It can be quite confusing in terms of whether this was a non-medically induced clot (such as after a car accident), or whether it represents an underlying clotting disorder, and future therapy.  Also there are those who have suffered from adverse pregnancy outcomes like pre-eclampsia, a growth-restricted baby, abruption of the placenta, or multiple miscarriages.  The questions include:  who should be worked up, what should the work-up entail, who should be treated with anti-coagulation during pregnancy?  Some highlights:

Should you test for clotting disorders in a woman who has had a blood clot while on oral contraceptive pills (birth control pills, OCPs) and should you anti-coagulate them during pregnancy (a state when your baseline risk for clotting is higher).  Dr. Stamilio says NO you should not test because YES you are going to treat (put them on blood thinners during pregnancy and during the post-partum period).  His point is that the testing is not going to change the management.  My opinion:  I would still test them, mostly because I feel it has implications beyond whether to anti-coagulate during pregnancy.  This patient will want to know if you should use OCPS ever again, she will want to know about her risks for hormone therapy during menopause, and if she has daughters, what their risk might be.

What if you had a blood clot after a car accident, with no history of a prior clot or family history?  No, don’t test, yes, treat them during pregnancy.  One study showed that even patients with a temporary risk factor (like an accident) have a higher risk of a repeat clot.   My opinion:  I would probably not work up this person if they did not have any other risk factors (like they were on OCPs at the time of the accident).

What if you have a pregnant patient with no prior abnormal OB history who has a positive family history of blood clots?  Yes, you would test, specifically for Protein C, Protein S, Factor V Leiden, Anti-thrombin III because these are most likely to cause significant clinical problems.  You would treat them only if they test positive for a clotting disorder.  My opinion:  Agree.

What if you have a newly pregnant patient who had an incidental finding on lab work of a clotting disorder?  NO DATA, but the recommendation is if you are a homozygote (2 copies of a mutation) or a compound heterozygote (one copy for two different clotting disorders):  Yes, treat them.  If they test positive for ONE copy of ONE clotting disorder, the recommendation is NO treatment.  My opinion:  I am not sure if I would be comfortable NOT treating them during pregnancy, after all, there is NO DATA stating one way or another.  I also would recommend that this patient NOT TAKE oral estrogen of any kind.

What if you have a patient with a prior 2nd trimester (after 12 weeks) miscarriage and no family history?  Not much data support for one first trimester loss, but there is data to support testing for those with a 2nd trimester loss or multiple first trimester losses.  His recommendation is NOT to test for familial clotting disorders but to test for acquired clotting disorders like anti-phospholipid syndrome and treat if that is present.  My opinion:  I don’t see how you justify testing for some clotting disorders and not all.  I would test for all.

What if you are pregnant and have a past history of severe preeclampsia and/or abruption pre-term (before 37 weeks)?  The literature doesn’t support testing or treating these patients.  My opinion:  I know a lot of people who would put this patient on aspirin therapy, even without literature support.  Any takers on this one?

Overall:  Excellent lecture, however I found out that these guys don’t test for MethylTetraHydroFolateReductase mutations (MTHFR).  He states many people are positive for these mutations and there is no association with VTE or early miscarriage.  This information is very interesting because in my clinical practice I have seen this mutation be the only abnormality in someone with a prior blood clot.  Other literature also says this mutation doesn’t mean anything unless the patient also has high homocysteine levels.   I don’t know if I am quite ready to quit testing for this, mostly because my response to the finding is to put people on B6/B12/folate, which doesn’t really put them at risk for anything, and may benefit.

PREGNANCY AND LONG TERM HEALTH RISK  by Haywood Brown, MD, Professor of OB/GYN at Duke University.

This was the standout lecture of the symposium!  I found myself looking back at this guy’s credentials and saying I can’t believe he is advocating for breastfeeding like this!  Not to be cynical or anything, I have come across those in the medical establishment who get it, but he was such a breath of fresh air, because you could tell he is one of those minds that wants to know WHY and how to fix problems by avoiding them in the first place!  Plus he was a great public speaker, jokes, engaging the audience, etc.  Just great!

Dr. Haywood began by talking about the greatly escalating rates of cardiovascular disease, obesity and diabetes general, but specifically in the child-bearing population.  His point is that obesity begins in the womb through poor maternal nutrition which results in small birth weight, but initial poor growth is followed by rapid catch-up growth resulting in increased body fat and increased plasma leptin.  (Who hasn’t seen a preemie who is now really big, even obese?)  The Barker hypothesis is “Adverse influences early in development, and particularly during intrauterine life, can result in permanent changes in physiology and metabolism, which results in increased disease risk in adulthood.  Reduced fetal growth is strongly associated with a number of chronic conditions later in life:  coronary heart disease, stroke, diabetes & hypertension.”

He also discussed the “Undernourished Fetus:  Thrifty Phenotype”:  The fetal response to limited nutrients directs calories away from the body to the head, heart and adrenals which results in tissues becoming insulin resistant.  Thus low birth weight babies who have accelerated catch up growth are at increased risk for obesity, insulin resistance and cardiovascular disease.  Conversely, high birth weight babies are also at increased risk for obesity, diabetes and premenopausal breast cancer.  This gives rise to the definition of gestational programming which means that the negative consequences of fetal adaptation (higher risk for developing certain chronic diseases) may remain dormant for decades, until triggered by other negative factors later in life (smoking, obesity, lifestyle).

So what is the answer to all this disturbing information??  BREASTFEEDING!!!  Ob/Gyns are on the frontlines for encouraging, educating and supporting breastfeeding which can substantially affect the long-term health for SGA & LGA babies!  The Nurses Study showed that those women who have been breastfed had a reduced risk of cardiovascular disease.   Breastfed babies also have lower blood pressure and obesity down the road.  Preemies who receive mother’s own milk (as opposed to donor milk or preemie formula) have less necrotizing enterocolitis, sepsis and shorter hospital stays.

Having an adverse pregnancy outcome like pre-eclampsia, eclampsia, low birth weight baby, or preterm birth can increase your risk of cardiovascular disease later in life.  If you’ve had all three conditions (pre-eclampsia, prematurity and low birth weight), your risk of ischemic heart disease later in life is greatly increased.  Women who’ve had a pregnancy complication like previously mentioned have an increased risk of an early cerebrovascular event.

The sum of the lecture was to have a focus on this concept of Interconceptional Care:  Intrauterine nutrition, postnatal feeding, and environmental changes are the keys to breaking the cycle of generational adverse health from chronic disease and narrowing the gap in ethnic disparity of disease.  i.e.  eat well during pregnancy, breastfeed  your baby as long as possible, and make healthy lifestyle choices like not smoking, eating well, exercising (and my addition, take your supplements like fish oil, antioxidants, Vit D, CoQ10).   A++++ Dr. Haywood!

INTRAPARTUM CONTROVERSIES AND UPDATES – 2009  by George Macones, MD, Professor of OB/GYN, Wash U

The main focus of this lecture was about the new Electronic Fetal Monitoring classification system and VBAC issues.

Contractions:  Normal is considered less than or equal to 5 contractions in 10 minutes.  Tachysystole is defined as greater than 5 contractions in 10 minutes (terms of hyperstimulation and hypercontractility are to be abandoned).

Decelerations features NOT defined:  slow return to baseline, biphasic decels, reflex tachycardia following variables, shoulders or overshoots, FHR fluctuations in the trough of decels, mild/mod/severe decels.

Category I tracings (Normal);  must include all of the following:  Baseline rate 110-160 bpm, moderate baseline variability, no late or variable decels, earlys may be present or absent, accelerations may be present or absent.  Reponse?  follow in routine manner.

Category II tracings (Indeterminate):  All tracings that are not categorized as I or III (helpful, huh?)  Response?  continued reevaluation, additional tests (like scalp stim, vibroacoustic stim, transabdominal halogen light), non surgical intervention (stop Pit, check for cord prolapse, maternal oxygen, position change, correct blood pressure problems, amnioinfusion for persistant deep variables).

Category III tracings (Abnormal):  Can include either:  Absent FHR variability and any of the following recurrent late decels, recurrent variable decels, or bradycardia.  OR a sinusoidal pattern for greater than or equal to 20 minutes.  Response? predictive of abnormal acid/base balance, prompt evaluation required, resolve the pattern (supportive measures, delivery).

VBAC:  Lowest risk of uterine rupture is in those who go into spontaneous labor or those induced without Pitocin or Prostaglandin.  More success if cervix ripe (avoid difficult inductions).  Avoid high dose Pitocin (as someone who had a uterine window, eminent rupture, on high dose Pit, I agree).  Do not use Cytotec, period.  My opinion:  Pick your patients well, avoid induction, if things aren’t going well STOP, but don’t be afraid of VBAC (sorry not for homebirthers or birth center births).  I am grateful for both of my VBACs, but would never consider it safe for outside of the hospital.

SHOULDER DYSTOCIA:  THE UNPREDICTABLE EMERGENCY  by Haywood Brown, Professor of Ob/Gyn, Duke University

Increase in incidence of shoulder dystocia (after delivery of head, baby is prevented from delivering spontaneously by impaction of  the shoulders in the maternal pelvis) from 0.6 percent of births to 1.4% due to increases in birth weight, increasing prevalance of maternal obesity and diabetes.  However, the incidence may be more like 4%, 50% of shoulder dystocia in infants less than 4000 gm (8.8 pounds), however, 11 times higher if baby is greater than 4000 gm and 22 times higher if greater than 4500 gm (9.9 pounds).

Risk factors:  Macrosomia (diabetes and post-dates), maternal obesity and excessive weight gain, previous baby greater than 4000 gm, diabetes mellitus, prolonged second stage of labor, prolonged deceleration phase (after 8 cm), rapid descent of fetal head, forceps midpelvic delivery.

Main concerns:  Brachial plexus injury, to spinal nerves (incidence 4 to 40% following shoulder dystocia, less than 10% permanent), Fracture of clavicle or humerus.

Take home message:  You can’t predict shoulder dystocia, so be prepared ahead of time with the proper maneuvers.  Have a high degree of suspicision with macrosomia, maternal obesity, gestational diabetes and prolonged gestation.  Estimated fetal weights by ultrasound are problematic because of accuracy issues.  Dr. Haywood, “C-section for assumed macrosomia is inappropriate.”  This was my favorite:  A planned cesarean for greater than 4000 gm baby in a non-diabetic mother would result in a 27% increase in the total cesearean rate and would only reduce shoulder dystocia by 42%.  It would result in an additional 2345 cesareans at a cost of $4.9 million annually to prevent one permanent injury from shoulder dystocia.  Tell it like it is Dr. Haywood!

MANAGEMENT OF PERIPARTUM DEPRESSION  by Keith Garcia, MD, PdD, Assistant Professor of Psychiatry, Wash U

I have one word to describe this lecture:  CRAP!   Sorry, but I just had to get that off my chest.  I’m sure Dr. Garcia is considered to be a fine psychiatrist or he wouldn’t have been selected for this lecture…but this might as well have been one paid advertisement for SSRIs.  I guess it shouldn’t be surprising since he is a psychiatrist and not an obstetrician/gynecologist, but FOR REAL???  He spent the entire lecture talking about how imperative it is that women even with mild depression be medicated throughout the entire pregnancy, post-partum period, regardless if they are breastfeeding.  He discussed using various depression scales to assess women during pregnancy and afterward and I found myself asking what hormonal pregnant woman wouldn’t answer yes to some of these questions (e.g. I have been anxious or worried for no real reason).  He significantly downplayed the fetal risks from SSRI when it is clear there are risks to the baby especially in relation to respiratory problems.   He seems to think there is no appreciable transmission of SSRIs in breast milk, which I really question.  There is definite evidence that one agent, paroxetine or Paxil, when taken in the first trimester is associated with an increased risk of cardiac malformations. 

As always, one of my big areas of concern is the impact of hormone imbalance, specifically progesterone deficiency, with regard to depression in general and specifically post-partum depression (please see my post on this for more).  I think we have an epidemic of women with progesterone deficiency, who if they are even able to get pregnant since many have sub-fertility, have higher rates of preterm labor, bleeding during pregnancy, miscarriage and post-partum depression.  I wouldn’t expect this guy to really be concerned about hormonal issues (beyond the obligatory nod to checking thyroid function) since most Ob/Gyns ignore this important subject as well.  My main concern is his blase attitude toward proliferative drug use, perhaps reflecting his skewed patient population.  Don’t get me wrong, patients with psychotic disorders, suicide attempts, or multiple disorders need to be under the joint care of a psychiatrist and an obstetrician, and in their case, treatment is most likely to outweigh the risks, which have to be acknowledged.  However, in my opinion, this was far too liberal an approach. 

WEIGHING IN ON THE OCTOMOM:  KEY CONCEPTS IN EMBRYO TRANSFER – PRACTICES OF IVF AND SUPPORTING FAMILIES THROUGHOUT THE PROCESS  by Emily Jungheim, MD, Instructor in Ob/Gyn at Wash U & Kelly Ross, MD, Assistant Professor of Pediatrics, Wash U

Octomom has been a hot topic…how far can the human body really stretch??  In our Guiness Book of World Records mentality, it seems as if we will always have those patients and doctors willing to push the envelope farther when it comes to human reproduction.  While it is hard not to be shocked and dismayed at this modern feat of assisted reproductive technology, I find it interesting that the “get your hands of my uterus” crowd didn’t mind voicing their displeasure at Octomom.  It seems that only applies if you are bringing less children into the world rather than more.

Here’s what we know:  Only the 2nd live born set of octopulets in the US.  6 frozen embryos were implanted, two split into twins.  She had 6 other children, all born after IVF.  We have been told that she is also single and receiving public assistance, that she asked for multiple embryos to be implanted and that her REI doctor regularly implanted this many to augment his poor success rates.  Apparently he has been kicked out of ASRM, see below, for routinely transferring more than the recommended amount of embryos for a woman’s age.  The medical board of California hasn’t taken any steps against him, because as I noted above, he doesn’t appear to have broken any laws and was apparently doing what the patient requested.

The American Society of Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART) have both been pushing for physicians to strive toward implanting fewer embryos with more emphasis on single embryo transfer.  So far these have been recommendations and not mandates understanding that this is a process fraught with troublesome issues:  infertile couples wanting to get pregnant but not really understanding the risks of multiples, limited resources and limited cycles that couples are willing to undergo and able to afford, what to do with excess embryos.  Naturally the best time to discuss all this is before undergoing IVF, but this is difficult.  As another speaker said, the couples come in wanting a baby, not to wade through a 27 page consent form.  I disagree with their recommendation that after IVF is the time to discuss what happens if you end up with higher order multiples (more than twins):  issues such as whether you would consider abortion or selective reduction (picking which one of your tiny babies you’re going to “sacrifice” for the benefit of the others).  Surely a discussion of this magnitude should take place before undergoing any procedures:  the list of what-ifs grows longer by the day in the field of reproductive medicine.

If you’re not able to prevent them, then get ready to SUPPORT them, says Dr. Ross, herself a pediatrician and the mother of IVF-produced triplets.  Between 1980 and 1998, the triplet rate increased by 400%, mostly because of IVF.  Most higher order multiples are going to be preterm births and require NICU stays.  “The stresses and experiences of parents of multiples who have undergone multiple fertility treatments diffre from those who have unplanned or spontaneous multiples.”  Think Jon & Kate Plus 8?  You go from the stress of not being able to get pregnant, to the stress of being pregnant with higher order multiples with the physical, mental, and emotional stressors and the 5 times higher risk of complications, to the stress of a most-frequently surgical delivery, to babies in the NICU, financial stress, higher risk of death and cerebral palsy as well as other complications from prematurity…plus a higher rate of post-partum depression.

Another good quote:  “To a woman who has been unable to get pregnant with one baby, discussing her risks of getting pregnant with 3,4, or 5 is like discussing her risks of winning the Powerball.”  It is hard to wrap your mind around it…but the discussion must take place ahead of time.  And this one, “A history of infertility makes these new mothers feel as if they have ‘no right’ to complain about common experiences other new mothers complain about.”

Support for women with a multifetal pregnancy:  Refer to a true specialist in higher order multiples, strongly encourage joining a support group MOST (Mothers of Supertwins), www.MOSTonline.org, Triplet Connection.  What if you lose one of those babies:  CLIMB (Center for Loss in Muliple Births) and SHARE.  Collect memories, www.nowIlaymedowntosleep.com and www.3littleangels.com.

THE INFERTILITY EVALUATION:  EVOLUTION AND REVOLUTION by Marc Fritz, MD, Professor of Reproductive Endocrinology and Infertility, University of North Carolina at Chapel Hill

Ovarian factor:  1.  Day 20 serum progesterone, standard.  This guy thinks you shouldn’t put much credence in it because of problems with fluctuation of hormone levels, different cycle lengths etc.  To which I say, test in saliva!  You still have to take into consideration the cycle length issue, but it is well correlated to endogenous production of progesterone.  This very important issue was drastically underplayed.  2. Urinary LH monitoring, frequently used, not always reliable, expensive.  Optimal time for testing:  4 to 10 PM, due to pulsatile LH surge.  3.  Serial transvaginal ultrasound – Probably only useful if you are using ovulation induction agents.

Male factor:  Semen analysis:  Morphology is the best current predictor of sperm function and predicts poor or failed fertilization in IVF cycles.  Males should be referred for hormonal testing if they have oligospermia (less than 10 million/mL) or sexual dysfunction (decreased libido or impotence).  Of course, they recommend FSH, total testosterone, free testosterone, LH, prolactin.  I would also recommend estradiol, cortisol, DHEA and TSH along with that.  Males with low sperm count should be referred for urologic testing to rule out obstruction, other problems.  Don’t get Dr. Sherman Silber started on this topic.  He is a world-renowned fertility specialist who thinks people waste a lot of time at the urologist’s office instead of getting plugged in quickly to the right procedure for male subfertility.  Sometimes an abnormal semen analysis also warrants a genetic evaluation for things like Cystic Fibrosis or chromosomal abnormalities.

Cervical factor:  Postcoital test, not used or recommended anymore.  My favorite cervical factor trick:  Guaifenesin,  which thins all secretions, including semen to facilitate sperm mobility.  Especially important for people taking Clomid, which can thicken cervical mucous.

Uterine factor:  Hysterosalpingogram  (HSG) or dye study to evaluate the uterine cavity and the prescence of uterine anomalies or structural problems like fibroids.  Ultrasound is also used to evaluate the uterus.  If an abnormality is indicated, hysteroscopy of the uterus is helpful for diagnosis and treatment of intrauterine abnormalities.  Sonohysterogram is also helpful and may save a surgical procedure.   Throw out the endometrial biopsy, it is no longer recommended.

Tubal factor:  HSG to establish that the tubes are open so the egg and sperm can get to each other.   Chromotubation is where dye to put through the tubes at the time of laparoscopy to estalish tubal patency.  Some people start with a Chlamydia antibody test to determine whether to do an HSG, as this common infectious organism causes tubal scarring.

Peritoneal factor:  Evaluation for endometriosis and adhesions which can cause scarring, blockage or structural abnormalities.  Evaluated by laparoscopy.  Only do if there are symptoms, risk factors, or an abnormal HSG or ultrasound.  Otherwise the yield is low and doesn’t warrant the expense or risk of surgery.

Ovarian Reserve:  Indicated for age 35 or over, 1st degree relative with premature menopause, Previous ovarian insult (surgery, chemo, radiation), smoking, poor response to ovarian stimulation, unexplained infertility, candidate for IVF.  Cycle Day 3 FSH/estradiol:  FSH greater than 10-15 Iu/L, Estradiol greater than 75-80 pg/mL.  If abnormal, prognosis is poor, if normal, corelates with age.  Clomid challenge seems to be falling into disfavor.

Overall, a nice overview.  I differ by performing hormone testing on everyone who has infertility.  With so many endocrine disruptors in our lives, it is rare to see a completely normal hormone profile, especially progesterone, which as I have repeatedly stated is essential for fertility.

RISKS OF ADVANCED REPRODUCTIVE TECHNOLOGIES:  WHAT PHYSICIANS AND PATIENTS NEED TO KNOW by Randall Odem, MD Professor of Ob/Gyn, Reproductive Endocrinology and Infertility, Wash U

The primary problem is being able to address all the different forms of ART and all the individual risks associated with each facet of it.  It can be confusing for doctors, let alone patients.  I’m not going to review all the risks of every part of the ART process but rather will try to highlight those I think are most important to communicate.

Risks of the process:  We touched on this earlier.  The patient needs to be fully informed regarding the specifics of the procedure she is undergoing, the cost of the cycle, and the age-related success rates for the procedure.  She needs to be informed of the chances of multiple gestations, a clear and explicit discussion of how many embryos are to be transferred and why, and what is going to become of any leftover embryos.  A good IVF clinic is going to have a counselor who spends a good amount of time with the patient and her family regarding these issues.   Certainly the process of IVF is mentally challenging, time-consuming, expensive and emotionally draining and the psychosocial aspects of it need to be addressed.

Risks of the pregnancy:  The risk of multiples extends not just to babies but to the mother who must carry the pregnancy and be subjected to likely complications.  This entails more frequent than average doctors visits, more ultrasounds, more possibility of maternal complications, more chance of a surgical delivery.  However, what is more disturbing in my mind, simply because I think it is unrecognized with the focus on multiples, is the higher risk of pregnancy complications in women who conceive ONE baby after IVF.  According to one meta-analysis, those increased risks include gestational diabetes, placenta previa, preeclampsia, stillbirth and neonatal death.  Another study showed a nearly 3 fold increase in the risk of placenta previa and nearly 2.5 fold increase in placental abruption.  Is this from the IVF process itself, or is this simply a reflection of older moms or women with fertility problems being higher risk in general?  We don’t have the answer to that.

Risk to the Offspring:  Certainly, twins and higher run the routinely higher risk of premature births.  However, there are non-prematurity risks with IVF.  In the normal population, the risk of birth defects is 2-3%.  In the IVF population, it is 2.6-3.9%  While this might be felt to be a marginally higher risk, the data does seem to show that babies conceived through ICSI (Intracytoplasmic Sperm Injection, used primarily in male factor infertility) have a higher birth defect rate as well as an increase of sex chromosome abnormalities.  One of the hypotheses is that an inherent paternal problem leading to infertility when overcome by ART procedures is possibly magnifying these genetic abnormalities.

Overall, a sobering topic…or some might say, ”IVF:  Enter At Your Own Risk.”  Here’s my pet peeve:  the REI doctors’ main concern is getting someone pregnant (which they often do for lots of money, since many IVF procedures are not covered by insurance)…then they are transferred to a regular OB or a high risk OB specialist, who then has to assume the care and the liability for these often extremely high risk pregnancies.  And often they only get the same global OB fee.  It’s not about the money, sure, but you create these incredibly high risk patients…and then punt them off and they become someone else’s problem…I just think REI docs need to consider not just the burden to the patient, but to the other doctors.

RECURRENT EARLY PREGNANCY LOSS by Marc Fritz, MD, Professor of REI, University of North Carolina, Chapel Hill

Early pregnancy loss affects 12-15% of clinically recognized pregnancies, 60% of all conceptions (many unrecognized).  60% or more may be related to chromosomal abnormalities, most commonly trisomies.  Miscarriage rate certainly increases with age.

Recurrent early pregnancy loss is defined  as 3 or more losses before 20 weeks, affects less than 1% of couples, and 50-70% ultimately go on to have a live birth.  Indications for work-up include 3 or more losses or 2 losses in women older than 35, history of subfertility, normal chromosomes on miscarriage, or loss after heart tones are detected.

Genetic causes include parental chromosomal abnormalities.  Testing products of conception for chromosomes after miscarriage is problematic/not always accurate.  Can be age-related chromosomal problems in older moms.  Preimplantation testing for chromosomal abnormalities prior to IVF is not currently advocated for screening, only in those with a known chromosomal abnormality are the risks considered acceptable (if the parents would even consider themselves).

Anatomic causes include congenital uterine anomalies, fibroids or adhesions.  Usually diagnosed by HSG, sonohysterogram or MRI.  Miscarriage rate is highest for septate uterus, it is also the most common anomaly.  Repair improves outcomes.  Only large fibroids disrupting the uterine cavity seem to be the biggest risk and warrent removal.  Adhesions can usually be easily removed.

Endocrine causes include undertreated/subclinical hypothyroidism (this is very common), hyperthyroidism (not so common), poorly controlled diabetes.  The most common endocrine abnormality in women:  PCOS (polycystic ovarian syndrome), although it more frequently causes infertility rather than recurrent early pregnancy loss (PCOS is extremely common in my practice).  Luteal phase deficiency due to inadequate progesterone support.  He really underplayed this as a risk and again talked about not testing progesterone because it was not reliable to which I say, BUNK!!  My opinion:  Every women with a history of miscarriage (even if it just one) warrants progesterone support in the first trimester (in my practice, I document their low progesterone level which is easy with saliva testing).  You have nothing to lose and everything to gain!

Immunologic factors include lupus and anti-phospholipid syndrome.  Optimize control of the disease before conception and anti-coagulation (ASA and heparin or LMWH) if you have the antibodies.  Other auto-immune disease may contributre to risk.  Inherited clotting disorders has some association:  Worse ones are Factor V Leiden and prothrombin mutations.  Treat during pregnancy with anti-coagulation.

Infectious factors:  not straightforward but there may be more risk with Mycoplasma infections and chronic or recurrent bacterial vaginosis.  Treat if found but looking for it has low yield. 

Environmental factors include excessive alcohol, smoking, environmental toxins like heavy metals, organic solvents, hyperthermia, radiation, certain medications.  Assess for and address.

Up to 70% of women have no identifiable cause or predisposing risk factor.  Support women, encourage women and keep looking.  Although this expert doubts the true success of progesterone supplementation, again there is no risk in using it and those of us in clinical practice know it works.  The use of prophylactic ASA is also contraversial, no data to support using it, but many people do, usually it is low risk, not always.

CLOMIPHENE (CLOMID):  KEEPING IT SIMPLE – USING IT WISELY by Valerie Ratts, MD, Associate Professor of Ob/Gyn, Wash U

Interesting drug:  has some estrogen-stimulating characteristics, some estrogen-antagonizing characteristics.  Essentially fools the ovary into recruiting eggs.  Not always effective is women who are low in estrogen to start with.  Some start at 50 and go up every month to 250 until ovulation is achieved (seems kind of aggressive to me, but OK).  Some use basal body temperatures, LH predictor kits.  (I use cervical mucous!  Temps are retrospective, predictor kits are expensive and you can miss some good fertile days this way.)  She disputes using progesterone, which just amazes me.  Risk of multiple gestation is 7-10%, usually twins.  Also has side effects on cervical mucous, hot flashes, mood swings, ovarian cysts.  20-30% of people either don’t ovulate or don’t pregnant even if they ovulate with Clomid.  PCOS patients benefit from Metformin and Clomid together (Agree!)  Aromatase Inhibitors do not signficantly improve ovulation rates over Clomid.  Many use Clomid in patients who ovulate, to “optimize eggs” to be combined with intrauterine insemination.  She talks about adding estrogen support after last day of Clomid, but poo-poos progesterone (?!?).  I would never use Clomid without progesterone, it just doesn’t make physiologic sense.

Alright, well, that’s a lot of information to process so I’ll leave you to that for now.  Stay tuned for Part Two which will address issues in gynecology and oncology.  You get to hear my opinion of the highly esteemed (by the establishment, that is) Wulf Utian, Executive Director of the North American Menopause Society (NAMS) regarding hormone therapy.  Readers of this blog will guess which direction that is going!

It’s good to see the light bulbs turn on (oh, sorry, compact fluorescent bulbs…just don’t break them and release toxic mercury everywhere…).  Gee, if I’m going to pay extra for organic free-range chicken and buy those cute little all natural sheets from Target, maybe I should reconsider synthetic hormones in birth control, both going into the body and coming out into the water supply.  Birth control used to be standard fare for the modern feminist.  No babies, follow the career, control those pesky periods, how could you lose, right?  Plus they never gave you any other option when you went the gynecologist, it was just a given, you were on the pill.  Except I personally just never wanted to put continuous chemicals in my body on purpose, at the time blissfully ignorant of all the ones I put in unknowingly.  Of course, I was raised with a different perspective.  My parents were hippies, back-to-the-landers, growing things in the earth;  they were organic before organic was cool (and at the time, I felt they were decidedly uncool).  They were part of the era of natural childbirth, the resurgence of breastfeeding, dads in the delivery room.  If you were really groovy, you delivered your baby at the Farm, a rural Tennessee commune, guided by Ina May Gaskin, guru of Spiritual Midwifery.  My birth wasn’t that earthy;  to hear my mom tell it, the Boston hospital where I was born was really busy and she did most of her unmedicated laboring on a gurney in the hallway.  Not exactly your hippie orgasmic patchouli-saturated water birth.

So I guess my parents were eco-conscious from the get-go.  Besides the organic garden, we lived in a recycled house (they tore an abandoned house down and used the materials to build our house).  There was no television until I was a freshman in high school, which meant when we visited other people, my brother and I were glued to the TV.  As far as I could tell, they never even considered synthetic birth control.  It was not just a money issue because we lived on a shoestring single income budget, the philosophy was to always be  striving for the natural.  Their method of choice was Natural Family Planning taught by a local Catholic woman although they weren’t doing it for religious reasons.  Not the rythym method as everyone supposed, it was a method based on observing your cervical mucous for the hormone-dependent changes that indicate your level of fertility.  Cycles are charted using red and green stamps and it is truly couple-centered fertility;  that is, the method is dependent upon communication between the two people about whether it is to be used to avoid or acheive pregnancy.  See, my dad was the one that felt, in deference to the planet, they should only have two children, to replace themselves.  Naturally he was appalled when I used to walk around trumpeting that I wanted to have 10 kids (I was 50% right).  I knew my mom always wanted to have more children but my dad’s philosophy prevailed, two kids it was.

I grew up knowing about NFP, eventually learning it for myself even when I wasn’t sexually active, and I became adept at charting my own cycles.  It truly is an awesome experience to know the shifts and changes of your own body;  that to me is the essence of empowerment, in sharp contrast to the suppression of your own natural hormone production by the pill.  Other than that, condoms were the choice (other than the total of 3-4 months when I “tried” the pill because at that time I couldn’t “afford” to get pregnant, not a good experiment which I quickly and gladly gave up).  Then I started getting pregnant and breastfeeding (oh yeah, and that diaphragm I never got around to using)….Anyway, I guess the reason that NFP had pretty much been relegated to Catholics (since the church does not condone birth control), was the concept that really, birth control was so liberating for every one else.  You didn’t have to think about it, you could have sex and not have a baby, awesome…right?!?   Unfortunately, it also brought with it mood swings, migraine headaches, blood clots, in some cases, more bleeding problems, not less.  As if that wasn’t bad enough, some crazy person invented Norplant and the Depo-Provera shot, which often made women feel like THEY were crazy, and let’s not forget the astronomical weight gain.  Great trade-off.  IUDs, once they got that pesky pelvic infection/toxic shock problem ironed out were the perfect answer.  Wait, those don’t prevent conception, just implantation of the embryo into the uterus.  No problem, my OB/GYN colleagues said, we get around that problem by saying life doesn’t begin until implantation, see no issue there.  Then they came up with Mirena, saying let’s put some synthetic progestin in it (you know that one that is associated with an increased risk of breast cancer) to reduce the chance of ovulation.  But it doesn’t do a great job of doing that, just read the Mirena package insert.

Well, apparently, NFP is making a resurgence in the eco-movement when some realized maybe they should consider the personal and environmental impact of birth control.  A recent article in Time discussed how NFP is not just for Catholics anymore!  It’s for uber eco-vegetarians who practice yoga!  The article goes out of its way to state that this method is not “100%  accurate,” I suppose in reference to the old joke about NFP users, “also called parents,” hardy-har.  Show me a birth control method which is 100% effective (is what they meant to say).  I am not going to address the rest of the article which was focused on things like vegan condoms, organic lubricant, and eco-friendly sex toys like whips made from recycled tired, ugghh.  Then there’s a spectacularly terrible article in Slate about the greenest birth control, whose author is naturally more concerned about the impact of hormones in the pill on aquatic life than human life.   She praises the IUD and is woefully inaccurate about the effectiveness of NFP, claiming a failure rate of 25% which is straight-up misinformation.  The capper is this truly offensive statement:  “No matter what type you choose, it’s guaranteed to have less of an impact on the environment than the unwitting creation of a fossil-fuel burning, diaper-wearing copy of yourself.”  By all means, don’t have children!!  Are you crazy!?!  Yeah for population control says John Holdren!!

What if you do that truly awful thing and actually get pregnant!  Well, after you sit around feeling guilty for increasing your carbon footprint by reproducing (NOT, please don’t waste your time with such nonsense), you have to figure out how and where you’re going to have this baby.  If you’re like most people in the US, you will have a hospital birth with many expensive interventions and a high chance of having a C-section, average cost $15,000.   Impact on the environment?  Well, who really knows, but a birth center or home birth is definitely a no-brainer here:  minimal cost, minimal waste from IV tubing, epidurals, endless fetal monitoring strips, fetal scalp electrodes, etc, etc.  It seems we are in the midst of a war of two worlds.  Take doctors talking about the usual “pregnant woman as bomb waiting to go off” approach to birth and performing C-sections (at a rate of 31% in the US) many times defensively to avoid being sued for any potential birth complications vs. the natural birthing/midwifery movement.  Add in a dead baby from a home birth and you have the Today show doing a hatchet job on midwifery (and refusing to even mention the home birth of the first GrandDuggar).  Don’t you dare try to come in here with a birth plan, says one OB, “I am the expert, you are the patient, you will follow orders or else.”  One wonders if the same people campaigning for health care reform are supportive of such cost-cutting approachs as out-of-hospital maternity care for low risk patients.  No one is arguing that high risk moms need to be having such a birth.  I’ve had a C-section, two VBACs, and another C-section due to an “almost” uterine rupture.  I have no business delivering anywhere but a hospital.  But in countries like Denmark, as beautifully demonstrated by Ricki Lake’s documentary “The Business of Being Born,” the majority of low risk moms are delivered at home by midwives.  There is no controversy, no clash of the titans (actually more like big guy beating up on little guy), just good maternity care and great outcomes.  Of course, there is major differences between our two countries, but the point is, it is being done successfully other places in the world.  Here’s an insider’s perspective on the C-section problem, P.S. she was my mentor in residency!  Although there is many of the Our Bodies Ourselves viewpoints with which I disagree, I do support and have signed their position statement on Choices in Childbirth.

Anyway, I certainly think it makes sense to do what we can to help the environment, without going off the deep end.  However, my own physical environment is a pretty big priority to me, hence the avoidance of synthetic hormones.  And when it comes to childbirth, it sure makes sense to save money and resources by not turning the natural birthing process into a over-medicalized, wasteful and expensive experience when it can be avoided.

In honor of October being Breast Cancer Awareness Month, I am writing a blog about breast cancer.  In reality, BCAM annoys me.  So do all the pink ribbons, the Susan G. Komen Foundation and all the Facebook invites to join this or that breast cancer group.  Now before people start to get their dander up, let me explain.  One of my big missions is to do whatever I can to prevent breast cancer.  I, like everyone else, have dear friends and patients who have suffered from this horrible affliction.  So the impact of breast cancer, and actively doing something about it, is very near and dear to my heart.  But frankly, I think breast cancer fund-raising is one big racket.  You can hardly open the pages of a magazine without seeing pink bracelets, t-shirts, pins, earrings, for goodness sake, I just saw a pink cutting board and kitchen gadgets.  Why is this?  Because breast cancer has touched almost everybody, either personally or through a close friend or family member.  So you almost feel guilty not buying that yogurt because it has the pink lid.  It almost screams at you…DON’T YOU CARE ABOUT BREAST CANCER????  GIVE YOUR MONEY, PEOPLE, OR MORE WOMEN WILL DIE!!!!   Yeah, well, all these well-funded campaigns have not reduced the rate of breast cancer in this country, instead, it keeps going up, now at a truly dismal, 1 out of 8 women striken. 

So where has all the money gone, besides to these expensive, slick marketing campaigns?  Some people were a little concerned that the Susan G. Komen foundation was giving grants to Planned Parenthood.  Oh, yeah,  SGK said the money was for providing “breast services”….I’m sorry what other organization could get away with saying that…and not abortions.  We know PP isn’t doing mammograms, so that supposedly means breast exams.  And since I doubt people go into PP just wanting a breast exam, that means they are going there to get birth control pills or an abortion.  Well, of course, SGK certainly don’t want people to think that the organization that is supposed to be saving women’s lives is supporting ending them, so this little PR problem was swept under the rug and now you can be sure that any money flow is, um, more discrete. 

But, really, where is all this money going?  My favorite is when they say that the money is going to increase breast cancer ”awareness,” as if there is a soul left in our multimedia world that doesn’t know about breast cancer.  Some of the money is supposed to be going to increase screening rates.   I was a little surprised when my local newspaper carried an October ad for mammograms claiming they prevented breast cancer.  Sorry folks, imaging prevents nothing, merely diagnoses something that is already there.  In the case of mammograms, they don’t “diagnose” cancer until it’s been there for 10-15 years.  Many of us support a different approach to breast screening utilizing breast ultrasound and thermography; read here about a wholistic radiologist who is also a regenerative physician and doesn’t do mammograms.  However, thermography is not widely available and so mammography screening remains the standard of care.  So there is nothing “preventative” about getting a mammogram.  Our throwaway journals bemoan the problem of not getting anywhere with reducing breast cancer rates and tells everyone to take “chemopreventatives,” see my earlier blog about iodine.  That’s drugs folks, with real side effects, so not truly a solution to the problem.   So here I would like to outline my approach to defeating breast cancer, acknowledging that we will likely continue to uncover factors that relate to whether or not one individual gets breast cancer and also that sometimes people do everything right and still get cancer.  I am not focusing on those patients that have a known breast cancer gene like BRCA, but rather average people, those with or without a family history of breast cancer, really anyone concerned about modifying their risk.  I am also not suggesting that people not pursue traditional therapies if they are diagnosed with breast cancer although I think you should do your own research about whatever options are presented to you so that you can try to be as informed as you can be.

Lifestyle factors:

One of my pet peeves is people who live moment to moment and do not think about the impact of daily decisions on long term health.   This is why I have long urged women to quit pouring synthetic hormones in their bodies in the form of birth control pills.  What are we trading for convenience?  As someone who deferred child-bearing to pursue a career, I certainly am not telling women to get pregnant when they are not ready, but I am saying that you should have a mind for the future if child-bearing is your desire.   There is protection in getting pregnant before age 30 although this isn’t always a possibility for career, relationship or fertility reasons.  Consider abstinence until circumstances are right to welcome a pregnancy (responsibility, no?), openness to the idea of the possibility of pregnancy if it occurs, or non-hormonal options for contraception:  condoms, diaphragms, fertility awareness methods or natural family planning (NOT the rhythm method, easy, you learn a lot about your body).  If we change our philosophy to one of welcoming pregnancy when it comes, we can find more than just health benefits.  If you do have an unplanned pregnancy, please don’t get an abortion!  Set aside all religious and moral and philosophical arguments.  Let’s just talk biological.  Whatever you might believe, there is mounting evidence that abortion increases your subsequent risk of breast cancer (and preterm birth in subsequent pregnancies).  There are plenty of people who have tried to discredit the literature about this link, although they usually have a reason for discrediting it…they don’t want to endanger their beloved abortion procedures by medical evidence of harm.  Let’s say you don’t buy the ABC link (Abortion-Breast-Cancer).  The point is that pregnancy is protective against breast cancer and stopping a pregnancy does not confer protection.   The recent rash of young childless celebrities getting breast cancer in their 30s and 40s makes one wonder if abortion did not play a role, either that or continuous hormonal birth control.  But then let’s remember Sheryl everyone-should-only-use-two-squares-of toilet-paper Crow apparently partly blamed hers on plastic water bottles, which may have played a role (keep reading) but I doubt it was the only factor.   Then if you do become pregnant, breastfeed as long as possible.  Breastfeeding is also protective against breast cancer, among the  many other benefits to mother and child.  The hormones in pregnancy and lactation including hCG (human chorionic gonadotropin) and progesterone cause there to be differentiation in the breast that is protective.  The biologic mechanism of the ABC link is that abortion cuts off the differentiation of the breast tissue at a very immature stage that later predisposes the breast to abnormal cellular development.

Avoidance of synthetic hormones

I have already touched on the health dangers of synthetic hormones in other blogs.  The fact that you may not get breast cancer from taking synthetic hormones doesn’t mean they are safe.  First, the pill.  Anyone who doubts that the pill is associated with an increased risk of pre-menopausal breast cancer needs to read this journal article.  The greatest concern is actually for those women who use the pill 4 or more years before a first full-term pregnancy, young women, and those who use OCPs for the long-term.

Synthetic hormones in the form of traditional HRT were exposed as a breast carcinogen  to a worldwide audience with the Women’s Health Initiative, but this was by no means the first time the association was identified in the literature.  As with politics, when something bad happens (like WHI), people like to look back and say “how come we didn’t know this was going to happen?”  Meanwhile, the warning signs were there all the time.  The culprit in WHI was actually not estrogen but synthetic progestin.  So that man-made chemical that was supposed to mimic the breast-cancer fighting qualities of natural progesterone, actually did the complete opposite and caused abnormal breast tissues changes that can lead to cancer.  Low dose estrogen therapy seems to actually be protective against breast cancer but estrogen dominance (high levels of estrogen not balanced by progesterone) is also a factor with breast cancer.

Iodine

The breast stores and uses iodine for the purposes of facilitating lactation.  In the female, iodine sufficiency is essential for optimal functioning of the breast, the ovary, and the thyroid.  There is an association between thyroid disfunction and breast cancer.  Because iodine can actually decrease or alter gene expression in breast cancer cells, it is clear that there is an anti-estrogen effect of iodine in the breast.  What we have also seen is a great increase in the amounts of toxins like bromide (found in bakery products, sodas like Squirt and Mountain Dew) and percholorate (rocket fuel).  These toxins displace iodine from the thyroid leading to iodine deficiency and subsequent thyroid and breast problems.  When patients take iodine, they will then, in reverse, displace these toxins from the thyroid.  Although a good thing, people can have detox reactions because they are so overloaded with the chemicals.  Those people that are more toxin-loaded are more likely to be at risk for cancers.  All of the breast cancer patients I have tested for iodine levels are extremely deficient and many of them have concurrent thyroid problems like goiters, nodules or hypothyroidism.  The website www.breastcancerchoices.org has plenty of information about iodine supplementation in breast cancer, discussion forums and tips for dealing with detox reactions.

Optimizing Vitamin D

There is becoming more and more evidence of the protective effect of Vitamin D on the breast.  It seems a no-brainer to optimize such an essential vitamin that is easily measured and easily supplemented.  Vitamin D deficiency is also related to an increased risk for recurrence in those who have had breast cancer.  It continues to amaze me that those who have not familiarized themselves with the extensive literature on this subject, always express concern for people running out and supplementing with Vitamin D all willy-nilly.  “Too much Vitamin D causes toxicity,” they scream.  Of course people should have their 25-OH-Vitamin D level monitored to avoid overdosing, but as Dr. Joseph Mercola says of the naysayers of the Vitamin D deficiency epidemic, this is like telling a person in the middle of the desert that they might drown.  For more info on Vitamin D, see my blog on the subject.

Dietary factors

Unfortunately, there’s been a lot of focus on the association of fat in the diet with breast cancer, but little emphasis on what types of fats (trans, hydrogenated and rancid vs. healthy fats like olive oil, coconut oil, avocados) and the additional impact of excessive carbohydrates, highly refined and preservative-laden foods.  Also there is quite a bit of evidence that the Brassica family (cauliflower, broccoli, brussel sprouts) have anti-estrogen and cancer-protective effects.  Obviously, avoiding foods like milk and meat with artificial hormones (recombinant bovine growth-hormone) and antibiotics are a good idea.  I’ve been happy to see how much easier (and cheaper) it has been to find organic, hormone-free products than it used to be.  Alcohol has also been linked to breast cancer but this factor is likely due to the effect of liver metabolism of alcohol, which is also where oral estrogens are metabolized.  The benefits of polyphenols in wine mean it is fine in moderation, but excessive consumption of alcohol (especially if you are on birth control pills) is not a good idea for breast protection as well as social reasons (nobody likes a sloppy drunk).  The negative effect of alcohol on the breast may be mitigated by folate.  Flaxseed lignans, released by grinding whole flaxseeds, are great estrogen-binders.

Other nutritional supplements

Indole-3-Carbinole/DIM is a concentrate of the Brassica family that enables you to get the benefit of large amounts of cruciferous vegetables in a capsule, especially good if you are obese and/or estrogen dominant.  CoQ10, long regarded as a cardioprotective supplement, has actually been shown to be good for women with breast cancer.  Iodine, of course, is essential in any breast cancer prevention/treatment program.  Curcumin, the cancer-fighting ingredient in turmeric, is a good choice.  A group from my alma mater, University of Missouri-Columbia, found that curcumin reverses some of the negative effects of synthetic progestins in the breast cancer cells of rats.   Since curcumin also increases glutathione synthesis in your body, it augments your body’s detoxification mechanisms.  Your omega-3 fatty acids in the form of purified/toxin-free fish or flaxseed oil, I think should be a part of everyone’s supplement regimen, but definitely anyone who is trying to treat or prevent cancer.  You should address folate and B12 deficiency, especially since these key vitamin deficiencies are common.  It also makes sense in anyone, but especially those wanting to treat/prevent cancer, to increase their anti-oxidant intake:  Vitamin C, E (mixed natural tocopherols, not the fake stuff), resveratrol, grapeseed, EGCG (epigallocatechin gallate, found highest in green tea).

Body composition

A woman I know who was treated for breast cancer stopped going to her oncologist appointments because every time she went, they would tell her if she didn’t lose weight, her cancer would recur.  Besides being an outrageous and fear-mongering thing to say to a breast cancer survivor, I find it very telling that in the world of breast cancer treatment, the so-called experts have resorted to “blaming the victim” since they can’t give her any better answers about why she got, in her case, pre-menopausal breast cancer.  What I think is way more productive, since there is an association between obesity and breast cancer, is to help the patient understand how obesity can be associated with breast cancer and what she can do about it.  There are two main concerns from a physiological standpoint:  insulin resistance and estrogen excess/dominance.  Basically what happens is that insulin resistance, which is frequently occuring in the face of normal or even low blood sugars, is caused by excessive sugar and refined carbohydrate intake in conjunction with synthetic hormones or hormone imbalance, and genetic predisposition also playing a role.  What happens next is weight gain, predominantly middle abdominal and visceral weight gain.  More adipose tissue results in increased peripheral estrogen conversion which leads to the second problem:  estrogen dominance.  In general, heavier women are estrogen-rich and thinner women are estrogen deficient.  So the solution to this is your healthy, lower-carb diet such as the Mediterranean diet rich in protein, healthy fats, lots of veggies and minimal refined carbohydrates.   Also for additional reading, I suggest checking out Dr. Diana Schwarzbein’s and Drs. Mary and Michael Eades’ books for dietary guidelines.  Also recommended, targeted training with weights/resistance/bands, to increase lean muscle mass and improve fat-burning.  I am not a big cardio fan unless your cortisol levels are normal.  I see so many people with adrenal fatigue from chronic stress, which cardio worsens.

Detoxification

The problem of living in a polluted environment may not seem like such a big factor to some people, especially those who consider themselves healthy:  eating right, not smoking and taking care of themselves…but I’m sorry, nobody gets off easy.  Effects from toxins and pollutants are universal even if people are not acutely ill.  We are as a world experiencing unprecedented rates of cancers, auto-immune disease, infertility, autism, developmental and behavioral disorders.  The fact that almost everything from food to water to hormones to even vitamins is contaminated is the reason why detoxification is pretty much an obligation to achieve true wellness and good health in our modern society.  Xenoestrogens are foreign substances that act in a hormonal fashion but are actually what are called endocrine disruptors, which means they interfere with normal hormone functioning in the human body.  So yes, Sheryl Crow’s water bottles are a factor.  When plastics and phthalates, styrene and benzenes, are an everyday part of our food intake through packaging, these plasticizers are released into the food or drink and disrupt hormone receptors or accumulate to toxic levels in our organs, leading to chronic illness and cancer.  Heating plastics (through microwaving in plastic containers or dishwashing your plastic baby bottles or leaving your water bottles in the car) accelerates this process.  So switch to porcelain or glass containers, take your drinks in reusable stainless steel or glass containers and try to get as much of your food as possible fresh and whole to mimize contact with chemicals.  Due to the high levels of hormones in municipal water supplies from people being on hormones and those hormones not being eliminated during treatment processing, we have the problem of escalating rates of precocious puberty, breast, uterine, and prostate cancer, not to mention ambiguous genitalia in animals and humans.  Your Standard American Diet (SAD), is full of convenience and fast foods that are highly processed, perservative and chemical laden, and full of fake fats, artificial sweeteners, flavor enhancers and the heart-toxic trans-fats that the FDA still lets the food industry get away with.  So everyone needs to detoxify, especially someone who is trying to treat/prevent cancer.   Since this is just an overview, I am not going to get into specific detoxing regimens but some natural detoxing elements besides trying to eliminate the chemical cascade as best you can:  iodine, Vitamin C, glutathione, alpha lipoic acid, your trace minerals like magnesium/zinc/selenium, detoxifying foods like citrus fruits especially lemon, flaxseed, cranberry, and your anti-oxidants mentioned above.   Some people need deeper levels of detoxing with chelation.  Point is, even if you feel healthy, but especially if you don’t, you need to detoxify.  For more information, see Dr. Sherry Rogers’ excellent book Detoxify or Die.

The Mind-Body-Spirit Connection

Dealing with toxic emotions is important in any healing process, not just cancer.  It is hard for the body to heal if the mind is loaded down with fear, anger, bitterness, resentment and unforgiveness.  While it is normal to experience some conflicting emotions when hearing a diagnosis, I strongly encourage you to use those feelings to turn you in a new productive direction:  a desire to fight.  Attitude plays a big role in people’s response even to traditional medical treatments.  So do whatever you can to tap into a support system that will help you fight whether that be your family, a support group, your faith community or just good friends.  Controlling stress is easier said than done but is also essential for healing.  It is necessary to deal with the toxic emotions listed above, through prayer, counseling, and active stress management.  Keeping your mind on positive feelings and thoughts will enable your body to respond in amazing ways.  For those of faith, the power of prayer is one of the main things we rely on, and even the literature has shown it can have real therapeutic effects.  Walking in forgiveness for those who have hurt you, actually frees you from the burden of carrying that hurt around so that it can’t interfere with your healing process.

Options for testing

Complete screening blood work, saliva hormone testing, 24 hour urine-iodine excretion test, glucose tolerance testing with insulin levels, urine testing for good and bad estrogen metabolites (2-OH-estrone/16-OH-estrone ratio), erythrocyte nutrient and toxin testing, heavy metal urine excretion in response to chelator, COMT testing, BRCA testing for those with extensive family history of  cancer.  There are more tests available but this is more of a list for those who do not currently have breast cancer.

Well, I hope this helps someone and I know that when people begin to truly think about disease prevention and what they can do NOW, we will be able to fight the scourge of breast cancer and make a real difference.