My Health - Keep using sunscreen while FDA updates recommendations on safety of sunscreen ingredients

Media coverage of a recent study has left many people concerned about the safety of sunscreen. But while further testing appears to be warranted, we know for certain that sunscreen protects against skin cancer.

Let’s take a closer look at the JAMA study, evolving FDA recommendations on sunscreen ingredients, and how you and your family can safely protect yourself from the sun’s rays.

What did the study look at?

First, some background. The FDA recently announced that it will be updating its recommendations on the safety of sunscreen ingredients later this year. In general terms, they are trying to answer two questions:

• To what extent are the chemicals in sunscreen absorbed into the body?
• What are the health effects of these chemicals being absorbed into the body?

In the JAMA study, FDA researchers asked 24 healthy individuals to apply sunscreen four times a day for four days to large areas of their body. The participants were randomly assigned to apply a sunscreen spray, cream, or lotion. All of the sunscreens contained some combination of four active ingredients: avobenzone, oxybenzone, octocrylene, and ecamsule. Thirty blood samples were collected from the participants over seven days.

What did the study find, and what do the results mean?

The researchers found systemic concentrations of more than 0.5 nanograms per milliliter (ng/ml) of all four active ingredients in the blood of these volunteers.

These findings, while interesting, should be considered in the context of several limitations. This study is called an exploratory maximal usage trial (MUsT), because the sunscreen products were applied according to the maximum limit of the products’ directions for use, which likely far exceeds use by the average consumer.

Furthermore, while the FDA recommends that active ingredients in sunscreen that exceed 0.5 ng/ml should undergo toxicology testing to check for harmful health effects, this number is somewhat arbitrary, as it is not known what the significance of this blood level means. The FDA acknowledges that without further testing, we do not know what degree of absorption should be considered safe.

What is the FDA saying about sunscreen?

Thus far, titanium dioxide and zinc oxide are two sunscreen ingredients that the FDA deems “generally recognized as safe and effective” (GRASE). These ingredients are not absorbed into the body.

In order to be determined GRASE, a drug must have gone through adequate clinical testing to establish its safety and efficacy, and medical experts must agree, based on those studies, that the product is safe based on the intended, recommended usage. Two other active sunscreen ingredients, PABA and tolamine salicylate, are considered non-GRASE, and they are not legally available in the US.

The FDA is asking for more safety data on an additional 12 active sunscreen ingredients in order to determine whether they can be classified as GRASE. Any sunscreen ingredients that do not receive a GRASE designation in the FDA’s final report, due to be delivered in November 2019, will need to go through a New Drug Application (NDA) process. New products that contain GRASE ingredients do not need to go through the NDA process.

Should I keep using sunscreen?

Absolutely. Exposure to ultraviolet (UV) rays from the sun is a major risk factor for skin cancer, which is the most common type of cancer in the US. Sunscreen use has been shown to protect against UV-induced skin cancers — as well as sunburns and signs of aging.

The FDA has not asked the public to stop using sunscreens that contain avobenzone, oxybenzone, octocrylene, or ecamsule. That’s because while the JAMA study concluded these ingredients were absorbed by the body when applied at high concentrations, we do not know whether this affects a person’s health.

Furthermore, there have not been any reports of serious side effects from sunscreen products related to systemic absorption. In fact, the FDA has announced on its website that “given the recognized public health benefits of sunscreen use, Americans should continue to use sunscreen and other sun protective measures as this important rulemaking effort moves forward.”

What should I do to protect my skin until the FDA releases its new recommendations?

Continue to follow these dermatologist-recommended practices:

• Avoid going into direct sunlight or seek shade between 10 am and 2 pm, which is when UV radiation is the strongest.
• Apply sunscreen to all exposed areas, using a broad-spectrum sunscreen that is SPF 30 or higher.
• Sun protective clothing, including long-sleeve shirts, long pants, hats, and sunglasses, can be a wonderful option for sun protection, especially for young children. Look for clothing that has an ultraviolet protection factor (UPF) rating.

For more information on sunscreens and safety, visit this website by the American Academy of Dermatology.

Follow me on Twitter @KristinaLiuMD

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My Health - Should you see a chiropractor for low back pain?

If you’ve ever seen a doctor for back pain, you’re not alone. An estimated 85% of people experience back pain severe enough to see a doctor for at some point in their life. Yet despite how common it is, the precise cause of pain is often unclear. And a single, best treatment for most low back pain is unknown. For these reasons, doctors’ recommendations tend to vary. “Standard care” includes a balance of rest, stretching and exercise, heat, pain relievers, and time. Some doctors also suggest trying chiropractic care. The good news is that no matter what treatment is recommended, most people with a recent onset of back pain are better within a few weeks — often within a few days.

What’s the role of chiropractic care?

Some doctors refer back pain sufferers to a physical therapist right away. But many people with back pain see acupuncturists, massage therapists, or a chiropractor on their own. Experts disagree about the role of chiropractic care, and there are not many high-quality studies to consult about this approach. As a result, there are a number of questions regarding the role of chiropractic care: Should it be a routine part of initial care? Should it be reserved for people who don’t improve with other treatments? Are some people more likely to improve with chiropractic care than others?

The answers to these questions go beyond any academic debate about how good chiropractic care is. Estimates suggest that low back pain costs up to $200 billion a year in the US (including costs of care and missed work), and it’s a leading cause of disability worldwide. With the backdrop of the opioid crisis, we badly need an effective, safe, and non-opioid alternative to treat low back pain.

A recent study on chiropractic care for low back pain

A 2018 study published in JAMA Network Open is among the latest to weigh in on the pros and cons of chiropractic care for treating low back pain. Researchers enrolled 750 active-duty military personnel who complained of back pain. Half were randomly assigned to receive usual care (including medications, self-care, and physical therapy) while the other half received usual care plus up to 12 chiropractic treatments.
After six weeks of treatment, those assigned to receive chiropractic care:

• reported less pain intensity
• experienced less disability and more improvement in function
• reported higher satisfaction with their treatment
• needed less pain medicine.

While no serious side effects were reported, about 10% of those receiving chiropractic care described adverse effects (mostly stiffness in the joints or muscles). Five percent of those receiving usual care had similar complaints.

All studies have limitations

And this one is no exception. While this study suggests that chiropractic care may be helpful for low back pain, some aspects of the study make it hard to be sure. For example:

• It only lasted six weeks. As mentioned, most new-onset back pain is better by then regardless of treatment. For those with more long-lasting back pain, we’ll need more than a six-week study.
• The differences in improvement between those receiving chiropractic and usual care were small. It’s not clear how noticeable such a difference would be, or whether the cost of chiropractic care would be worth that small difference.
• The study included a mix of people with new and longer-standing low back pain and a mix of types of pain (including pain due to a pinched nerve, muscle spasm, or other reasons). If this study had included only people with muscle spasm, or only people who were obese (rather than military recruits), the results might differ. So, it’s hard to generalize these results to everyone with back pain.
• Most of the study subjects were young (average age 31) and male (77%). All were generally healthy and fit enough to pass military fitness testing.
• Study subjects knew which treatment they were receiving. This creates potential for a placebo effect. Also, the added time and attention (rather than the spinal manipulation) might have contributed to the response. Then again, these factors may not matter to a person who just wants relief.
• This study only included people who were willing to receive chiropractic care.
  Even within the two groups, the care varied — that is, not everyone in the usual care group received the same treatment, and this can also be said for the chiropractic group.

If any of these factors had been different, the results might have been different. For example, it’s possible that if an older population of people with chronic low back pain had been studied, “usual care” might have been the better treatment.

Bottom line

This new study lends support for chiropractic care to treat low back pain. But it’s important to recognize the limitations of this trial, and keep in mind that treatment side effects were more common among those receiving chiropractic care. In addition, chiropractic treatments aren’t free (although, fortunately, insurance coverage for chiropractic care is becoming more common).

This won’t be — and shouldn’t be — the last study of chiropractic care for low back pain. But until we know more, I’ll continue to offer it as one of many treatment options.

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My Health - New FDA-approved weight loss device shows promise

Obesity is a disease that currently affects our population in epidemic proportions, and which has a profound effect on health and quality of life. As a physician dedicated to the prevention and treatment of the medical complications of excess weight, I frequently see patients whose efforts at restricting calories and increasing physical activity are not resulting in sustained weight loss.

When that’s the case, particularly if the excess weight is causing health issues, we can consider adding other treatment tools, which include weight loss medications, or weight loss surgeries. And while these options have increased dramatically over the last one to two decades, we still desperately need more treatments, as neither medications nor surgery are accessible or appropriate for every individual affected by obesity.

What is Plenity?

Gelesis100 (Plenity), just approved by the Food and Drug Administration in April and expected to come on the market later this year, is an exciting recent innovation in weight management. Although Plenity comes in capsule form, it is actually a weight loss device, not a medication. The capsules are filled with hydrogel particles. When taken with a full glass of water before meals, the particles expand in the stomach and take up space, leading to the sensation of fullness. The gel particles eventually move through the intestinal tract, and are broken down by enzymes and excreted.

In the pivotal randomized, double-blind, placebo-controlled clinical trial about 60% of those who followed a diet and exercise plan plus took Plenity lost 5% or more of their initial weight. And about 25% of those who took it were high responders, losing 10% or more of initial weight. Average weight loss was modest: -6.4% for the Plenity group vs -4.4% for the control group. (Of note, the desired endpoint of achieving at least 3% more weight loss in the Plenity group compared to the control group was not met.)

Who might benefit from Plenity?

Given the modest weight loss effects, Plenity will not be the cure to the obesity epidemic. And for people with significant weight to lose, it may not help enough.

Even so, I am enthusiastic about the approval of Plenity as the first treatment of its kind for overweight and obesity, because of how it will fit into the landscape of weight reduction treatments. Plenity is approved for use not only in those with obesity (defined as a body mass index [BMI] above 30) but also in people who are overweight (starting at a BMI of 25). This means that a broader population might be eligible to use Plenity compared to weight loss medications, which are approved for people with a BMI above 30, or a BMI above 27 with certain medical conditions, such as type 2 diabetes.

Access for those who have overweight, but who would not be eligible for pharmacologic (or surgical) treatments, could be incredibly impactful. Not only is close to 40% of the world population in the overweight range, but weight loss at lower BMI can help prevent future weight-related health problems.

What else do I need to know about this new weight-loss device?

There were few safety concerns in the clinical trial of Plenity; in fact, no treatment-related serious adverse events occurred. In addition, Plenity is not absorbed into the body at all. As a result, there is little reason to worry about pharmacologic side effects, or interactions with other medications, both of which frequently limit people’s ability to use weight-loss drugs.

This treatment approach also holds promise for future incremental innovations. For example, the in-the-pipeline Gelesis200 (not to be confused by Harry Potter fans with the Nimbus 2000), is based on Gelesis100 and is currently being studied for possible effects on coexisting obesity and diabetes. And as further research is conducted, we may gain the ability to predict who will be a high responder, and select those individuals for treatment.

The devil is always in the details, and we still don’t know how much these capsules are going to cost. Those of us who work to help people lose weight — and those of us who need to lose it — stand to be quite disappointed if it’s priced as high as most weight loss medications, or is not covered by insurance.

It is exciting that as we continue to understand more about obesity, we have more medical strategies to help people lose weight. I am cautiously optimistic that Plenity will represent a safe and effective option for a subset of people with overweight and obesity.

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My Health - From Brexit to TRexit: Transperineal biopsies pose a challenge to the traditional transrectal biopsy method

By now most of us are familiar with Brexit, the UK’s pending divorce with the European Union. But in a play on that term, British doctors are also moving towards an exit they’ve dubbed “TRexit” from the most common sort of prostate biopsy: the transrectal ultrasound guided biopsy, or TRUS.

Men who test positive on the PSA cancer screening test will usually have a prostate biopsy that’s performed in either of two ways. With a TRUS, doctors guided by an ultrasound machine can sample the prostate using a biopsy needle inserted through the rectum. Alternatively, the biopsy needle can be inserted (also under ultrasound guidance) through the perineum, the patch of skin located between the anus and the scrotum. Since it’s traditionally been easier to perform, and less painful for the patient, the TRUS method is preferred globally, accounting for 99% of the estimated one million prostate biopsies performed every year in the United States.

But now, UK doctors want to abandon the TRUS for the transperineal method. Why? In short, because TRUS biopsies have been associated with a growing risk of hard-to-treat infections. According to Michael Gross, a researcher in the department of urology at Weill Cornell Medical College in New York, “up to 25% of all men carry antibiotic-resistant strains of E. coli bacteria at biopsy, and those rates are increasing across the country and across the world.”

During a TRUS procedure, E. coli and other fecal strains can glom onto the biopsy needle and enter the prostate. Up to 5% of TRUS-biopsied men develop sepsis, and many of them require costly hospitalizations. But since transperineal biopsies bypass the rectum and its associated bacteria altogether, the risks of infection are negligible by comparison.

Fewer threats from drug-resistant bacteria

At the 2019 annual meeting of the American Urological Association last May, a British team from Guy’s Hospital, London, reported results from a feasibility study with 678 men who were given a transperineal biopsy (58% of them under local anesthesia) for either suspected or diagnosed prostate cancer. The complication rates were low, and the incidence of sepsis requiring treatment among the men was 0.16%.

Doctors have mostly avoided transperineal biopsies because of the perceived need for general anesthesia, which is expensive and potentially risky for certain patients. Unlike the rectum, which has few nerve endings in regions close to the prostate, the perineum is highly innervated and sensitive to pain. But according to Gross, local nerve blockers can effectively limit pain from the transperineal biopsy, and recent published evidence shows some men actually prefer it to TRUS.

Studies have shown that, when combined with magnetic resonance imaging scans that focus on regions of the prostate that look suspicious for cancer, both sorts of biopsies detect clinically significant tumors with comparable accuracy.

Will doctors here take TRexit’s lead in abandoning TRUS for the transperineal approach? That remains to be seen, and depends on more access to training opportunities. “The doctor’s experience and comfort level with a transperineal biopsy is very important,” says Dr. David Crawford, a urologist at the University of California, San Diego. The American Urological Association gave its first course on transperineal office-based biopsy this year.

Gross and his colleagues say transperineal biopsies performed under local anesthesia in a doctor’s office offer a viable alternative as threats from antibiotic-resistant bacterial strains steadily increase. But in what’s becoming a more widespread practice, doctors who perform TRUS biopsies can also swab the rectum for bacteria days prior to conducting the procedure, and then give antibiotics targeted at the specific species they find. Dr. Jim Hu at Weill Cornell Medical College is currently putting together a multi-institutional study designed to compare infection rates between transperineal biopsies and TRUS biopsies preceded by a rectal swab.

“As with any procedure, the physician performing the biopsy must feel comfortable and familiar with it,” says Dr. Marc Garnick, Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org. “Future research is needed compare quality of the biopsies obtained by either approach, as well as their associated complication rates and overall patient satisfaction, before the transperineal biopsies procedure displaces the more traditional TRUS method here.”

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My Health - HPV vaccine: A vaccine that works, and one all children should get

Human papillomavirus, or HPV, is the most common sexually transmitted infection. Most of the time, the body clears it without problems. But when it doesn’t, it can lead to cancer. HPV is the leading cause of cervical cancer, and it can also lead to cancers of the vagina, vulva, penis, anus, and mouth. Every year, there are more than 40,000 cases of cancer caused by HPV.

The HPV vaccine can prevent most of them.

Research shows the HPV vaccine is effective

A study published in the journal Pediatrics underlined just how effective the vaccine is. Researchers studied women ages 13 to 26 between 2006 and 2017, looking at their protection against different strains of HPV. They studied women because initially the vaccine was given only to women, so we have the longest data about its effects in women. What they found was really encouraging. Not only did the vaccine seem to protect against the strains covered by the vaccine, but women who got it were less likely to be infected by other strains, showing that the vaccine has cross-reactivity against other strains of HPV.

What was even more encouraging was that over the 10-year period, even women who didn’t get the vaccine became less likely to be infected with HPV. This is called herd immunity. By making the infection less common, those who are vaccinated help protect other people.

All of this is great news — and yet only about half of US teens are fully vaccinated against HPV. For comparison, 94% of US children have had both doses of MMR when they start kindergarten.

What makes some families hesitate about the HPV vaccine?

For some families, the fact that the vaccine prevents a sexually transmitted infection makes parents squeamish. While it’s understandable that parents of 11- and 12-year-olds (when vaccination usually begins, although it can be given as early as 9) might not think that their child needs to be protected against a sexually transmitted infection, vaccinating early makes sense. The vaccine works best if vaccination is complete well before they start having sex — and being realistic, not only is it hard to predict exactly when that will happen, but once teens get older it’s not always as easy to be sure they go to the doctor and get vaccinated. Doing it early ensures their protection.

And for parents who worry that giving the vaccine could somehow be perceived as permission to have sex, and might make teens more likely to do so, research shows that this doesn’t happen.

Parents also worry about the safety of the HPV vaccine. We have now had many years of experience with the vaccine, with many thousands of doses. The vast majority of side effects are mild, such as fever or muscle pain, and last only a day or two. Some teens feel faint after getting it, which is why it’s recommended that they sit or lie down for about 15 minutes afterward. While unexpected allergic reactions can always occur, lots of very careful research has not shown any serious side effects from the vaccine.

The bottom line

The bottom line: the HPV is a safe, effective vaccine that helps to prevent cancer. Whenever we are given a chance to prevent cancer, we should take it.

Follow me on Twitter@drClaire

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My Health - The DASH diet: A great way to eat foods that are healthy AND delicious

The Dietary Approaches to Stop Hypertension (DASH) diet is an eating plan based on eating plenty of fresh fruits and vegetables, and choosing lean proteins, low-fat dairy, beans, nuts, and vegetable oils, while limiting sweets and foods high in saturated fats.

A recent study published the American Journal of Preventive Medicine found that men and women younger than 75 who most closely followed the DASH diet had a significantly lower risk of heart failure compared to study participants who did not follow the DASH diet. Currently, about 5.7 million adults in the United States have heart failure, and about half of those who develop heart failure die within five years of diagnosis.

The DASH diet and heart health

This latest study adds to established research linking the DASH diet with heart health. For example, the original DASH trial, published in the New England Journal of Medicine in 1997, found that the DASH diet reduced blood pressure in adults with borderline high blood pressure (hypertension). Importantly, the DASH trial represented a broad spectrum of men and women, including racial and ethnic minorities from a variety of socioeconomic levels.

In a second study, researchers added a low-sodium modification to the DASH diet. In this trial, participants following a DASH diet were randomized to receive 3,000, 2,300, or 1,500 milligrams (mg) of sodium per day. The study found that the low-sodium (1,500 mg/day) DASH diet was as effective for lowering blood pressure as a first-line blood pressure-lowering medication. This is significant because, according to the American Heart Association, an estimated 103 million adults in the United States have high blood pressure, defined as a reading of 130/80 mm Hg or greater.

Why does the DASH diet work?

The DASH diet

• is low in saturated fat and dietary cholesterol
• is low in sodium (if following the low-sodium version)
• is rich in potassium, magnesium, calcium, protein, and fiber
• emphasizes fruits, vegetables, and low-fat dairy
• includes whole grains, fish, poultry, and nuts
• limits red meat, sweets, and sugary beverages.

These components seem to work synergistically to reduce risk factors for heart disease.

Getting started on the DASH diet

If you’d like to try the DASH diet, follow these guidelines, which are based on a 2,000 calorie per day diet.

Food group	Daily servings	Examples of one serving
Whole grains	6–8	1 slice bread; 1/2 cup cooked rice; pasta; 1 ounce dry cereal
Vegetables	4–5	1 cup raw, leafy vegetables; 1/2 cup cooked vegetable
Fruit	4–5	1 medium apple; 1 cup melon
Low-fat/fat-free dairy	2–3	1 cup milk or yogurt; 1 1/2 ounces cheese
Lean meat, poultry, fish	6 or less	1 ounce cooked lean meat, fish, poultry; 1 egg
Nuts, legumes, seeds	4–5 per week	1/3 cup nuts; 2 tablespoons peanut butter; 1/2 cup cooked legumes
Fats and oils	2–3	1 teaspoon healthy oil (olive); 2 tablespoons salad dressing
Sweets	5 or less per week	1 tablespoon sugar; 1 cup soda; 1/2 cup sorbet
Adapted from the National Heart, Lung, and Blood Institute, National Institutes of Health

Here are some tips for incorporating the DASH diet throughout your day.

Fruits and vegetables

• Start loading up on fruits and vegetables with your first meal of the day. Try an egg white omelet, cooked in olive oil. Add spinach, mushrooms, and yellow and orange peppers. Or make a quick smoothie using strawberries, blueberries, greens, and low-fat yogurt or low-fat milk.
• Assemble a marvelous salad for lunch with fresh salad greens, your favorite fruits and veggies, a healthy protein like beans, tuna, chicken, or tofu, a sprinkling of nuts or seeds, some whole grains like farro or quinoa, and a drizzle of olive oil and lemon.
• Make a stir-fry for dinner. Start with a healthy oil (olive or peanut), add some garlic, and load up with onions, peppers, baby bok choy, broccoli, mushrooms, asparagus, and any other vegetables you may have. Frozen vegetables are fine too. Make a little space in the wok to cook some chicken, shrimp, or tofu. Don’t forget to add some spices for flavor!

Dairy and whole grains

• Try a whole-grain cold cereal with low-fat milk or old-fashioned oats prepared using milk.
• Use low-fat cottage cheese and add some fresh chives. Serve on a few whole-grain crackers.
• Make a whole-wheat pasta and add some low-fat feta or goat cheese. Include a few peas and cherry tomatoes. Top with some extra virgin olive oil or a little pesto.

Healthy fats

• For a healthy dressing, mix 2/3 cup extra virgin olive oil to 1/3 cup vinegar, add a teaspoon of Dijon mustard, a dash of salt, and some ground pepper.
• Use olive oil when preparing roasted, stir-fried, or grilled vegetables.
• Try avocado toast — a slice of whole-grain bread with 1/2 an avocado sliced thin. Squeeze some fresh lemon over, and top with a teaspoon of sesame seeds.

Nuts, legumes, and seeds

• Add some nuts to your oatmeal or plain yogurt.
• Add pumpkin or sunflower seeds to salads.
• Have a small package of nuts or seeds on hand as a late afternoon snack.
• Make a vegetarian chili with black or red beans, chopped onions, canned tomatoes, minced garlic, cumin, and chili powder. If you use canned beans, rinse and drain them or buy the low-sodium version.

Fish, poultry, or lean meat

• Use lean protein as a part of the meal, not as the focus or the only food on your plate.
• Add chicken, fish, and occasionally lean meat to soups and salads where vegetables, whole grains, herbs, and nuts can take center stage.
• Try fish or chicken kabobs on the grill with chunks of red onion, portobello mushrooms, and yellow, red, and green peppers.

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My Health - Opioids for acute pain: How much is too much?

Two recent articles have again highlighted how often opioid pain relievers — medications like oxycodone and hydrocodone — are excessively prescribed in the US for acute pain, sometimes for vulnerable populations and sometimes for conditions for which they are probably not even indicated.

The first paper, by authors at Boston Children’s Hospital, evaluated visits to the emergency department by adolescents and young adults (ages 13 to 22) over an 11-year period from a nationwide sample. About 15% of patients — roughly one in six — were prescribed an opioid, with high rates seen for ankle sprains, hand fractures, collarbone fractures, and particularly dental issues, for which an incredibly high 60% of patients in this age group received an opioid.

Speaking of dental issues, the second paper compared opioid prescribing by dentists in the US and England. In this study, the researchers looked at opioid prescriptions in 2016, and the numbers are shocking. In the US, 22% of prescriptions written by dentists were for opioids, compared with just 0.6% for British dentists, and US dentists prescribed about 35 opioids per 1,000 population, compared to just 0.5 opioid prescriptions per 1,000 population in England. Additionally, the opioid prescribed in England was a relatively weak codeine-like drug, whereas in the US the majority of prescriptions were for hydrocodone, a stronger opioid with greater abuse potential.

When does an opioid prescription make sense?

It is simply impossible that pain experienced by people in the US is that staggeringly different than in the UK. So why the discrepancy? While it is possible that pain is being undertreated in the UK and more adequately treated in the US, I don’t believe that to be the case. The difference is that, in the US, prescribers were reassured for years that opioids were a safe and effective way to treat pain. And yes, they are effective, but as evidenced by the vast increase in opioid-related overdose deaths seen in the country over the past decade, they are not safe.

On the other hand, medications like acetaminophen and ibuprofen — those over-the-counter pain medicines that you can get at any supermarket — actually work amazingly well for acute pain. As an example, a large survey study of over 2,000 patients who underwent a range of dental procedures discovered that the vast majority experienced adequate pain relief with over-the-counter or non-opioid prescribed pain medications. And similar studies are abundant. Another study looked at patients treated for low back pain in the emergency department and found no difference in pain after five days, whether the patient was treated with an anti-inflammatory medicine (naproxen) or if an opioid was added. It just didn’t make a difference, so why take the risk?

Yet another study evaluated variation within the US for treatment of ankle sprains. Over 30,000 patients were studied. On average, about a quarter of patients received an opioid prescription, but the state-level differences were astounding, ranging from under 3% in North Dakota to 40% in Arkansas! All for a condition that, in general, should get better with ice, elevation, and a brace.

Of course, there are times when the over-the-counter medications are not going to be sufficient to treat acute pain. In those situations, the goal should be to take the non-prescription medications first, and then add an opioid only when the pain is unbearable. Typically, this period of severe pain is in the first three days after a surgery or trauma. For example, colleagues in my department evaluated opioid consumption in the days after suffering an acute fracture. Most patients needed only about six pills of oxycodone.

The same trend is seen after surgery. A large study of six other studies found that between two-thirds and 90% of post-operative patients reported unused opioids after their surgery, and as many as 71% of the tablets went unused. We therefore subscribe to the recommendations of the Opioid Prescribing Engagement Network (OPEN) program in Michigan, which recommends relatively small opioid prescriptions after surgery, such as 10 pills after having your appendix removed or hernia repaired, and just five for procedures like a breast biopsy. Patients do fine, even with these smaller numbers of pills, and are at less risk of developing long-term opioid use.

What to be aware of for teenagers and young adults who get an opioid prescription

My general recommendation for opioid-naïve patients, regardless of age, is the following: if you have a simple problem, like a sprain or a dental procedure, or even back pain, do whatever you can to avoid an opioid. Ask your doctor about which over-the-counter pain treatments you can safely take and maximize those. For more severe pain, such as from fractures or after surgery, use the minimum number of opioids needed to tolerate the pain, then back off once the pain is bearable and continue with the non-prescription treatments.

For adolescents and young adults, extra caution is needed. The adolescent brain is developmentally predisposed to developing addiction, and therefore at high risk. Although opioid misuse among teens is decreasing, it still is a major problem. Among high school seniors, past-year misuse of pain medication was 3.4% in 2018, and about a third of high school seniors thought that these drugs are easily accessible. It is therefore paramount to protect adolescents from these medications. If prescribed, they should ideally be stored securely and dispensed by a parent or guardian following the appropriately prescribed schedule. Education about the medicine, and the dangers of being dependent on the medication, is essential. This is also a great time for parents to talk to their children about drug use in general.

What to do with leftover pills

When the acute pain from those first few days is gone, if there are leftover opioid pills, discard them safely. I cannot reiterate this enough. About two-thirds of adolescents who misused opioids got them from friends or family for free. There are lots of places to safely discard pills. In fact, the Drug Enforcement Administration offers a website that lists the closest bin locations. If one of those is not accessible, mix the medication with coffee grounds or dirt, seal it in a plastic bag, and dispose of it in the trash. Just be sure not to flush it down the toilet, as opioids and other drugs can contaminate the water supply.

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My Health - DNA testing forever changed donor conception

DNA testing (and the family secrets it sometimes reveals) has been in the news a lot this year. As Dani Shapiro’s memoir Inheritance made clear, a simple DNA test can upend an identity and dismantle a family story. Those of us working in the field of reproductive medicine know that Shapiro’s story is far from unique. Increasingly often, young (and not so young) adults learn “by accident” that they were donor-conceived.

Readers may wonder how this happens. How can parents keep a secret so significant from their children? As a therapist whose practice includes many parents who had children through donor conception, I would like to shed some light on this.

(In a future blog, I’ll address the feelings and experiences of their children. Many are bewildered by their parents’ decisions not to tell them. They’re angry about the widespread practice — and seeming acceptance — of anonymous egg and sperm donation. Possibly for them, and for their parents, one step toward healing might be gaining an understanding of the reasons and patterns for this secrecy.)

Two major reasons for secrecy around donor conception

Donor parents have usually experienced infertility. Donor conception is almost never a first choice. Often, men and women who have children through the help of a donor experienced infertility or had an illness that rendered them infertile. Possibly, they have a genetic condition that they want to avoid passing on to a child. Loss brings them to donor conception and remains with them during and after the process. Some feel that everyone “will be better off” if they try to pretend that this is their full genetic child.

Doctors advised secrecy. For many years (and even in some places today), physicians encouraged denial, secrecy, avoidance. As recently as the 1980s and ‘90s, some doctors selected sperm donors for their patients and told them that they had found ideal matches. The plot thickened for many couples when their doctor told them that that he (it was usually a he) would mix the donor sperm with the husband’s sperm. That way, the doctor said, they would never really know.

Three patterns of not telling about donor conception

In recent months, I’ve talked with several parents of young adults who do not know they were donor-conceived. In all instances, the parents contacted me because some member of the family purchased a DNA kit or was talking about doing so. Although their stories differ, all the parents I spoke with were in anguish over their “failure” to tell. Each one of them loves their child or children. Each approached me tormented by what it would mean for their offspring to learn of their donor conception as an adult. In talking with them, I observed three patterns of not telling.

Not telling because it seems best to keep it a secret. Some parents believed it best that the child not know they were donor-conceived — sometimes because their doctor planted that thought. As the burden of secrecy sets in, they may — or may not — have a change of heart along the way. One mother of four adult children, now all in their 30s and married with children, described her family as close and loving, people who genuinely enjoy spending time together. Neither she nor her husband had ever seen any reason to tell. This changed only when her daughter’s mother-in-law gave her a DNA kit as a Christmas present.

Not telling because life got in the way of telling. One dad told me he and his late wife had always planned to tell their two children that he was not their genetic father. Plans changed when his wife died suddenly, leaving him with a 3-year-old and 5-year-old. For years following her death, he was simply in survival mode. He didn’t think about telling his kids until they were teenagers, yet that felt like the wrong time to tell them. Now in their 20s, one of his children was curious about genealogy and had purchased a test.

Not telling because it was a non-issue. Although most people come to donor conception after experiencing infertility and reproductive loss, occasionally I meet people with different reasons. One man had a vasectomy after the birth of his second son because his wife was advised not to become pregnant again. The couple divorced and he went on to remarry. When he and his new wife wanted to have a child together, donor sperm represented an opportunity rather than a loss. This dad said he had always felt closest to his third son, the one conceived with donor sperm. He never considered donor conception an issue. Only when he began reading articles of people accidentally learning that they were donor-conceived did he become alarmed.

A changing landscape

Although the idea that “nobody needs to know” has not entirely vanished from the practice of donor conception, I am happy to be able to end on a positive note. Today, most people who have a child through the help of a donor recognize that their child has a right to know their origin story.

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My Health - Need to check your thyroid? Maybe not

As medical science advances, we have more tests and biomarkers available to help identify illnesses. Yet overdiagnosis and overtreatment that may occur following abnormal results can cause dangerous adverse effects and costly consequences. Hypothyroidism — a lower than normal range of thyroid hormones — may be the poster child for this problem because it is such a common condition.

What is hypothyroidism?

At the front of your neck lies the thyroid, a butterfly-shaped gland that makes the hormone T4. When released into the bloodstream, T4 converts to T3, the most active form of thyroid hormone. Having sufficient levels of these hormones is important because the thyroid regulates body temperature, metabolism, blood pressure, and heart rate.

Hypothyroidism occurs when the thyroid is underactive (not working optimally). It affects as many as five in 100 people. Symptoms of hypothyroidism include fatigue, cold intolerance, constipation, dry skin, hair loss, muscle weakness, weight gain, and fertility problems.

In my primary care practice, I’m finding that more and more of my patients are reporting feeling tired and concerned about whether they have hypothyroidism. Some patients request many different thyroid blood tests to diagnose and treat hypothyroidism. But are these tests really necessary?

How is hypothyroidism diagnosed?

Most major medical associations recommended diagnosing hypothyroidism through a blood test using a simple two-step approach.

• First, we check the level of thyroid stimulating hormone (TSH), which the pituitary gland in the brain releases to stimulate thyroid hormone production.
• If TSH is high, we confirm low thyroid function with a test called free or unbound T4 (T4 in the bloodstream that is not attached to a protein).

It may help to think of the pituitary gland as a thermostat and the thyroid gland as a heater. The thermostat senses low temperatures outside of the body and turns on the internal heater. When body temperature reaches a set threshold, the thermostat signals the heater to stop working. In the body, it is the TSH produced by the pituitary gland that signals the thyroid to make more T4. When there is less free T4 in the blood, the pituitary senses the low levels and starts making more TSH.

Why not check thyroid hormones directly?

Why not check the thyroid hormones (T3 and T4) themselves, to see if the gland is not functioning properly?

The thyroid only makes small amounts of T3. Even in cases of severe hypothyroidism, T3 levels don’t go down that much. T4 is produced in large quantities by the thyroid. However, TSH is a far superior screening test because small changes in T4 cause large TSH spikes. Usually when a person has hypothyroidism, TSH levels become very high way before T4 levels fall below normal. So, in our analogy, the thermostat is very sensitive to small variations in temperature.

That’s why a normal TSH almost always means the thyroid gland is healthy and producing enough thyroid hormones. Research finds that a simple TSH test is enough to identify hypothyroidism in 99.6% of the tests performed.

You may have heard of expanded or full thyroid panels, which often include tests for TSH, total T3, total T4, free T3, free T4, anti-TPO antibodies, thyroglobulin, and reverse T3. There is no evidence these extra tests help to diagnose and manage thyroid disease, although they definitely add to health care costs. Proponents of expanded thyroid analysis believe more data may support a personalized intervention plan. However, what happens in a lab test often fails to mirror the elaborate dance of hormones in the body. Additionally, findings are highly variable. What happens in your body today may change in a matter of days or weeks, even without significant interventions.

How is hypothyroidism treated?

To make matters even more confusing, we still do not recommend universal treatment for people who have subclinical hypothyroidism: slightly elevated TSH (between 4.12 and 10 mU/mL) and normal free T4.

Even though subclinical hypothyroidism is associated with worse health outcomes, treatment with thyroid hormone medicine may not significantly improve a person’s symptoms and quality of life.

From my perspective, more lab testing may cause anxiety, generate further tests, and lead to unnecessary treatment, which can cost hundreds, and sometimes thousands, of dollars. We have good solid evidence to support simple tests to diagnose hypothyroidism and follow people who need treatment for it. I recommend questioning any doctors (and bloggers) who recommend tests that are not supported by clinical research. While it may sound like a good idea to check more biomarkers, it’s important to understand the limitations of weak evidence before embarking on this journey. On some of these websites, dollar signs are just a click away.

The bottom line

According to most guidelines, a TSH below 10 provides good reassurance that a person does not have hypothyroidism.

If you are diagnosed with subclinical hypothyroidism and you do not want to take thyroid hormones, it’s reasonable to recheck TSH and free T4 in two to three months to see if any changes have occurred.

If your main concern is your energy level, eating a healthy whole food diet, exercising more, reducing stress, and sleeping well can help. What’s more, this approach may improve many chronic health problems — and it certainly will not deplete your bank account.

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My Health - Children and gun safety: What to know and do

Stories about shootings are becoming far too common. The news is full of stories of shootings at schools, workplaces, and other public places. While stories of mass shootings get the headlines, guns kill people every day. According to the Centers for Disease Control and Prevention (CDC), guns killed almost 40,000 people in 2017, the highest amount in the nearly 50 years since the CDC started their electronic database.

Here are some other important facts:

• Firearm injury is the cause of death in 74% of all homicides and 87% of all youth homicides.
• Every day, 78 children, teens, and young adults are injured or killed by guns in the US.
• The risk of death by suicide is four to 10 times higher in homes with guns. Firearms are used in 50% of all suicides, and 42% of youth suicides.
• One in three homes with children in the US has a gun.
• Children as young as 3 years old may be strong enough to pull the trigger on a handgun.
• Three out of four children (including children less than 10 years old) living in a house with a gun know where the gun is, even when their parents think they don’t.
• While many people feel that having a gun keeps them safer, the research suggests that the opposite is true.

Three ways to keep everyone safer

Gun ownership is a polarizing issue here in the US. But whatever anyone thinks about gun ownership, all can agree that we need to work to keep people safe — particularly our children. Here are three things all parents can do:

• If you own a gun, lock it up, unloaded. Keep ammunition locked up separately.
• Ask if there is an unlocked gun where your child plays. This simple question can save your child’s life. If the answer is yes, ask if it can be locked up (unloaded, with the ammunition locked separately). If the gun isn’t stored safely, your child shouldn’t play there.
• If your child has a history of depression or other mental health problems, don’t keep a gun at home. Locking it up may not be enough to keep your child safe.

Somehow, we need to come together to put some common sense laws to keep people safe. As a country, we have a very high rate of gun deaths compared to other developed countries. That’s something that should alarm us. Background checks and waiting periods make good sense, as do measures that work to make guns less available to people with mental health problems.

Our children rely on us to keep them safe — including from gun injury.

Follow me on Twitter @drClaire

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My Health - Kidney stones: What are your treatment options?

If you’ve been diagnosed with kidney stones (urolithiasis), you may have several options for treatment. These include medical therapy, extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotripsy (PCNL), and ureteroscopy.

A brief anatomy of the urinary tract

The urinary tract includes

• kidneys (two organs that filter waste and extra water from the blood)
• ureters (two tubes bringing urine from each kidney to the bladder)
• bladder (organ that collects urine)
• urethra (a single tube through which urine in the bladder passes out of the body).

The evaluation for kidney stones

If your symptoms suggest kidney stones, imaging is often the first step in an evaluation. For many years the standard of care was a type of abdominal x-ray called an intravenous pyelogram (IVP). In most medical centers, this has been replaced by a type of computed tomography (CT) called unenhanced helical CT scanning. In some cases, such as when a person has impaired renal function or a contrast dye allergy, renal ultrasound may be used as an alternative.

You will also have blood tests, including tests for renal function (creatinine, BUN). Your doctor may suggest other blood tests as well. A urinalysis will be obtained and if infection is suspected, a urine culture will be sent.

Keeping kidney stone pain under control

If you are experiencing the intense discomfort of kidney stones (renal colic), pain control is a top priority. A 2018 analysis of multiple randomized trials looked at different pain relief medicines given to people treated in the emergency department for acute renal colic. It compared nonsteroidal anti-inflammatory drugs (NSAIDs, such as aspirin, ibuprofen, or naproxen) with paracetamol (similar to acetaminophen) or opioids. The study found NSAIDs offered effective pain relief with fewer side effects than paracetamol or opioids. NSAIDs directly inhibit the synthesis of prostaglandins, which decreases activation of pain receptors and reduces renal blood flow and ureteral contractions.

Medical therapy for kidney stones

Most evidence suggests that stones less than 10 mm in diameter have a reasonable chance of passing through the urinary tract spontaneously. You may be offered medical expulsive therapy (MET) using an alpha blocker medication, such as tamsulosin. It’s important to understand that this is an off-label use of the drug. Rarely, tamsulosin causes a condition called intraoperative floppy iris syndrome that can complicate cataract surgery.

Not all experts feel MET is worthwhile, and its use remains controversial. Discuss your options with your doctor or a urologist.

Extracorporeal shock wave lithotripsy

All shock wave lithotripsy machines deliver shock waves through the skin to the stone in the kidney. Most but not all of the energy from the shock wave is delivered to the stone.

Stone size is the greatest predictor of ESWL success. Generally:

• stones less than 10 mm in size can be successfully treated
• for stones 10 to 20 mm in size, additional factors such as stone composition and stone location should be considered
• stones larger than 20 mm are usually not successfully treated with ESWL.

Stones in the lower third of the kidney can also be problematic because, after fragmentation, the stone fragments may not be cleared from the kidney. Due to gravity, these fragments don’t pass out of the kidney as easily as fragments from the middle and upper thirds of the kidney.

Obesity also influences whether ESWL treatment will be successful. The urologist will calculate the skin-to-stone distance (SSD) to help determine whether this treatment is likely to be effective.

The possible complications of ESWL include:

• Injury to kidney tissue, such as bruising (hematoma), can occur in a small number of cases, but usually heals without additional treatment.
• Fragmented stones may accumulate in the ureter and form an obstruction. This is known as a steinstrasse (“street of stones”). A ureteral stent often minimizes any problems associated with steinstrasse. The stent is removed in a few days or weeks.
• A small percentage of patients undergoing ESWL develop hypertension, although the mechanism is not well understood.
• An increased risk of diabetes mellitus following ESWL has also been reported. However, these results were not confirmed by a large population study done at the same institution.

Percutaneous nephrolithotripsy

Using ultrasound or fluoroscopic guidance, a surgeon gains access to kidney stones through a small incision in the lower back during percutaneous nephrolithotripsy. A power source, such as ultrasound or laser, breaks the stones into fragments, which are flushed out of the kidney through an external tube or internal stent.

This treatment is usually considered for larger kidney stones (2 cm or more), complex stones, or lower pole renal stones larger than 1 cm. Possible complications may include bleeding, infection, and injury to surrounding organs.

Ureteroscopy

During ureteroscopy, a surgeon places a tube through the urethra and bladder into the ureter, possibly going all the way up into the kidney. Ureteroscopy employs either semirigid or flexible instruments through which the surgeon has an excellent view of everything inside the urethra. The surgeon then uses a power source threaded up through the ureteroscope to fragment the stones under direct visualization. A postoperative stent can be placed for a few days at the discretion of the urologist.

Complications are infrequent, but may include injury to or narrowing of the ureter, as well as sepsis.

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My Health - A new therapy for osteoporosis: Romosozumab

Osteoporosis is a condition in which bones become porous (less dense) and weaker. It affects 10 million people in the United States: approximately eight million women and two million men. As bone weakens, people are more likely to experience fractures, especially in the spine, hip, and forearm. This causes pain, diminishes a person’s ability to function, and reduces quality of life. Anything that can lower the risk of osteoporosis and fractures has major positive public health implications. That’s why a new drug called romosozumab (Evenity) is getting a lot of attention.

Which medications can help treat osteoporosis?

There are currently several medications available to treat osteoporosis. These include medications that

• block the breakdown of bone (anti-resorptive therapies). Examples include bisphosphonates such as alendronate (Fosamax), which is a pill, and zoledronate (Reclast), which is given intravenously. Other types of anti-resorptive agents include raloxifene (Evista) and denosumab (Prolia).
• enhance the formation of bone (anabolic therapies). Examples include teriparatide (Forteo) and abaloparatide (Tymlos).

Now, for the first time since 2010, a new class of medication is available to treat osteoporosis. Romosozumab (Evenity) is in a class called sclerostin inhibitors and is considered an anabolic agent.

Sclerostin is a protein that helps regulate bone metabolism. Produced by osteocytes (bone cells), it inhibits bone formation (making new bone). Romosozumab binds sclerostin, which keeps it from blocking the signaling pathway for new bone formation. The result is an increase in new bone. To a lesser degree, it also decreases bone resorption (breakdown of bone).

Romosozumab is approved by the FDA to treat osteoporosis in women who have completed menopause and are at high risk for fracture. A history of fracture due to osteoporosis, multiple risk factors for fracture, no success with other therapies, or being unable to tolerate other therapies are reasons to consider romosozumab.

How is romosozumab given?

The medication is injected once a month using two separate prefilled syringes for a full dose. Romosozumab should only be taken for one year, because its bone-making activity wanes after 12 months. Women using this therapy should also make sure they get enough calcium and vitamin D during treatment.

What does research tell us?

Two large trials in The New England Journal of Medicine(which were funded by the drug manufacturer) have looked at this new medication. One trial enrolled over 7,000 postmenopausal women with osteoporosis based on low bone density measurements. Half received romosozumab and half placebo (inactive medication) for one year. Women using romosozumab versus placebo had far fewer new vertebral fractures: 16 in the treatment group, 59 in the placebo group.

In the second year of the study, all participants — including those who had been taking a placebo — were given the anti-resorptive agent denosumab. The group that received romosozumab followed by denosumab had 21 vertebral fractures, compared to 84 in the group that received placebo followed by denosumab.

Another trial enrolled more than 4,000 postmenopausal women with osteoporosis and a history of related fractures. Half were treated with a monthly injection of romosozumab for one year, followed by alendronate once a week for the second year. The other half received alendronate once a week for both years.

At the end of the study:

• those assigned to receive romosozumab in the first year had fewer new spine fractures than those receiving alendronate for both years (127 vs. 243)
• hip fractures also occurred less often among those receiving romosozumab (41 versus 66)
• bone density was higher in the group that received romosozumab.

What are the possible side effects?

Joint pain and headache are the most common side effects of romosozumab. Very rarely, some people experience loss of bone tissue (osteonecrosis) in the jaw and atypical thigh bone fractures. (This also occurs very rarely with bisphosphonates and denosumab.)

Additionally, the risk of heart attacks, stroke, and cardiovascular death was slightly higher among those given romosozumab in the first year than it was among those given alendronate for both years. If you have had a heart attack or stroke, or are at high risk for either, ask your doctor whether you should choose a different type of osteoporosis medication.

The bottom line

We do not yet have long-term data on romosozumab. But a dual effect (increasing bone formation and decreasing bone resorption) makes it a welcome addition to available treatments for osteoporosis — at least for postmenopausal women at high risk for fracture.

Based on this research, a year of romosozumab therapy, followed by an anti-resorptive agent like alendronate, zoledronate, or denosumab, is a new and effective option for certain women to prevent fractures related to osteoporosis. However, cost may be a factor, and there may be small but important risks to understand about this approach when discussing your treatment options with your doctor. Ultimately, more long-term research is needed to help determine safety and effectiveness over time.

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My Health - The fourth trimester: What you should know

We hear a lot about the three trimesters of pregnancy. But many women (and even some medical professionals) know little about a newly described and critical time period in women’s lives that desperately needs our attention: the fourth trimester.

As a practicing obstetrician-gynecologist, I know that the medical care of women before, during, and immediately after pregnancy has long focused on the goal of achieving a healthy pregnancy and a healthy baby. But too often, the fourth trimester — that time between birth and 12 weeks postpartum — is swept aside.

For example, we encourage all women to start taking prenatal vitamins before conceiving and meet with their primary care providers to optimize their health before conception. During pregnancy, women’s schedules are filled with appointments for prenatal care visits, ultrasounds, and lab tests, and perhaps even nutrition and social work consultations. Weekly visits in the final month of pregnancy provide opportunities for fetal heart checks, maternal blood pressure and weight evaluations, paired with slow and steady counseling and anticipatory guidance for the process of labor and birth. Though some attention is given to preparing pregnant women for the challenges of breastfeeding and the pitfalls of postpartum depression, women, families, and healthcare providers tend to focus on a healthy outcome at birth.

What happens during the fourth trimester?

After birth, the close attention given to mothers in the last few weeks of pregnancy is picked up with a similar intensity by pediatric providers caring for newborns. Usually, babies have their first pediatric visit within one week of birth. Their well-being is closely monitored over the first weeks and months of life.

And for the mothers? Well, your routine postpartum visit (yes — usually there’s only one) is scheduled for six to eight weeks after childbirth. Perhaps for many low-risk women, this long interval between giving birth and a postpartum visit with their obstetric provider is adequate. But let’s review: by the time they arrive at their office at six weeks, most women who give birth have survived the pain caused by tearing during a vaginal birth, a surgical incision after cesarean delivery, and/or hemorrhoids in the first two to three weeks. Many are coping with the physical and emotional challenges of breastfeeding. They’ve grappled with sleeplessness and may have overcome their initial baby blues.

While this early postpartum period is a time of great joy for many, it’s also a very vulnerable time. Women and their families experience substantial physiological, social, and emotional changes. Why, then, do we not offer careful monitoring, support, and anticipatory guidance with the same fervor as in the weeks before childbirth, in order to keep women safe? Most women would benefit from much closer follow-up during the fourth trimester.

Attitudes are changing

Fortunately, attitudes toward the fourth trimester are changing. The American College of Obstetrics and Gynecology (ACOG), which governs standards of care and guides practice, now recommends that medical professionals view postpartum care through the lens of maternal health. A committee report:

• Calls for closer follow-up of women after birth
• Provides doctors with specific recommendations
• Emphasizes that a change in reimbursement policies is needed to support individualized, continuous postpartum care for each woman.

Their focus on the fourth trimester clearly acknowledges that the goals of pregnancy care must go beyond achieving a healthy pregnancy and a healthy baby to include a healthy mother!

How can you gain support during the fourth trimester?

If you are pregnant, start by talking to your obstetric team to learn what sort of support they can offer you during the fourth trimester.

Online resources are available to help you and your family create a “postpartum plan,” such as this one created by Mara Acel-Green, LICSW. Having a plan can help you anticipate difficulties and be prepared to get the types of support you need, which can be very challenging to access from scratch during the sleep-deprived early weeks after childbirth.

It helps to add your own individualized medical section to any postpartum plan you fill out. Discuss these questions with your obstetric team and any other healthcare providers you typically see:

• Do you have medical or emotional conditions that are expected to change during the postpartum period?
• Will any medications you take need to be adjusted?
• What warning signs should you or your family look for?
• When is the best time for your first postpartum check-up?

Finally, pregnancy is a window into future health. Ask your providers about how best to maintain the medical discoveries made during pregnancy as part of your long-term health maintenance plan.

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My Health - Dermal fillers: The good, the bad and the dangerous

The four major structural components of our face are skin, fat, muscle, and bone. As we age, volume loss in these structures contributes to many of the visible signs of aging. Dermal fillers may help.

Over time, age-related bone loss in the face can lead to retraction of the jawline, descent of the nose, and loss of high cheekbones. The facial muscles also decrease in volume and elasticity, and deflation and movement of facial fat further accentuates the signs of aging. Finally, the skin stretches and loses elasticity — compounded by the loss of scaffolding provided by fat, muscle, and bone, this leads to wrinkles, sagging skin, and other familiar signs of aging.

Dermal fillers, an injectable treatment performed in a doctor’s office, can help smooth lines and replenish lost volume, restoring a more youthful appearance.

What are dermal fillers?

Dermal fillers are soft, gel-like substances that are injected under the skin. They can address a number of common concerns including smoothing of deep under-eye circles, lifting of cheekbones, volumization of the lips, smoothing of lip lines and nasolabilal folds (the creases that run from the side of the nose to the corners of the mouth), and rejuvenation of the hands.

Dermal fillers can be composed of a variety of substances, some naturally occurring and some synthetic. One of the most common compounds used in dermal fillers is hyaluronic acid (HA). HA is a naturally occurring substance found in our skin, and it plays a major role in keeping skin hydrated and volumized. HA fillers, depending on their specific chemical makeup, can last from six months to much longer before being gradually absorbed by the body.

One of the main benefits of HA fillers, aside from their natural appearance when injected, is that they can be dissolved by a special solution in case of an adverse event, or if the person dislikes the appearance. Also, most HA fillers are premixed with lidocaine, a numbing agent, to maximize comfort during treatment.

Other available dermal fillers include those made from calcium hydroxylapatite, poly-L-lactic acid, polymethyl methacrylate, and autologous fat (fat that is transplanted from another part of your body). Calcium hydroxylapatite is a mineral-like compound naturally found in human bones. It has been used in dentistry and reconstructive plastic surgery for years with a long track-record of safety. Poly-L-lactic acid is a synthetic filler that helps to stimulate collagen production. This filler is different from other fillers because its results are gradual; volumization occurs over several months as it stimulates the body to produce collagen. Polymethyl methacrylate is a semi-permanent filler. While it is more durable compared to other more readily biodegradable fillers, it has potential complications such as forming lumps or being visible under the skin.

Each of these substances has its own pros and cons, as well as a unique density, longevity, and texture, which means a particular material may be more or less suited to a specific area of the face or desired result. Choosing the right type of dermal filler requires the guidance of an experienced, board-certified dermatologist or cosmetic surgeon with a thorough understanding of facial anatomy, and familiarity with the variety of available fillers and their respective injection techniques. A medical professional will thoroughly evaluate any specific areas of concern, understand what you hope to get out of the procedure, and review what to expect before, during, and after the treatment to ensure the best cosmetic outcome.

Avoid black market dermal fillers

 Dermal filler procedures can be expensive, which has prompted some consumers to turn to the online black market to purchase do-it-yourself fillers. In the last month, there have been multiple reports in media outlets and in the medical literature of dangerous complications resulting from self-injection of fillers by non-health professionals.

One risk is that fillers purchased online can contain a variety of nonsterile substances, such as hair gel. When injected, these substances can cause allergic reactions, infections, and the death of skin cells. Another risk is that improper injection technique can lead not only to swelling and lumpiness, but also more serious side effects such as death of skin cells, and embolism leading to blindness. The FDA has issued an official warning urging consumers to “never buy dermal fillers on the internet. They may be fake, contaminated, or harmful.”

Dermal fillers are safe and effective in the right hands

So where does this leave the savvy consumer interested in noninvasive treatments to reduce the signs of aging? Finding the right physician to perform your dermal filler procedure is key. Don’t be afraid to ask about training and certification to ensure you’re receiving care from a board-certified, experienced dermatologist or cosmetic surgeon.

With the right preparation and communication between you and your physician, you can achieve natural, beautiful, and safe results.

Follow me on Twitter @KristinaLiuMD

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My Health - Infant car seats are for cars only (how not to use an infant car seat)

Infant car seats are crucial for keeping infants safe when transporting them in cars or other vehicles. That’s what they are meant for — and that’s all that they should be used for, or the consequences can be lethal.

When you have one of those infant car seats that detaches from a base and can be carried, it’s very tempting to leave Baby in it after transporting him. If he’s asleep, you can bring him to wherever you are going and let him sleep — nobody wants to wake a sleeping baby — while you do chores or visit or whatever you were going to do. If you are leaving him with a babysitter, the car seat seems like a convenient place for him to sleep. And when you are home, the car seat can seem like a great place to put Baby when you need your hands free.

Except that none of this is a good idea.

In a study published in the journal Pediatrics, researchers looked at information about 11,779 infant sleep-related deaths. They found that 3% of these deaths took place in sitting devices, and of those, 63% were in infant car seats.

The majority of these deaths took place in the child’s home and in the presence of a parent or guardian — but the risk was higher when the child was being cared for by a child care provider or babysitter. There were other risk factors, too:

• the person supervising the child was asleep (34%)
• history of maternal drug use during pregnancy (24%)
• exposure to secondhand smoke (23%)
• baby born before 37 weeks of pregnancy (23%)
• item (like a blanket) present (20%)
• a new sleep environment (18%)
• low birth weight (16%).

There was also a higher risk when the baby was loosely buckled into the seat — and when left alone in the car.

This is why the American Academy of Pediatrics recommends that infant car seats only be used for travel. That’s what they were designed for: to keep babies safe in the event of a crash or other travel event. They weren’t designed to keep babies safe during sleep; for that, babies need to be on a flat, firm surface without any bedding or anything else around them.

At a minimum, if you bring Baby inside in his car seat, you must

• keep your eyes on him at all times
• make sure he is safely buckled in, the same way you’d do it in the car.

But the better idea is to simply take him out. If there isn’t a crib or bassinet or other safe place to put him where you are going, bring a portable one with you. Talk to your doctor about the safest, most affordable choice if you have any questions. If you are home and Baby needs attention and you need your hands free, consider a baby carrier.

Convenience is key to making life work as a parent. But safety comes first.

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My Health - 10,000 steps a day — or fewer?

10,000 steps a day has become the gold standard for many people. That number has sold many step-counting devices and inspired interoffice competitions. But it’s a big number that can be hard to reach. When people continue to not hit five digits, eventually some ditch the effort altogether.

Dr. I-Min Lee is an associate epidemiologist at Brigham and Women’s Hospital, a professor of medicine at Harvard Medical School, and a researcher on physical activity. She and her colleagues wanted to look at the basis for 10,000 steps and its validity. Their new study in JAMA Internal Medicine answers two questions about mortality: How many steps a day are associated with lowering the mortality rate? Does stepping intensity level make a difference in mortality when people take the same number of steps?

Where does 10,000 steps a day come from?

Dr. Lee discovered that the origins of the number go back to 1965, when a Japanese company made a device named Manpo-kei, which translates to “10,000 steps meter.” “The name was a marketing tool,” she says. But since the figure has become so ingrained in our health consciousness (it’s often the default setting in fitness trackers), she wanted to see if it had any scientific basis for health.

She had already been studying the relationship of physical activity and health in older women, and it made sense to stay with that population, she says. This group tends to be less active, yet health issues that occur more often as people age become more important. The research looked at 16,741 women ages 62 to 101 (average age 72). Between 2011 and 2015, all participants wore tracking devices called accelerometers during waking hours. The central question was: are increased steps associated with fewer deaths?

What did the research find?

Key findings from the study include these:

• Sedentary women averaged 2,700 steps a day.
• Women who averaged 4,400 daily steps had a 41% reduction in mortality.
• Mortality rates progressively improved before leveling off at approximately 7,500 steps per day.
• There were about nine fewer deaths per 1,000 person-years in the most active group compared with the least active group.

So, if mortality — death — is your major concern, this study suggests you can reap benefits from 7,500 steps a day. That’s 25% fewer steps than the more common goal of 10,000 steps.

What are the study’s limitations?

Dr. Lee notes that this study was designed to look at only two factors. One is mortality — not anything related to quality of life, cognitive functions, or physical conditions. So, this particular study doesn’t tell us how many steps to aim for in order to maximize our quality of life, or help prevent cognitive decline or physical ailments.

The second question Dr. Lee hoped to answer is whether the intensity of the steps a person took mattered. It doesn’t. “Every step counts,” she says.

What’s the bigger picture?

While the scope of this study is narrow, Dr. Lee draws some bigger-picture findings.

• Exercise recommendations are often measured in time: at least 150 minutes of moderate aerobic activity a week has been the federal government’s recommendation since 2008. People who aren’t active may find it difficult to know exactly how long they’ve been moving. Quantifying exercise by counting steps can feel more doable and less overwhelming.
• If you’re sedentary, add 2,000 more daily steps so that you average at least 4,400 daily steps. While 2,000 steps equals one mile, it’s not necessary to walk it all at once. Instead, try to take extra steps over the course of each waking hour.

She offers good advice for everyone, particularly those looking for extra steps:

• Take the stairs instead of the elevator.
• Park at the first empty space you see, not the one closest to the entrance.
• Get off the bus one stop earlier than your destination.
• At home, break up chores. Make more than one trip to bring the dinner dishes into the kitchen, or when bringing groceries in from your car.

“Those little things collectively add up,” Dr. Lee says. “Don’t be intimidated or dissuaded by the 10,000 number.”

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My Health - 4 behavioral changes to tame urinary incontinence

Although urinary incontinence is not a life-threatening medical condition, it can significantly affect quality of life. When urinary incontinence becomes bothersome, people often stop traveling, exercising, visiting family and friends — in short, people stop doing the activities they enjoy.

Surprisingly, approximately 70% of urinary incontinence can be significantly improved just by changing behavioral habits. This is called behavioral therapy. In a recent study published in Annals of Internal Medicine, behavioral therapy, either alone or in combination with medication therapy, was more effective than medication treatment alone for treating urinary incontinence.

This means if you are motivated enough to stick with a behavioral treatment program, there’s a strong chance you can improve your bladder control yourself.

Urinary incontinence: The basics

Urinary incontinence can be very minimal, leaking only a few drops. Or it can be severe, leaking so much that your pants are soaked.

The two most common types of urinary incontinence are stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). SUI is the type of leaking that happens when you cough, sneeze, lift, or exercise. UUI is when you get the urge to urinate, and leak before you make it to the toilet.

Behavioral modifications help both types of urinary incontinence.

Restrict fluids

Many women do not realize that too much fluid, such as water, soft drinks, juices, and coffee, can increase the likelihood of urinary incontinence. Too much fluid can lead to an overactive bladder (OAB). The symptoms of OAB are having to urinate frequently, having to urinate urgently (possibly with urge incontinence), and having to get up throughout the night to urinate.

Drinking too much fluid can also increase the likelihood of stress incontinence. A bladder is like a balloon filled with water, with a rubber band (the urethral sphincter muscle) wrapped around the neck. If the balloon is really full and you squeeze it, the water will leak or squirt out.

It is best to keep your fluid intake in the range of 48 to 64 ounces per day. That’s just six to eight 8-ounce glasses. Spread your fluid intake throughout the day.

Limit caffeine

Caffeine is another important contributor to urinary incontinence. Caffeine stimulates the kidneys to make more urine at a faster-than-normal rate. Bladders do not like to be filled rapidly. They react by becoming overactive, or squeezing down (spasming) when they shouldn’t, making it more likely that you’ll experience UUI.

Try to minimize or even stop your caffeine intake. If you have to have some caffeine, limit your intake to 8 ounces per day.

Train your bladder

If you need to urinate frequently, you can treat this with bladder training. Bladder training involves spacing out your voids. So if you currently urinate every hour, make yourself wait 1 1/2 hours before your next trip to the bathroom. Once you can do that easily, make yourself wait two hours, and so on. Your goal should be three to four hours between urinating. This may take several months to achieve.

Try pelvic floor exercises

When you perform pelvic floor exercises, also called Kegels, you tighten up, or contract, the pelvic floor muscles as if you need to prevent gas from escaping. You should feel the contraction more in the back (near the anus) than in the front.

Kegels can help with both SUI and UUI, but you’ll time the exercise differently depending on which type you are trying to control.

To prevent UUI: If you feel the urge to void and do not think you will make it to the toilet in time, stop, do a Kegel, wait until you feel the urgency subside, then walk to the toilet under control. The more times you do this, the more your bladder control will improve. It may take three months to see a significant improvement.

To prevent SUI: When you Kegel, the muscles pull up tissue under the urethra and help to keep the urethra closed when pressure hits the bladder. The trick is you need to Kegel before the pressure hits the bladder. This means if you are going to sneeze, you need to tighten at the moment you are inhaling. This takes practice, and it may take two to four months before you see a difference.

It is helpful to do approximately 30 Kegels every day. You can do 10 in a row (hold each Kegel for five to 10 seconds), three times every day.

If you don’t improve on your own, you can ask your PCP or gynecologist to refer you to a pelvic floor physical therapist, or search for one here. If your incontinence still does not improve, see a urogynecologist or a urologist who specializes in female bladder control problems.

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My Health - Hyperemesis: (Way) beyond morning sickness

Morning sickness — the common term for nausea and vomiting during early pregnancy — is not unusual, as many women know. Starting around the sixth to eighth week of pregnancy, as many as 80% of women report having nausea and 50% experience vomiting. But as comedian Amy Schumer can attest, hyperemesis goes well beyond what people generally think of as morning sickness. Marked by doggedly persistent nausea and vomiting, hyperemesis occurs in up to three out of 100 pregnancies. Not surprisingly, women who have hyperemesis often lose weight: losing approximately 5% of pre-pregnancy weight is common.

Why does hyperemesis occur?

We don’t know why women experience nausea and vomiting during pregnancy. Nor do we know why some women experience such an extreme version of symptoms. One possibility is higher levels of certain hormones, such as estrogen or the hormone human chorionic gonadotropin (hCG), which is sometimes called the pregnancy hormone.

We do know that certain women are at higher risk for hyperemesis. This includes women with twin or triplet pregnancies, a history of motion sickness or migraine headaches, or a family history of hyperemesis. Women who had hyperemesis in a prior pregnancy are also more likely to experience it again.

What happens when women have hyperemesis?

Hyperemesis is the most common reason for admission to the hospital in the first trimester of pregnancy, most often due to severe dehydration. Kate Middleton was hospitalized during her first pregnancy due to the severity of her symptoms. Women who are severely affected may develop electrolyte abnormalities that require treatment with intravenous fluids.

If vomiting is so severe that a woman cannot take in any liquid or solid food, she may need a feeding tube placed through her nose to carry a nutritious liquid supplement to her stomach. This is helpful when a woman is losing weight or having electrolyte abnormalities, which can affect heart rhythms. Particularly if hospitalization occurs, hyperemesis can interfere with a woman’s ability to work and perform daily activities. Research suggests women with severe symptoms may have higher rates of depression and pregnancy termination.

Are there health risks to the fetus?

Usually, health risks to the fetus are minimal. Women with hyperemesis have lower rates of miscarriage. Possibly, this is due to the increased levels of pregnancy hormone hCG, which may be linked to their symptoms in the first place. No research on women with hyperemesis shows problems with fetal organ development. However, a systematic review of studies did show an increased risk of low-birthweight infants and premature infants. The long-term effects of hyperemesis on children are unknown, but generally it is unlikely to be linked to permanent harm.

Can hyperemesis be prevented or eased?

• The first step is prevention, though clearly this will not solve the problem for every woman.
  Women who take a multivitamin before getting pregnant, such as a prenatal vitamin, are less likely to have severe symptoms.
• If women develop hyperemesis, the American College of Obstetrics and Gynecology recommends lifestyle changes. Examples include eating small, frequent meals that are high in protein; avoiding spicy, fatty, or oily foods; and not taking a prenatal vitamin that contains iron.
• Ginger, such as ginger tea, capsules, or candy, may help decrease symptoms of nausea. However, one systematic review of studies found that it did not decrease the incidence of vomiting.

What treatments help relieve hyperemesis?

Acupressure, acupuncture, and acustimulation have been studied in women with hyperemesis.

• Acupressure applies pressure alone to certain trigger points on the body.
• Acupuncture involves placing very thin needles at those trigger points.
• Acustimulation involves mild electrical stimulation of acupressure points.

The research is mixed, but some evidence suggests acupressure may be helpful in treating symptoms. I advise my patients that it is safe. If they feel it could help, they can try it.

Pharmacologic therapy is also recommended to keep symptoms from getting worse. First-line treatment is vitamin B6 with the antihistamine doxylamine (Unisom). If this fails, a woman might try a combination of antinausea and antihistamine medications. If severe bouts of nausea and vomiting last beyond 10 weeks of pregnancy, her healthcare team may recommend a short course of high-dose steroids.

What’s the good news?

Generally, symptoms of hyperemesis peak in the first trimester. Most likely this is due to rapidly increasing levels of the pregnancy hormone hCG, although increasing levels of estrogen also contribute to nausea and vomiting. Most women find their symptoms resolve by 20 weeks of pregnancy — halfway to a full-term pregnancy. However, some women have persistent symptoms beyond that time. And a very few women may have symptoms until they give birth.

The best options for women with persistent symptoms may be a combination of

• rest
• hydration
• avoiding a somewhat lengthy list of triggers that provoke nausea and vomiting
• trying complementary and pharmacologic treatments.

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