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Breast-feeding and birth control

Is it safe to use oral contraceptives, birth control pills while breastfeeding?

 

There is some controversy about this.

The American Academy of Pediatrics recently stated that it is perfectly safe to use one of the low dose oral contraceptives while breast-feeding once the feeding pattern has been well established.

Use of hormone contraceptives before the body has had time to heal from the pregnancy may increase the risk of blood clots in the legs or lungs.  It is usually recommended to wait at least 6 weeks before starting the medication.

Starting hormone contraceptives before 6 weeks may also interfere with the milk production or dry up the milk completely.

The various pharmaceutical companies that sell birth control pills, still state that it is not a good idea to use the estrogen containing oral contraceptives while breast-feeding.  They describe a decreased quality of the breast milk produced if the mother is taking birth control pills.  Some studies have reported small decreased amounts of protein and lactose in the breast milk of these mothers.

In the past, the “mini-pill” was used.  This is a birth control pill that contains only one hormone, progestin, and no estrogen.   Many doctors are returning to this birth control pill in their breast-feeding mothers.  Only a small amount of the progestin passes into the breast milk.  There have been a number of reports of complaints of decreased breast milk production even with this pill.  There have not been any reports of long term harm to infants that were breastfeed while the mother used progestin contraceptives.

The “mini-pill” is not as effective as the estrogen containing pill. It might be safer to use condoms with the pill as a backup.  Some studies have found that this pill may only be up to 92% to 95% effective versus up to 99% with the other estrogen progestin pills.

The pharmaceutical companies that sell progestin only contraceptives still recommend caution when breastfeeding however.

The Mirena IUD, a device placed inside the womb that releases progestin hormone or Depo Provera, an injectable form of progestin that lasts 3 months, are other options also.

 

So, to answer the question: A breast feeding mother could use a progestin only contraceptive and starting 6 weeks after breast feeding. She may consider using a backup method along with the pill to ensure 99%+ protection.  If there is a decrease in the milk production, she may consider stopping the medication if she plans to continue breastfeeding.

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Irregular Menstrual Cycles

Why do I have irregular cycles?  How can we treat irregular cycles?

There’s a long list of possibilities causing the menstrual cycles to vary from the usual 28 to 35 days periods and lasting 4 to 7 days that most women usually experience.

Of course once we rule out pregnancy, a gynecology exam can help us zero in on the cause and develop a treatment plan.

A change in hormone levels from stress, weight gain or illness or other disruptions in a woman’s routine can affect the menstrual cycle.  If the thyroid or other glands are not functioning properly, one sign may be problems of the menstrual cycle.

Polyps or dangling growths in the lining of the uterus  and fibroids, also known as leiomyoma are knots or growths of the muscle layer of the uterus may cause heavy bleeding and bleeding between cycles.  These growths are usually benign.

Endometriosis or adenomyosis can occur when the lining tissue of the uterus starts to growth outside the uterus or into the wall of the uterus.  These may cause abnormal bleeding as well as pain during the cycles and painful intercourse.

Other causes include polycystic ovary syndrome which can be seen on ultrasound, pelvic infections caused when bacteria enters the genital tract usually during sexual intercourse, bleeding disorders such as Von Willebrand’s disease,  and cervical or upper uterine cancer.

A history of use of medication such as blood thinners, skipped or late birth control pills would give us the answer also.

Pelvic examination may help us determine if there are fibroids of the uterus or any large ovarian cysts.   A Pelvic ultrasound will locate abnormalities of the thickness of the lining of the uterus or polycystic ovaries.  The Pap test will help us determine if there is pre-cancer or cancer of the cervix.  A complete blood count, blood sugar, thyroid hormone test, or other hormone tests may be very helpful.

Hysteroscopy, scoping the inside of the uterus with a directed biopsy tells us if there are polyps, pre-cancer or uterine cancer. The polyps can be removed and sometimes fibroids can also be scrapped away.  Young women may not need this step to determine the cause of the abnormal bleeding.

If all the results so far are normal or unremarkable, a daily pill of estrogen and progestin or progestin only may be all that’s needed to return the cycles to a regular and short interval.

Laparoscopy, a surgery to look inside the pelvis may be required if the cycles remain irregular to locate and treat endometriosis.

Fibroids can be treated with surgery to remove them, or a procedure to block their blood supply, or in some cases with anti-estrogen medications.

Menopause or premature ovarian failure, when the ovaries stop working, may lead to absent or very infrequent cycles.

 

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The Affordable Care Act/Obamacare

What is this Obamacare?  What if I have a pre-existing condition, such as diabetes?

 

The Patient Protection and Affordable Care Act or Obamacare was signed into law March 2010.  The aim of the law is to increase access to medical care and ensure high quality care. The estimates are that there were about 65 million people in the US without healthcare coverage when this became law. Texas had the highest rate of uninsured people followed by Florida.

 

The health law is rolling out in phases through 2018.

 

  • Young people can be covered under the parent’s insurance up to age 26.

 

  •  Preventive care (well woman exams, mammograms) is covered without co-pay.

 

  •  Insurance companies must publicly justify rate increases of 10 percent or more before raising premiums.

 

  • Insurance companies are required to spend at least 80 percent of customer premiums on healthcare and quality improvement or issue a rebate to policyholders.  Quite a few people have already received a rebate check from their insurance carrier.

 

  • Insurance companies are no longer allowed to place lifetime limits on coverage and they’re not allowed to rescind coverage except in cases of fraud.

 

  •  And starting next year, insurance companies can no longer deny coverage to individuals based on preexisting medical conditions such as diabetes, or heart disease.

 

The centerpiece of the healthcare reform law, the online health insurance exchanges unveiled Oct. 1 where Americans can shop for health insurance plans at http://www.healthcare.gov/

 

On the exchanges, people will find out if they are eligible for federal subsidies to help pay for insurance premiums and out-of-pocket costs such as deductibles, or if they are eligible for Medicaid, the federal-state health insurance program for the poor.

 

For the physician the great part of the Affordable Care act is the incentives for people to get preventive services, get checkups, find things early, get it taken care of, fill their prescriptions and follow the doctor’s advice so that you don’t end up back in the hospital. Physicians see people come in to the office or ER with advanced stage diseases/ problems that there may be little or nothing that can be done.  If these people had the ability to afford healthcare or had come in earlier, the problems could have been taken care of simply and completely. It breaks your heart to watch someone suffer, die of a problem that with all the technical advances in medicine could have been avoided.

 

It should be pointed out the Affordable Care Act does not mean the government will be doing your pelvic exams or the cost of insurance will be going up for the people who already have insurance.  As millions more people enter the healthcare market and purchase insurance with or without government subsidies, the overall cost of insurance is spread out over more individuals.  Right now, when a very sick person is admitted to the hospital without insurance coverage, the cost of that care is eventually passed on to everyone else who does have insurance in greater costs overall.  The sick person is not working, is not contributing to society.  Healthy people obviously do not utilize as much healthcare, so costs for everyone goes down.

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Epidurals in labor

What is an epidural?

 

An epidural is anesthesia used during labor or for a cesarean section. It delivers continuous pain relief to the lower part of your body while allowing you to remain fully conscious in labor or during surgery.  Medication used is delivered through a catheter inserted into the epidural space just outside the spine.  The discomfort of placing an epidural is minimal.

The anesthesiologist will have you sit up on the edge of the bed or curled on your side.  She then cleans your back, injects the lower back with a numbing medicine, and carefully guides a long skinny needle into the proper space. The anesthesiologist then passes a catheter through the needle, takes out the needle, and tapes the catheter in place.  Intravenous fluids are given prior to the epidural to hydrate you. Usually you’re given a small dose of medicine to test your response and test placement.  Then a full dose will be administered.  Medication is administered by a continuous pump while you are in labor.  There will be continuous monitoring of the baby’s heart rate and your blood pressure is checked frequently to watch for any side effects.

The epidural provides a good deal of pain relief and also numbs your lower abdomen, pelvis and legs to a certain degree.  After the baby is delivered, the catheter will be removed.

You will want to be in active labor before getting the epidural to reduce the chance that it could slow down your contractions. Active labor is usually at least at 4 cm. dilated with regular contractions.

When or if you get your epidural is a decision you’ll make while you are in labor.  You will probably want to get it before the baby’s head is crowning, or showing at the perineum.

There have been a few cases, up to 3% of patients who experience a severe headache caused by leakage of spinal fluid after an epidural.  This may be treated with liberal amounts of oral fluids and pain medication. If symptoms persist, a procedure called a “blood patch”, which is an injection of your blood into the epidural space, can be performed to relieve the headache.

If labor continues for more than a few hours you will probably need a catheter placed in the bladder because your abdomen will be numb, temporarily making urinating difficult.

If the labor progresses quickly, you may need the attendant to tell you when to push because the lower half of the body is still numb.  Sometimes the mother may rest with the epidural turned off to allow enough sensation to return to allow effective pushing.

In some case the woman in labor may not be able to have an epidural administered because of a low platelet count, an infection of the skin of the back, or infection in the blood, or labor is progressing so fast there is no time for the medication to be administered.

If you are coping well with labor you may choose not to use any medication for relief.  Some women may use just a shot in the IV periodically and find that this gives adequate relief. Some women may use both the IV medication and later the epidural.  It is always completely up to the laboring mother.  We always remind our laboring mothers that there is no medal given for not using medication in labor and certainly no disgrace if analgesia is used.  The focus is on having a safe delivery and healthy mother and infant.

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Sexually transmitted diseases: Silent Infections

Do I really need to use condoms since I only have sex with my partner?  And he is _________ (fill in the blank here)

 

It would be wonderful if we could tell who has a sexually transmitted disease (STD) by just looking or talking to a person.  Unfortunately most people who have a STD don’t realize it.  It is worth saying again that the Head Bacteria or the Head Virus does not know that this person is a good kind, hardworking special individual from a good family, etc and will not tell the other bugs to stay away from this person and wait for someone to come along more deserving of a disease.

Since the days of the sexual revolution of the late 20th century, the number of STDs has skyrocketed.  There’s genital herpes, chlamydia, syphilis, molluscum contagiosum, gonorrhea, hepatitis, human papilloma virus, AIDs, and on and on.  Most of these diseases are silent, you don’t have any signs or symptoms of the infection at least initially and they can be passed on to a sexual partner without any symptoms as well.  Some of these diseases are treatable, others are not.

It’s been said that when we have sex with someone, we’re having sex with everyone that person has had sex with for the past number of years, and everyone they have had sex with and on.  Depending on the person’s history it may be very crowded in that room.

The only protection we have is knowledge, education, and good common sense.  Talk with your partner and sound out his or her attitude about STD prevention.  A waving red flag is someone saying something like nice people like the two of you don’t get STDs.  Understand the person’s attitude and feelings about having other sexual partners or casual sexual relationships.  Even if you and the partner have already engaged in sexual activity consider starting the use of condoms; it could be the one thousand and one time that you have sex that you will pick up the HIV virus.

Everyone who is sexually active should be tested for any all diseases that can be tested.  You may want to accompany your partner to the doctor or clinic and sit with him to receive the results of regular testing.

When we think about all the various STDs and the way they can harm us, you may be so worried you don’t even want to shake hands with other people.  If we plan, use that good common horse sense, and have some frank open discussions we can’t help but be safe.