Wednesday, February 20, 2013

When should I call the doctor in labor?

If you are full term (37--41 weeks) and you are having contractions lasting at least 30--60 seconds every 5 minutes for more than an hour, they are getting intense enough to make you not be able to converse normally during the contraction, and they don't go away with rest and fluids, then you may very well be in labor.  If it's during office hours, feel free to call us there.  If not, The Birthing Inn is always open and the staff there will be happy to evaluate your contraction pattern and cervical exam and determine if it's false labor or the real thing.  If you are just not sure you can call us on the on-call number any time after hours at (703)740-5378.  If you have a history of having had rapid labors in the past, or you have already had cervical dilitation of 3 or more centimeters, we may want you to come in a little sooner, especially if you live distant from Leesburg.

If you are contracting prior to being full-term, drink lots of water, empty your bladder, lie down, and if the contractions continue to occur more than 5 or 6 times in an hour, come over to TBI to be evaluated.  If you think your water has broken or if you have significant vaginal bleeding, we'd like you to be evaluated as well.  Finally, the baby should move at least a dozen times a day in the last 2 months of pregnancy.  If you think it is moving less than that, we would like to have you monitored at TBI.  

Is it HOT in here or is it just me?

Oftentimes we have patients complaining about hot flashes or night sweats.  About 80% of women will have some degree of these symptoms as they enter menopause.  Those who enter surgical menopause (by having both ovaries removed in their pre-menopausal years) have the most dramatic onset of symptoms.   Hormone replacement therapy (available in a wide variety of forms) has gotten a bad rap over the last decade, but in reasonably low doses used short term, it is still a very effective and safe option for many patients.

For those patients who are unable or unwilling to use hormone replacement, there are also a number of alternative behavioral, nutritional and pharmeceutical options as well.  For patients with mild to moderate symptoms, we often start simply by recommending dressing in layers in natural fibers, using fans at home and work, avoiding alcohol and spicy foods, etc.  Aerobic exercise on a regular basis also has been shown to reduce hot flashes.  Soy supplements contain plant estrogens and can be helpful.  Estroven is one such supplement, although drinking soy milk or eating tofu or edamame can give you similar benefits.  The benefit of black cohosh products is controversial, although I have had patients say Remifemin works for them.

I have also had patients do well with accupuncture in some cases as well.   Many patients find relief on an antihypertensive medication called Clonidine (aka Catapress).   It is usually given once a day in a 0.1mg dose.  It can also be given as a patch.  There are a number of antidepressant medications that have been shown to have benefit for patients with hot flashes including Effexor and Pristiq.  Gabapentin has also been shown to help reduce symptoms, although it usually has to be given 2 or 3 times a day.  Most patient's symptoms will reduce spontaneously without treatment within a year, and those using hormone therapy are generally recommended not to stop treament "cold turkey" but rather to do a gradual wean in order to prevent recurrent symptoms. 

Tuesday, February 5, 2013

Healthy Bones and How to Keep Them

How does one keep from getting osteoporosis?

Well, the most important thing is probably paying more attention to building a good skeleton in childhood and adolescence by giving ourselves lots of calcium-rich foods.  We want to encourage girls to be lean and active, but intense physical exercise or dieting that leads to the disappearance of periods is bad for the bones. 

As we age, our bones naturally start to lose minerals and become thinner starting in our late 20's.  The most rapid period of decline is in the first few years after menopause.  The National Osteoporosis Foundation and other organizations agree that for low risk women without a history of fracture, the first test of bone density should be at 65 and then periodically thereafter if indicated.  Higher risk patients may need to be evaluated earlier, especially heavy smokers and drinkers, very thin patients, anyone on chronic steroid therapies, those with a strong family history of osteoporosis/fracture, or those with a premature onset of menopause.  

Most medications available to treat osteoporosis are not indicated for the pre-menopausal patient population, but there are a number of nutritional and lifestyle recommendations that are helpful, particularly with regard to Vitamin D and Calcium intake.  Medications include bisphosphonates, estrogen replacement,  raloxifene, and Prolia injections.  

For post-menopausal patients, we use prescription medications for those diagnosed with osteoporosis (T score of -2.5 or worse) or for patients with osteopenia (T score -1.0 to -2.4) who have fractured or who have a FRAX score indicating a high risk of fracture.  Go to the  FRAX calculation tool at to calculate your risk of fracture.  

Given the increasing lifespan of women, it is vital we start early in preventing fractures that can disable us as we age and rob us of our independence.