"I Didn't Sleep a Wink Last Night, Doc!" Part 2, Nonpregnant patients

For those who don't have a baby inside nudging them awake all night long, there are still lots of reasons  why you might have trouble sleeping.  Stress, excess stimulation, various types of physical discomfort, anxiety/depression, and age-related changes in the need for sleep can all be involved.

There are basically two types of insomnia:  the kind where you can't fall asleep and the kind where you fall asleep just fine but awaken earlier than you'd like and then you can't fall back to sleep.  The second kind in general is frequently associated with anxiety and depression, so getting those problems treated is very important as well as reducing those sources of stress that you can control.  I've had several patients with longstanding insomnia that resolved after finally leaving a stressful job, for instance.

Physical discomfort can also awaken people during the night, including the need to urinate.  It is considered abnormal if you have to get up more than twice a night to empty one's bladder.  I often look at a patient's medications to see if they are using diuretics to manage high blood pressure.  While diuretics are great medications for blood pressure, there are also lots of alternatives out there that may do just as good of a job without causing frequent urination.  (Of course, your family/internal medicine doctor would need to be consulted regarding the best plan for your blood pressure management.)  Caffeine and alcohol are also potent diuretics that should be avoided close to bedtime, and avoiding drinking fluids for two hours prior to bedtime can also help keep your bladder from becoming excessively full during the night.

Other medications that can be excessively stimulating for many patients are those used to treat nasal congestion caused by allergies or upper respiratory tract infections.  Antihistamines in general are more sedating while decongestants are more stimulating.  Neti pots are a good non-pharmaceutical alternative to managing chronic nasal congestion.

Other sources of physical pain and discomfort need to be addressed if they interfere with sleep, as lack of sleep tends to perpetuate pain syndromes.  Many chronic pain patients can be managed well with certain antidepressants, anti-seizures medications, and other agents that reduce pain without leading to drug dependence.

One of the more serious issues of sleeplessness is sleep apnea.  Common symptoms are snoring reported by one's sleeping partner along with periods of absent breathing followed by a sudden intake of breath.  This can be associated with obesity, alcohol intake, certain medications, sleeping position (mostly back sleepers), and certain anatomic conditions of the neck and throat.  Untreated, sleep apnea can be very hard on the heart and is associated with an increased risk for sudden cardiac death.  Many local neurology practices offer sleep studies to help identify the extent of the condition and recommend treatment options, which may include a special breathing machine called CPAP.

As people age, many do not need as many hours of sleep at night as they might have in preceding years.  If you awaken after 6 hours of sleep feeling refreshed and don't develop significant fatigue during the day thereafter, that may be all you require.

If daytime fatigue is a problem, there are a number of ways to help yourself get back to sleep including avoiding bright lights/computer screens/TV/suspenseful books, etc.  Avoiding heavy meals close to bedtime is also important, particularly for those who tend to suffer with heartburn.  Making sure your bedroom is dark, quiet and that the temperature is right around 70 degrees, and sticking to a regular sleep schedule all work toward good sleep hygiene.  I like to use a white noisemaker myself to drown out random noises around my house.  Warm milk, a light snack or herbal teas can be relaxing, or even a warm bath.  Meditation techniques to control persistent worrisome thoughts are also very effective for many people.  Daytime exercise (ending at least 4 hours before bedtime) is also associated with a variety of health benefits, including more sound sleep.  Short naps in the daytime can be a wonderful way to refresh oneself, but long naps (more than 45 minutes) can interfere with nightime sleep.   Short term sleeping medications are useful for acute insomnia, although in older patients, I worry about sedatives contributing to falls at night. 

"I Didn't Sleep a Wink Last Night, Doc!" Part 1--Pregnancy Insomnia

I'm often asked by pregnant patients and their partners what they can do to help them get better sleep.  Oftentimes, they are physically uncomfortable in the back and hips and cannot seem to find a comfortable sleeping position.  Other times hand numbness/tingling/discomfort is the culprit, and nasal congestion and shortness of breath can also be reasons for difficulty resting.  Finally, a very common source of insomnia for both pregnant and non-pregnant patients is stress and anxiety.

The most common sleep aid I recommend is a "body pillow" to provide support for the full length of the body while sleeping on either the left or right side (after 16 weeks it's a no-no to sleep on one's back in pregnancy).  Other smaller pillows may also be useful to support the enlarging abdomen or to place in the lumbar area.  If the bed is just not comfortable to sleep in at some point, it may be necessary to find another place in the house that's more comfortable--the guest room bed, the couch, the recliner, etc.  I always say "whatever works".  

For those with hand discomfort, wrist braces can be purchased at a pharmacy that carries medical supplies and adjusted to keep the hand(s) at a neutral position during sleep, decreasing compression on the nerves.  Avoiding hi sodium/salty foods is also useful in reducing fluid retention and nerve compression in the wrists as well.

For those with nasal congestion, using saline nasal spray and/or a humidifier can be helpful, and many of my patients with chronic sinus congestion swear by the "Neti Pot" irrigation techniques.  We only recommend nasal decongestants for short term (i.e. 3 days or less) management of upper respiratory tract infections, as they are stimulants to the cardiovascular system, and can actually worsen insomnia as well.

Shortness of breath is a very common symptom in advancing pregnancy, in part due to the compression of the diaphragm from below as well as to other physiologic changes in pregnancy.  Proper positioning and posture can help, as well as elimination of common allergens such as pet dander (no sleeping with Fido!), mold/dust (break out the vacuum, Dad!), and appropriate prescription medications for those who suffer with asthma.  Of course, we always recommend avoiding smoking in pregnancy and exposure to second hand smoke.

Stress and anxiety are very common, especially with the excitement of impending birth and changes to family structure, financial concerns, relationship issues, and so on.  This is particularly true if you are carrying a high risk pregnancy that has caused you to be on bedrest or to modify your work hours.  There are also lots of patients who were anxious people long before they conceived a pregnancy.  Doing what you can to control the sources of stress in your life is an obvious (though not always easy) fix.  Avoiding stimulants such as caffeine, exercising close to bedtime, too much screentime (TV, computer, smartphone, etc) close to bedtime, and so on can be very effective.  Sometimes sleep aids are recommended short term such as diphenhydramine, Ambien, etc., but we like to clear the system prior to the onset of labor of any sedative medications that may hang around longer in baby than in mom.  Finally for those who are clinically depressed/anxious, certain prescription medications may be recommended to avoid the consequences of those conditions in pregnancy, including insomnia.

Finally, one of the most frequent complaints I get from pregnant women is that they have to urinate all the time, including during the night.  Clearly avoiding over-drinking prior to bedtime can help, and as long as your urine is a light yellow color you don't have to worry about being dehydrated.  If there is burning with frequent urination, a urine culture should be done to rule-out infection.

Sometimes I look at a little insomnia as God's way of getting us ready for the true sleep deprivation yet to come after baby's arrival, but getting as much sleep as you can before baby is a gift to yourself.  Happy dreams!

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. http://www.menopause.org/for-women/menopauseflashes/the-experts-do-agree-about-hormone-therapy

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. http://www.menopause.org/for-women/menopauseflashes/the-experts-do-agree-about-hormone-therapy

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. 

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 http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=9 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.  

WEIGHT LOSS AND YOU

So...It's a Happy New Year and you're thinking about losing weight.   You've put it off long enough.  You tried not to put on the usual 5-10 pounds that usually occurs during the holiday season, but did anyway.  Where do you start?

Well, you first might want to figure out why you want to lose weight.  Likely, you think if you lose the weight you will look great!  This is like the feeling you experienced while dating the best looking guy in the history of your love life;  nice for a while, but superficial and ultimately not as satisfying as you imagined, not to mention short-lived.  How about to live a longer life?  That has to be it!  No again.  A recent study published in the Journal of the American Medical Association found that only people with body mass indices (BMIs) of greater than or equal to 35 were at a higher risk of death from any cause than compared to people that were normal weight or moderately overweight.  That's right, I said OVERWEIGHT.  In fact, they found that people that were overweight actually had a LOWER chance of dying (by 6%) than people with normal BMIs (equal to 19-25).  I can actually hear all of you breathing a sigh of relief. 

Why would people that are overweight have a lower chance of dying than those of a normal weight?  Well, the experts theorize that possibly people that are overweight are treated more aggressively for medical conditions such as diabetes, elevated cholesterol, and high blood pressure than their normal weight counterparts.  Overweight people are less likely to have osteoporosis, a condition that leads to an increased risk for life threatening hip fractures.   Another factor may be that if you are overweight and develop a life threatening illness, that those extra pounds provide needed energy reserves.

Ok, so now you say, why should I lose weight at all?  How about to FEEL GOOD!?  How about to have the energy we need to meet the demands of our fast paced lives?  How about so you don't need all those medications to treat medical conditions that come from eating the wrong foods and not being active enough?  That sounds pretty good.  If we eat healthily and maintain an active lifestyle (watching TV or playing on your Ipad does not constitute an active lifestyle) but are not rail thin, let's not beat ourselves up too much.  Make sure you are getting screened for elevated cholesterol, diabetes, and hypertension on a regular basis.  Make sure you are eating a diet rich in a variety of vegetables (yes, these come first in priority and amounts), fruits, lean proteins, and complex carbohydrates.  Minimize your alcohol intake (ladies, this is <7 glasses of alcohol per week and no more than 2 glasses at a time).  Move, exercise, dance, walk, park your car far away from the mall entrance/from the grocery store entrance, take the stairs, just get going!  If your BMI happens to fall into the "overweight" category, but you are living a healthy lifestyle, don't fret.  You'll have less of a chance of dying than the skinniest person you most envy!


To calculate your BMI (body mass index): take your weight converted into kilograms and divide it by your height (converted into meters) squared. 

Happy New Year from Loudoun Physicians for Women

Happy New Year, 2013!
We at Loudoun Physicians for Women wish you and yours all the best for the new year.  Now that we've narrowly averted going over a fiscal cliff, what's next for the coming months?  For those interested in a resolution to lose weight and get healthy, I'm a big fan of the Weight Watchers program, both online and in-person.  It's been shown to help folks maintain their losses better than those other programs that provide you their food options without really teaching you better attitudes toward your food/shopping/cooking/eating out, etc.  Even modest losses (10-15% of your total body weight) have measurable health benefits to your blood pressure, cholesterol and glucose levels.  Small increases in your physical activity (taking stairs instead of elevators, parking at the far end of the parking lot, stretching and doing some light weight-lifting while watching TV in the evenings, etc.) can make noticeable differences in your energy level and flexibility, as well as your ability to maintain your weight.  Paying attention to your calcium and vitamin D intake can help to stave off the risk of osteoporosis and fracture as you age, especially the younger you start.  Reducing stress wherever you can affects not only your mental health but your physical status as well.  Making time for friendships, leisure activities, and spiritual growth are all important in keeping your "happiness quotient" up.  We see many of our patients doing wonders at taking care of everyone but themselves, and we want you to remember you're no good to them if you're not in the best shape you can be.  We're behind you all the way!