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!

Treatment of the Flu in Pregnancy

I treated my first influenza patient of the year this season. Even though she and her son received the flu vaccine they still contracted the flu. This unfortunately can happen and made me review the treatment guidelines for pregnant patients.

Pregnant patient and patients up to 2 weeks after delivery or miscarriage are considered high risk for complications of the flu. They are much more likely to need hospitalization , admission to the ICU and even death.

Therefore early empiric treatment for patient with flu symptoms including fever, respiratory symptoms and muscle aches. The earlier the treatment the more benefit is seen from the medications. ( Treatment within 2-4 days of onset of symptoms is preferred.)

Treatment with Osetamivir (Tamiflu) is preferred in pregnancy. This medication is considered Cat C because it has not been tested in pregnancy. Extensive use though has not found it not to cause harm.

Treatment of fever over 100.5 is recommended with Tylenol. Advil and aspirin are not recommended in pregnancy. High fever in pregnancy has been associated with birth defects in the first trimester.

If you are experiencing flu symptoms especially if you have a known household contact known to have the flu, please contact our office within two days.

We have recently obtained the Rapid Flu and Rapid Strep tests in our offices and can offer you empiric treatment until results obtained or an appointment is made.

Please notify our front desk personnel  immediately if you have fever and flu symptoms so we can isolate you from our other healthy OB patients.

Travel in Pregnancy

We are getting lots of questions with the upcoming holidays about travel during pregnancy.  Most airlines limit international/overseas travel to 32 weeks and domestic travel to 36 weeks of pregnancy.  Most cruise ships limit travel to 26 weeks or even less (be sure to check with your cruise line).  This is of course assuming everything in the pregnancy is going well.  Hi blood pressure, preterm contractions, bleeding or twin pregnancies would be a different story potentially.  The biggest risk with long trips in pregnancy is the increased risk of blood clots in the legs or pelvis which can break off and travel to the lungs, causing pulmonary embolus.  We recommend frequent breaks for a walk, avoiding crossing your legs, good hydration and maybe even anti-embolism stockings (medium strength) that can be found at better pharmacies.