control. period.

A tough thing to come to terms with as an adult is how little control we have over life.  Growing up we can’t wait to be in charge of our lives.  Then you become an adult and realize that there is very little you can control.  Today’s blog is about taking control back from your uterus…and your ovaries for that matter.   Hang on kids, this one’s not for the faint of heart.

I have control issues.  The more things I think I’m in charge of the better I feel.  Seriously.  I blame my parents.  (Just kidding mom and dad!)  I’ve been this way since I was small.  Trying to be in control of what I wore, what my older brother did, where we went when…sounds amazingly wonderful for my parents right?  This is why I was the LAST child.  Well one of my favorite things about my job is giving women control over their lives and their bodies.  If you haven’t heard the news ladies, your reproductive system is working hard most of your life just to do that…reproduce.  And that means a wonderfully complex rollercoaster of hormonal shifts resulting in either pregnancy or a menstrual bleed.  Really?  These are my options.  Awesome.

Humans have been trying to prevent pregnancy since at least the 1500’s.  I won’t drag you through the remote history of attempts at contraception but just know that it involves the use of alligator dung, fish bladders, mercury ingestion and more.  The first commercially available oral contraceptive was available around 1960.  In the 50 years since it has become illegal to advertise or have any public information distributed regarding contraception.   It was available to married couples only.  In fact, it wasn’t until 1972 that birth control became legal for everyone in the US.  Contraception as we know it, with many safe and reliable choices, is a reality that only came into existence in the 1980’s.  To recount all this is fascinating to me.  I have a dozen handouts and booklets on contraceptive options for my patients.  It is difficult if not impossible for me to imagine a reality where I wouldn’t have a choice in, if and when I wanted to become pregnant.  Not to mention no control overScreen Shot 2016-08-25 at 10.08.42 PM my own menstrual cycle or the multiple medical conditions that hormonal contraception is used to control and improve.  A world without hormonal contraceptive options for me is like a world without the internet on a handheld device for the pastor.  Disastrous.

When the pill first became publicly available most women requested it for menstrual regularity.  In fact, many packages had a warning label about the medications “contraceptive side effects.”  But a woman could go to her doctor and ask for the pill for these reasons and then use the medication to safely and appropriately space her family.  Using a hormonal contraceptive for a non-contraceptive indication is quite common these days.  In other words, a lot of my patients come wanting relief from their pain or anemia associated with monthly menses, improvement in their skin from excess androgens and relief from symptoms of things like endometriosis, polycystic ovarian syndrome and others.  Do some of these women use hormonal contraception to prevent pregnancy?  Yes. But some simply use it for these other reasons.  To take control away from their uterus and back into their own hands so to speak.

What most people don’t realize is that you can use the birth control pill and other hormonal methods to completely suppress their period.  No seriously, you can.  And guess what?  It’s safe to do so.  If you ask a room full of female gynecologists who aren’t actively trying to get pregnant if any of them are having regular cycles know what you’ll get?  Crickets.  We avoid periods like the plague.  Why?  Because they are disruptive.  And annoying.  And messy.  Do hormonal contraceptives have risks?  Yes, but these are small compared to the risks of having a baby.  Is hormonal contraception right for everyone? No.  But multiple studies and multiple systematic reviews of those studies have shown extended use of contraception to suppress the menstrual cycle to be no more risky than the usual use of the pill.  Oh yes, and they found that patients were happier not having their period come every month.  Shocking, I know.  When the pill was created it was supposed to mimic a regular cycle so that no one would know you were on the pill.  Sneaky, huh?  Well now every magazine you pick up contains some advertisement for birth control or tampons or something associated with your reproductive organs.  And while we still live in a culture where we raise a fuss about who is having sex with whom (well except for our own kids who would never do such a thing), we have come to terms a bit more with discussing issues surrounding reproduction.  We still have to fight battles for access to affordable and reliable contraception in a country where almost half of pregnancies are unintended.  Sex education in our culture is informal and erroneous at best which propigates most of those unintended pregnancies in both the young and the not so young. But thanks to those who have gone before and paved the way for us to make choices about our own body.  Seriously people.  Someone had to protest for me to gain control over my reproductive organs.  This is the world we live in.

So there you have it.  There are lots of things you can’t control.  What time the baby will deliver.  If your kids will behave in the restaurant.  My work schedule.  How many people will need to talk with Pastor Jason after church.  But fear not.  The menstrual cycle can be controlled.  Don’t want to have a period?   Don’t have to.  Don’t want another baby?  Don’t have to.  Don’t want to be bothered by anovulation or cramps or worsening of some other problem…don’t have to.  You can control at least one part of your life.  period.

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the problem of prematurity.

If you know me at all, you know I love completing a to-do list.  I am task oriented.  Sometimes I will make a to do list at the end of the day just to cross off everything I have completed already.  You’d think I’d be embarrassed about that…but nope.  But sometimes your to do list gets interrupted by meaningful conversations with friends.  That happened to me this week with my friend Jenny.  Jenny is a labor nurse, a mother, an entrepreneur and a friend.  Jenny is also one of the 10% of women in my state who has given birth prematurely.  She is the inspiration for this post which is a mix of medicine and miracles of God.

(please note that Jenny is not my patient and has seen and approved of this blog.  Here at gynecologyandtheology we like to remain accurate as well as HIPAA complaint.)

You see, each year in our country about 10% of babies are born premature (preterm) or before 37 weeks of gestation.  These babies fight for survival and then many of them face a myriad of health problems that can be life-long.  The problem of premature birth costs our nation about 26 billion dollars per year. Parents of these babies carry a huge emotional and financial burden.  In many cases we don’t know the cause of preterm birth and have few interventions to stop it from happening.  Age, pregnancy spacing, smoking, health complications and many other factors contribute to preterm birth.  For some of these problems we can help our mothers with education, contraception to appropriately space pregnancies and interventions to improve their health prior to and between pregnancies.  In some cases we don’t have any prevention methods such as preterm birth in twins or other multiple gestation pregnancies.

For my friend Jenny, her preterm birth story is particularly devastating.  You see Jenny’s first born daughter was born so extremely premature that she was too young to survive.  Jenny has a condition called cervical insufficiency; one of the many causes of premature birth.  Payton Marie was delivered in September of 2011 at 23 weeks gestation.  She was too young and too small for any interventions that would be life saving.  By the miracles of medicine and Jesus she now has two more beautiful healthy children.  Her story is filled with pain, suffering, the “what ifs” and more.  She had very few, if any, risk factors for preterm birth.

So what can be done?  First, be informed.  For those of you who are planning their first or next pregnancy, know the risk factors as well as signs and symptoms of preterm birth.  But for those of us who don’t plan to gestate anyone else in the future, we still need to be educated.  The problem of prematurity affects each of our communities.  You can find your state’s report card on preterm birth as well as a whole lot of other great information about prematurity from the March of Dimes.  The website has information about risk factors and symptoms of preterm birth as well as information about the problem of prematurity around the world.  And speaking of the March of Dimes, you can get involved.  I had the privilege of walking in an annual march for babies campaign to honor the friends and coworkers around me who have had a premature birth.  So get out and walk, mail that envelope back in with a donation, or become an advocate.  My state’s grade on preterm birth is a “C” so we have some work to do people!  I bet each of us know someone who has had a preterm birth.  Remember these families.  I know prematurity was probably not on your radar of problems to work on to make our world a healthier place to live…but it is a super important one!

As for Jenny, she is her own miracle.  I think my best evidence for God is that we can suffer unimaginable loss and pain and walk out the other side with continued love and compassion for those around us.  Why did Jenny have to lose her first born?  I can’t answer this.  It’s the problem of systemic evil and I will leave that one to Pastor Jason.  Jenny will Screen Shot 2016-07-17 at 7.58.47 AMprobably tell you that her two other children will never “replace” her firstborn.  She will always have 3 kids; one of them just didn’t come home with her.

I have been listening to a beautiful version of “It is Well” by Bethel Music and Kristene DiMarco.  Ironically I hated the song growing up.  People would always sing it at funerals and I just thought it was crap.  People were sad someone died.  I was sad someone died.  I really didn’t feel like it was well with anyone’s soul, nor should I feel like I was obligated for it to be well with my soul.  But I listen to this version with a renewed sense of hope.  It speaks of the power of Christ to move with us through incredible grief and pain and emerge on the other side knowing that He who suffers with us is working with us to make all things well.  This is Jenny and so many others close to me who have suffered incredible loss and heartbreak.  I think they would tell you that their friends, their families, their faith communities were the hands and feet of Jesus.  They were the grace, mercy, hope and love they needed.  That although it will never be OK, It is Well.

O09.521

If you don’t recognize it, the number above is the ICD10 code for “Supervision of elderly multigravida, first trimester.”  So what is an ICD10 code?  It is the International Classification of Diseases, 10th Edition.  The World Health Organization (WHO) owns the ICD system and it is adopted by the US Healthcare system.  Basically, these ICD10 codes are how we tell coders, insurance companies, government regulators and so many other what diseases or diagnoses a patient carries as well as what procedures were done for the patient.  Each version gets more detailed, and therefore, more complex.

Enough about ICD10.  The real point of this post is to discuss this awful designation of ELDERLY multigravida.  ELDERLY.  Sounds depressing, huh.   So what makes a pregnant woman elderly?  Get this…being over the age of 35.  No, seriously.  35. Most OBGYN’s refer to this as “advanced maternal age.”  It’s nicer.  Apparently the WHO is not nice.  But even then, when did 35 get old?  I just turned 38 and I still feel like I’m trying to figure out my life.

About 15% of women in the US give birth at the age of 35 and older and are considered AMA (advanced maternal age.)  Less than 3% give birth at age 40 and older.  Why the big deal about age?  Well, age comes with some risk.  Women who give birth in the US who are AMA have an increased risk of stillbirth compared to women under the age of 35.  Additionally, women in the AMA category are at increased risk for miscarriage, an increased risk for chromosomal abnormalities, an increased risk for high blood pressure, gestational diabetes, growth restriction of their babies, c section and other complications of pregnancy and delivery.  Once a woman reaches the age of 40 each of these risks sharply increases.  For women over the age of 40 we have special protocols to monitor their pregnancy and recommend they deliver by their due date or sooner.

So why would anyone have a baby after the age of 35?  And who are these nutty women having babies after the age of 40?  Surprisingly, I don’t hear this question a lot.  What I most commonly hear is “when should I stop having babies?”  I always ask the patient if they want my personal or professional opinion, or both.  If you know me, you know my personal opinion.  I love babies…when they belong to others.  Two of them was more than enough for me.  But seriously, what I tell the patient really depends on where they are in life and how many children they have.  When I am seeing someone who is over 35, has no children and wants to start a family I try to carefully counsel them on the small risks of complications for their age.  What about women approaching the age of 35 who already have one or more children and want to have “just one more”…or just two or three more?  Again, I counsel them carefully on the risks of their age.  This includes risks to both the mother and the child.

Last week I was asked “in your personal and professional opinion, what age is TOO OLD to have a baby?”  I loved it.  I told her that personally I am WAY TOO OLD AND TIRED to have any more kids (can I get an AMEN from Pastor Jason??).  Screen Shot 2016-07-10 at 4.44.26 PMBut then I went on to tell her that I think someone should carefully consider whether or not they want to have children once they reach the age of 40.  I think when most women think about having a baby over the age of 40 they think about the possibility of having a child with Down Syndrome or some other chromosomal problem.   But for me it’s all the other risk factors that make me nervous for my patients.  You see the risk of a chromosomal problem is about 1 in 70.  (For more information on screening for chromosomal problems go to a podcast found on perinatal quality.org ) That’s something I can personally live with.  But the increased risk of high blood pressure, diabetes, stillbirth and c section…that’s what gets me.  So what did I tell my patient?  I told her that if she wanted that “one more baby” I would advise her to be done by age 40.  What if she had no children?  Well, that’s a harder conversation for me to have.  I want her to know the risks, but I also want her to know that I support her strong desire to have a child despite life’s circumstances that have not allowed it to happen before the age of 40.

My best advice?  Try never to call a pregnant woman “elderly.”  Secondly, don’t ask women when they are going to be done having babies or if they are going to have babies.  But if you are considering when to begin or when to end your childbearing, ask your OBGYN or your MFM (high risk OB specialist).  I’m sure they will be oScreen Shot 2016-07-10 at 4.43.49 PMpen and honest with you and support you in your decision whether or not to enter the “elderly pregnancy” category.  You see, we all make different choices in life.  When we have kids and how many, where we send our kids to school, what we like on our pizza.  Some of these decisions are trivial, some have important consequences in our lives.  But we all deserve to be given compassion and understanding.  May we strive to understand our opposite, those that would choose a strikingly different path than us.  The kingdom will come near when put aside our differences and see each other as we are: people just trying to make the best in a world full of hurts.

get over it. period.

If you know me, you know that I am full of opinions and strong feelings.  Some of them are about “important things” like atonement theories, HPV vaccination, standing up for victims of abuse.  Most of them are about the “not important” things like what crust you should get on your pizza, naming your baby something that you know how to spell, wearing appropriate shoes for your outfit.  I buy clothes fairly swiftly because I know exactly what I like.  If you ask me to pick something for dinner I might not know what I want, but I will certainly tell you what I absolutely don’t want to eat.  When I picked out furniture for my home a few years ago I told the guy what he had picked that was atrocious and what was fine and he went from there.  I’ve been this way since I was small; my mother spent her mornings struggling to get me into a dress that was “too itchy” “too tight in the neck” or “just didn’t feel right.”  I would eat rice for dinner because nothing else was acceptable.  When my youngest tells me she knows best and I should stop helping her or telling her what to do my mother just smiles and I know that this is exactly what she went through.  I think many of us have stuff we feel strongly about.  One of my practice partners hates all white condiments, grammar errors, giant baby hair bows and spray tans. (love me some spray tan for my ultra-whiteness).

When does my “stop helping me, I know best” voice come through the strongest?  When I’m tired, when I’m stressed, when I’m hungry.  Oh, and when I was pregnant.  Ask any of my work friends about the day prior and the day I went into labor with each of my daughters.  I was full of opinions and strong feelings.  Most of them involved making a plan to fatally injure who I felt were the most annoying among my co-workers.  Yes, that’s right.  My friends knew I was going into labor because I threatened to kill people.  For one of my besties, it’s when she’s about to start her period.  Yes, that’s right.  PMS.  Three letters that strike fear in the hearts of husbands everywhere.  It’s what teenage boys use to blame girls for having any strong opinions.  “She told me I was out of line.  She must have PMS.”  Premenstrual Syndrome is like the government.  Everyone thinks they know how the country should be run but they have no idea how government works.  So with PMS.  They think they know what it is and what we should “do to fix it” but in reality for most it is a mystery.

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Does PMS exist? Why of course.  You see, your brain is a wonderfully strange organ.  Besides keeping you alive everyday by making sure you can breathe and swallow and move in an organized fashion, your brain is your regulatory system for your emotions, your thoughts and even your hormones.  Oh we’d like to blame our ovaries for everything, but it’s the brain that drives your body to work in the way it does.  For women, our brain is constantly “talking” to our reproductive organs, sending pulses of hormones trying to get them to spit out hormones in the hopes of getting us pregnant (no thank you).  That results in a lot of peaks and valleys throughout the menstrual cycle.  I like to tell my patients that for some women it’s like a horrible roller coaster and no one will let those bars up so you can get off the ride!  Some women have such bad symptoms that they are classified with premenstrual dysphoric disorder (PMDD) based on what poor quality of life they have during this time in their cycle.  Ouch!

So what is my response when usually well meaning spouses and significant others ask me to “fix” my patients PMS?  Usually I start with (surprise) my strong feelings about understanding what it means to be the sex that was created to carry and deliver another human being.  Give us a break.  They also give us the ability to bond with tiny humans that scream at us the moment they are born, they give us the ability to feed that tiny screaming human from our own body if we choose to do so.  Those same hormones are probably a big reason my bestie tolerates her husband who inspired this blog post with his eye rolling PMS commentary!  The truth is there aren’t a lot of options for treatment of PMS, especially if symptoms are severe.  While there is a lot of money to be made fixing erectile dysfunction, curing premenstrual syndrome just isn’t a sexy sell.  Fortunately for many women starting on a birth control pill, taking scheduled NSAID medications or even using medications to treat other disorders like depression and anxiety can help with PMS.

In the mean time, get over it. period.  Stop using PMS as an excuse for anybody like me who has lots of opinions and strong feelings.  I would never accuse Pastor Jason of having something like PMS if KD leaves OKC and he spends hours sobbing uncontrollably.  I choose not to buy into the belief that opinions and strong feelings are all bad.  Strong feelings get things done.  I hope my passion for the “important things” will be the reason we eliminate cervical cancer or domestic violence or sexual assault.  I’m sure my passion for the “not important” things keeps the church girls entertained on a daily basis.

So ladies, keep your strong feelings.  Make time for self care, even if you don’t have PMS.  Husbands, boyfriends, friends, significant others, partners, give grace to those around you.  It might be PMS.  It might be lack of food, lack of sleep, a looming deadline or some other stressor.  If you have terrible PMS talk to a physician you trust.  Hopefully you can find relief.  But most of all, give yourself some grace.  I won’t say that I have never regretted sharing my opinions or having strong feelings about something.  I am certain that a lot of my opinions are probably not correct or based on anything sound.  My opinions on lots of things have changed over time and are probably just as strong in the opposite direction of what I once thought.  And I probably won’t ever stop with the “don’t help me, I know best, here are my strong feelings” during those times of mental fatigue.  And maybe neither will you.  No apology needed.  I’m over it.  Period.

 

 

match.doc.

I had a wonderfully interesting conversation with a favorite friend this weekend.  She’s the kind of person who, when she laughs you can’t help but start laughing.  She’s unconventional in the best of ways.  When my friend moved back into town she was looking for a new gynecologist.  So, instead of asking friends or family, she just looked at pictures on the websites of doctors in town.  She was looking for someone who was “not too old but looked like they knew what they were doing.”

I could just imagine her perusing through online images of OBGYNs like an online dating site. Well, she picked a doctor and it turned out pretty well for her.  But it got me to thinking, how should you choose a gynecologist or any other doctor?  Looks?  Personality? Experience?  Data? Wait time?  Office location?

I don’t know that there is a magical answer for this.  First, most physicians are more than adequately trained.  They have spent thousands of hours in training to get to this point.  Will they be perfect?  No, we are human.  But finding a doctor is probably a lot like finding a house, a spouse or anything else in life.  I remember growing up thinking that God was using His laser beams to find me the one and only exact right person to marry and if I missed out I would never find another.  But, I DO think finding Pastor Jason is kind of the meaning of grace.  More than I deserve.  There probably aren’t any laser beams bringing you a spouse.  And there probably isn’t a laser beam directing you to the right physician.  But, I think you should look for a few key things when choosing a gynecologist or any other doctor.

  1. Do you feel free to ask questions to your doctor?  You should be able to be open and honest with your physician.
  2. Does being seen on time matter a lot to you?  Often doctors who spend more time answering questions or have a large patient population because of their great care might run behind.  You have to ask yourself if it’s worth the wait, so to speak
  3. Do you have a serious/rare illness?  Then it’s probably best to find a specialist who is highly regarding and highly skilled.  Do your homework.  Ask people with the same diagnosis or illness about who they saw and why.  Find out if any doctors you are currently seeing would recommend someone for your specific case.
  4. Do you have a gender preference?  I would say that gender isn’t a huge issue in choosing a doctor.  If your provider is a caring physician who expresses empathy then it shouldn’t matter what their gender is.  But, if you are only going to be comfortable sharing your full un-edited medical history with a specific gendered physician then maybe you should consider it.

Screen Shot 2016-06-27 at 11.03.23 AMNo, there are no laser beams directing you to the perfect doctor for you.  If you’re looking for a doctor to magically fix all your ills in one visit you probably won’t find them.  If you’re looking for someone to tell you exactly what you want to hear, you might find them but you might not actually be healthier at the end of the road.  But I do hope you find a physician who can be more than gracious to you.  Who can listen, guide, and care for you.  Who you respect and trust.  If you are seeing someone who isn’t caring for you in a way you find beneficial, seek another physician out.  I don’t want a patient to continue to see me if they don’t want to continue to be my patient.  Because while I find it hilarious that my friend found her doc in the same way you would find a date online, I would hate for anyone to be trapped on a bad date with their doctor.

May you find your perfect match.

what we don’t know.

At lot of medicine is about what we think we understand to be true.  We use the best available evidence, if there is evidence available, to help patients make decisions about their care and to manage disease to the best of our ability.  (I previously posted on this idea of evidence based medicine.)  I think most of life works this way.  Our minds compile what we think is the best available evidence to make decisions.  Like when I go to the grocery store.  Which package of strawberries seems to be the brightest, which milk carton expires latest, what granola bars my kids will eat this month.

But there are some things that we don’t have much evidence for.  Sometimes this is because we don’t have much experience or research with the problem.  Take, for example, the Zika virus.  Although the Zika virus has been around for some time, we have very little experience and research with the virus when it comes to adverse pregnancy outcomes such as microcephaly, miscarriage, and other complications in pregnancy.  You see, what was first noticed was an association.  A large number of women who had been exposed to the virus or were known to have the infection had babies born with microcephaly, or underdevelopment of the brain.  Does association mean causation?  No way.  So scientists from the CDC and other organizations began to explore how these two things were related.   For many other infections a pregnant woman might be exposed to doctors can give a significant amount of information to their patients about the risk to your baby depending on when you are exposed and other laboratory findings.  But for Zika we don’t know that information.  We have limited data that would say about 1/3 of pregnant women infected with Zika will have some kind of adverse pregnancy outcome.

So what do we do?  Well, the CDC says if you’re pregnant just never go outside. (I can hear you laughing all my pregnant ladies.)  We tell our patients to use insect repellent with DEET, to avoid travel to Zika infected areas while pregnant or for at least 6 months prior to attempting pregnancy and don’t have sex with men who have been exposed to Zika or have travelled to Zika infected areas if you are pregnant.  We have no vaccine; we have no treatment.  But, hopefully soon, we will.  Researchers will continue to work on how the virus is transmitted, why certain women’s infants are affected, and how to prevent or treat Zika before it becomes an even bigger health concern.

The other issue I’d like to address today that we don’t know much about is gun violence.  Oh yes, I went there.  You see the CDC has had a self imposed ban on gun violence research since 1996 when its funding was threatened.  It has been more than 4 years since Sandy Hook and only a week since the Orlando night club shooting.  Two large bills to fund gun violence research have failed to pass.  Is there some research out there on gun violence? Sure.  But consider this: if you do a PubMed search on Gun violence you will find about 1500 scientific articles or editorials on the topic.  If you do the same search on autism, you will find over 34,000 articles on the topic.  Is autism research important?  Absolutely.  Should we have the opportunity to publish over 30,000 more papers on gun violence?  Absolutely.  Because I can’t tell you if more guns or less guns or safer guns or more training or anything will keep men women and children from being gunned down by individuals hell bent on destroying the world around them but unless we try and find out what we can do we are powerless to do anything.  It’s like telling pregnant women not to go outside or just avoid travel to Zika areas…sometimes you need to go outside and Zika might just come to your area.  And then you need to know what best to do for yourself and your family.  You need to know what you don’t know.

So, on this Father’s day, I am thankful for a father who loved to hunt but always made us feel safe and secure when we went with him.  For a father in law who loves to travel and has been generous to take us with them.  And for a husband who loves his daughters, and everyone else around him for that matter, enough to work hard to bring more peace to the world on a weekly basis.

(photo credit to @jonmsutton on twitter)

an ounce of prevention.

An interesting thing happened to me a few months ago on a Sunday morning.  I was doing my after church thing…which means my children run around the sanctuary like banshees and pastor Jason is talking to a hundred or so folks and no one can decide what to do for lunch.  It’s a routine of madness.  In the midst of all of that I was approached by a family in our church.  These are people I adore.  They are faithful, they are helpful, they are fun.  Their oldest has started that tortuous time we call middle school.  As a side note there are literally 10 million things I would do over again before middle school.  Like medical school, the last 4 weeks of pregnancy in the Oklahoma heat, 24 weeks of Gyn Oncology service as a resident….middle school seems like the worst thing….but back to the story.

This lovely family had visited their local pediatrician for a routine well child check.  Their pediatrician had appropriately recommend the meningococcal vaccine and the Tdap vaccine (which they happily accepted) and then something strange happened….their pediatrician then asked them to “consider the HPV vaccine…to ask their friends, to read about it, to think and let the doc know what they wanted to do.”  So they came to me to find out “why wouldn’t our doctor want our daughter to have this vaccine?  Is there something wrong with it?  What should we do?”  At this point I am making that face when you are horrified by something…the one with your eyes wide and your mouth open.  And of course I said yes..yes..yes…please go back and get the HPV vaccine series for your child!

If you didn’t know, Human Papillomavirus (HPV) is responsible for about 17,000 cancers a year in women and about 9,000 cancer per year in men.  About half of men and women in the US will be infected with HPV at some point in their life…around 79 million Americans.  Most of those infections occur between ages 19-24 and most of those young men and women will clear the infection on their own without a problem.  So, you might ask, why do we vaccinate against HPV?  Well, we know that almost 13,000 women in the US will be diagnosed with cervical cancer, and 99% or more of cervical cancer is caused by one of the high risk strains of HPV.  4,000 of those women will die of their disease.  Additionally, more than 200 million health care dollars will be spent in 1 year in the US to treat other HPV related diseases such as genital warts.  When you take into account all the screening for HPV related cancer and treatment of pre-cancerous HPV diseases the cost adds up to about 8 billion dollars.  That’s billion, with a B.  Imagine what our health care system could do with those dollars if we would significantly decrease or eliminate the burden of HPV disease through vaccination.

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The vaccine works.  Multiple studies have shown it to be extremely effective.  We’re talking 99% effective against the pre-cancerous changes that I see and treat on a weekly basis to try and prevent my patients from getting cervical cancer.  Right now about 39% of US adolescents are being vaccinated.  The goal is for 80% of those eligible to receive the full vaccine series.  In short, we are doing a terrible job folks.  In contrast, our friends in Australia have a vaccination rate around 75%.  They have virtually eliminated genital warts in those women under the age of 21 and soon will see a dramatic reduction in cervical cancer.

So why wouldn’t all our girls and boys age 11-12 receive the 3 dose HPV vaccine series?  Well,  first of all, our health care providers aren’t recommending the vaccine.  My friends from church have great trust in their pediatrician and have faithfully received all the vaccinations recommended to them.  But the HPV vaccine was not.  If we as health care providers would recommend HPV vaccination along with other routine immunizations for 11 and 12 year olds we could exceed the 80% immunization goal.  What are the barriers to provider recommendation?  Well, there could be several.

Our culture has made the HPV vaccination into a moral argument.  Parents believe that their child is more likely to become sexually active if vaccinated.  This has been proved incorrect in the medical literature over and over and over again.  Kids are no more likely to become sexually active after HPV immunization than they are to go seeking out someone to snuggle up with who has meningitis after being immunized against it at the same age.  We assume that people infected with HPV and those who have HPV related diseases must have done something wrong, behaved inappropriately, had “loose morals” or some other kind of disgusting label such as that.  The reality is that this disease can affect anyone.  Show me someone whose life turned out exactly as they had planned and whose children turned out exactly as they had planned and maybe you have an argument against vaccination…maybe.  But really for all of us, we don’t know what life will bring.  We can’t predict much of what will happen to us or those around us.  As I like to tell the medical students…no one leaves on a plane for  Africa to do some good missionary work with the intention of finding someone with yellow fever and being infected…but we still get immunized before the trip without question.  Immunization against HPV is just the same.

Additionally, our culture loves to believe what we read on the internet (ironically what you are doing right now).  Despite this vaccine being shown by research in the US and multiple studies in Europe to be safe and demonstrate no pattern of serious neurologic or other injury, many in the US are still afraid that HPV immunization will make your child sick or is some kind of conspiracy theory.  Does the vaccine hurt?…yes.  Are adolescents, especially girls, more likely to pass out with this immunization?…sure.  Do all immunization involve a very small likelihood of serious risk?…yes.  But that’s about it.  And those risks are much smaller than the risk you or your child has of being affected by HPV related disease.  Our role as health care providers is to educate and advocate.  If you ask any of my medical students they will tell you how they endured the “all things HPV” lecture during their time on OBGYN.  My hope is that there will be more voices who advocate for HPV immunization and than any loud voice that might tell them otherwise.

Screen Shot 2016-05-30 at 1.19.37 AMSo, health care providers….RECOMMEND the HPV vaccine.  Telling a women she has cervical cancer, treating recurrent genital warts, seeing complication of pregnancies caused by the treatment of HPV related diseases is heart-breaking work.  Trust that your patients will listen to you.  Present them with the truth and advocate for their future health and the health of the people they love.

Parents, pre-adolescents, teens, and those who know or love a parent, pre-adolescent or teen: don’t assume it can’t happen to you.  As Ben Franklin said “an ounce of prevention is worth a pound of cure.”  I hope I have to find something to do with those 20 hours a month I spend screening and treating HPV related disease.  I hope that someday we will speak of cervical cancer and other HPV related diseases like we do of polio.  Ask questions, get vaccinated, tell others.  If you have questions, ask a trusted health care provider.  If they can’t answer them, find another health care provider who can.  You never know who the 4000 lives are that would be saved.

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a voice in the wilderness.

It has been quite a week.  Pastor Jason was involved in all the church Sacrements last weekend.  A funeral, a wedding, a baptism, a dedication and communion.  Which means it was a very. busy. weekend.  So I didn’t get my blog post done on Sunday.  I was a bit disappointed in myself but I just didn’t have peace about the final version.  Well, it got scrapped so here I am with version number 2.  Same title, different content direction.

My first version of this post told a story about Nancy and Mac, who we sat next to at the rehearsal dinner and who were a voice in the wilderness for us.  They spoke into our lives and reminded us that what we do each day has meaning and purpose, that our hard work is not thankless and that there is hope in the future.  And then Monday happened.  Work was work and people were acting a fool.  So the blog post sat.

But today my disappointment for not being done with the blog post “on time” was wiped away by renewed inspiration to be a voice in the wilderness.  If you didn’t know, I live in Oklahoma.  Today, our state passed a bill that makes it a crime for any physician to perform an abortion in our state, except for in the case of the life of the mother.  You must be thinking as a person of faith and a pastor’s wife that I would think this is great news, right?…wrong.  Fasten your seat belts kids, this Jesus loving gynecologist is going to try to explain to you why this is a terrible idea.  It’s going to take a minute, so bear with me.

First, I don’t think we can consider ourselves “pro life” unless we are really going to work to help make a life for those around us.  That means a living wage for all people, enough food for families to eat, prison reform, quality education for all and support for those women who find themselves raising a family alone…not to mention standing up against domestic violence and sexual assault.  And to be pro-life means you support planned and appropriately spaced pregnancies so that they are more likely to have healthy babies and take care of them in the ways we would all like.  It means you believe in access to affordable and reliable contraception for everyone.   Because even if you intend to be abstinent you might find yourself among the 1 in 5 women who is a victim of sexual assault..see previous blog post…needing emergency contraception.  Which, by the way, prevents ovulation…which happens PRIOR to conception, therefore not ending pregnancies, just preventing them.  And if we as the culture, the church or the community are really going to say we are pro-life…then we need to have the guts that two of my close friends did and invite a child from the over-flowing foster care system into your home.

Second, laws like this do not deter women from getting an abortion.  Electively terminating an pregnancy in my state is not easy to do.  Women must have money, transportation, time off of work, family or community support, not to mention navigation of the multiple laws.  So I don’t think adding this one will make a huge impact.  What makes abortion rates go down?  Access to affordable and reliable contraception.  In Western Europe abortion rates are very low, even though it would be easier to have an elective termination of pregnancy there compared to most places in the US.  Why?  They have a high rate of contraception use and a low unintended pregnancy rate.  Furthermore, I disagree with the legislation of reproductive rights.   What would happen if someone made a bill that said I couldn’t have fertility treatments to have my second child? What about a law that says no one can have more or less than 3 kids?  Uh, no thanks.  We think that these laws restricting or outlawing abortion are “good” because abortion is “bad,” but legislating reproductive rights in any way is never good. You just might not see it that way until you are on the receiving end of the law and it doesn’t fit your belief system.

Lastly, physicians don’t practice good medicine when we practice in fear.  In my job and within my belief system I would only be involved in a termination of pregnancy if the life of the mother is in danger.  I make these decisions based on clinical experience, medical evidence and science and standards of care if they exist.  Except…now that I might go to jail if I make the wrong decision will I second guess just what does “exceptions for the life of the mother” mean?  Can I remove the ectopic pregnancy, and therefore terminate the pregnancy, before it ruptures and tries to kill the mother?  Do we deliver the woman with very early and very severe preeclampsia knowing her baby will almost surely die from prematurity before she has a stroke or a seizure or is her life only in danger if one of those happens.  These seem like silly questions but when providers are asked to make decisions with a law hanging over their shoulder threatening to make a criminal out of them it just might impact judgment and decisions.  And that will certainly negatively impact the lives of women in our state.

So what do we do?  Well, it is my hope and prayer that no woman would need to undergo an elective or medically necessary termination of pregnancy (i,e, abortion).  I hope that I will be around to see that world.  But it won’t happen if I don’t do my part.  My solution, for today, was to be a voice in the wilderness.  Mostly, I try not to get myself or the pastor in too much trouble with my tendency to say whatever I am thinking and ask whatever is on my mind.  I will certainly have friends in my church, my Christian community and others around me strongly disagree with this post.  But as Pastor Jon and Jason say, we must find a way to disagree Christianly.  Nancy and Mac, from the rehearsal dinner, were a voice in the wilderness for me.  They weren’t afraid to say what they thought, to listen to us and to tell us that our voices matter.  Today I am a voice in the wilderness for the women and their children in my state.  My state that has no solution for a 25% reduction in state funded healthcare that will leave thousands without access to medical care, a state where the district I live in has a 3.6 million dollar deficit to make up for in education despite having some of the lowest paid teachers in the nation and no art program.  A state where we put more women in prison that almost anywhere else, where we have significant problems with tobacco abuse, obesity, cancer prevention and other community health needs.

Isaiah is one of my favorite books of the Bible.  It is the inspiration for this blog post.   I love Isaiah 40.

Comfort, O comfort my people,
says your God.
2 Speak tenderly to Jerusalem,
and cry to her
that she has served her term,
that her penalty is paid,
that she has received from the Lord’s hand
double for all her sins.
3 A voice cries out:
“In the wilderness prepare the way of the Lord,
make straight in the desert a highway for our God.
4 Every valley shall be lifted up,
and every mountain and hill be made low;
the uneven ground shall become level,
and the rough places a plain.
5 Then the glory of the Lord shall be revealed,
and all people shall see it together,
for the mouth of the Lord has spoken.”

Be a voice in the wilderness today.  I challenge you to think about what it means to be “pro-life” to everyone around you, whether you think like them or not.  The truth is they are loved by God just like you.  Maybe, together, our voices can improve the systems we live and work in so that the valleys can be lifted up, the ground will be leveled and the glory of the Lord will be revealed to the least of these that surround us.  Thanks for enduring with me on this one.

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the business of fertility. (part 2)

In part one of this post, I shared a bit about the “funny business of infertility.”  How no one thinks twice about asking when you’re having babies or thinks it odd to advise you on why you should have babies and how many you should have.  In fact, this was the topic at a lunch conversation with my colleagues at work this week.  I have a physician partner who had someone try and convince her to have a baby…about how great it was.  Like she doesn’t know how pregnancy and childbirth works so she needs someone else to convince her to do it?  People are crazy.

In that post I also told you to what great lengths it took Pastor Jason and I to become pregnant with our second child.  Infertility and recurrent miscarriage affect about 11% of people in this country.  Men and women both contribute equally to the problem of fertility, although I never heard anyone ask the pastor when he was going to have more kids. During the long journey to baby number 2 we got lots of “input” from many around us.  We were blessed to have many people from our church and our family praying for us to experience the joy of parenthood again.  We also had opinions about whether or not we should continue with treatment, adopt, and all sorts of things in between.  And I get it.  There’s some risk involved.  Personal and financial.  People have fundraisers for fertility treatment and adoption.  Marriages begin and end based on fertility.  Adoptions fall through…over and over again.  Treatment fails.

Another funny thing about the business of fertility is you don’t know what you would or wouldn’t do until you’re in it.  When I got pregnant I was in discussions with my specialist about moving forward with much more intense treatments.  I speak with women and their families every week that face decisions about pregnancy and fertility.  Some of them are trying to decide if and how they should pursue treatment to become parents.  Many of them are deciding whether or not this child will be their last.  Others are facing choices like whether to give their baby up for adoption or what to do if their child has a lethal malformation.  I believe that most of us think we know “what I would do in such and such situation” but the reality is that you won’t know what path you will choose until you get there.

So we should just mind our own business…right?  Well not entirely.  In some aspects fertility is everyone’s business.  While we are quick to ask when a baby or more babies are coming…we need to understand that the right to plan a family is paramount to the health of our society.  Unplanned pregnancies, closely spaced pregnancies, teen pregnancy all have a higher rate of poor outcomes.  If you want to talk about fertility then let’s focus on providing effective and affordable and reliable contraception to those who are young, vulnerable and who don’t want to be a parent at the moment.  We have spent far too much time talking about what we think will drive down the abortion rate.  We have a higher abortion rate in this country than in places where there is no regulation at all.  If you want to end abortion let’s drive down the unintended pregnancy rate.  Let’s stop filling up the shelters with children waiting for families.  Let’s stop asking when Dr. Smith is going to have baby number 3 (seriously) and start thinking about how we are going to educate, love and care for our young women so that they can lead us into a future filled that we will WANT them to bring kids into, a future with hope and peace.

And that, my friends, is the business of fertility.