Implanon Contraceptive Failures – Reality Check

The media is abuzz over recent reports of pregnancies occurring in women using Implanon, a single rod progestin-only contraceptive inserted under the skin of the upper arm and lasting for up to three years.

The headlines make it sound horrifying – “Hundreds Become Pregnant Despite Contraceptive Implanon” and “British Pregnancy Scare in UK Implicates Implanon”.  I love how terminology can make something so common sound so frightening…

Actually, what happened was that 584 pregnancies occurred in Britain among about 1.3 million women using Implanon, for a failure rate of .04%. In other words, the method had an efficacy of over 99%.

That’s a pretty effective contraceptive if you ask me.

But it should have been better than that.

As good as it may seem, this failure rate is significantly higher than most of us would have expected based upon data from clinical trails of Implanon.

I recall being told at an Implanon insertion training just prior to its introduction in the US  that in fact, not a single pregnancy had been reported at that point among users of the device in clinical trails.  This would put the method up there with sterilization and IUD in terms of efficacy.

So what happened?

How did Implanon go from perfect efficacy to something less than perfect ?

A study of Australian Implanon failures gives us a few clues. In that country, the majority of Implanon pregnancies occurred because the Implanon never left the needle at the time of insertion. In other words, there was an unrecognized failure to insert the device correctly.

For the rest, it appears that the women were actually pregnant at the time the device was inserted, were taking another medication that interfered with Implanon’s efficacy, expelled the device or had it inserted in the wrong time of the cycle to be effective that first month of use.

Only 13 reported pregnancies were actual device failures during a period when over 200,000 devices were sold.  13/200,000, or .0065% – Now that’s more in line with what we expected of Implanon.

Did Merck Do Enough to assure Implanon’s success?

While I have no idea what happened in Britian and Australia, I have to say that Implanon’s manufacturer (Organon, now Schering-Plough, which is now Merck) made an extraordinary effort to be sure that those who inserted Implanon in the United States knew what they were doing. I was part of the first groups trained, and found the training and follow-through to be above and beyond anything I’d ever seen.

Was this because they had an inkling of the post-marketing experience in Britian and Australia?

Or because they learned from watching the Norplant debacle that bad surgical technique on the part of a few practitioners, combined with a few greedy lawyers, could take down one of the most effective contraceptivesever to hit the market?

Either way, I was impressed.

Nexplanon – The New, Improved Implanon

I’m also impressed that the manufacturer, not satisfied with the insertion failures in real-world hands, have improved upon the design of the inserter. The device is also now visible under x-ray, allowing for a reliable way to assure its presence if it cannot be palpated under the skin.

But why is all this news?

You don’t see any headlines about the millions of pregnancies conceived while using condoms or the pill, do you?

Pregnancy Horror – I was too lazy to get up and put in my diaphragm, and now I’m the mother of twins!

Or better yet –

Pregnancy Shocker! I know I missed three pills this cycle, but I figured I’d get away with it…

While it probably should be, this is not news. That’s because when we get pregnant on the pill, or while using condoms or a diaphragm, we blame ourselves.

But if it’s someone else’s fault, well, that’s something to talk (and sue) about.

What also makes Implanon pregnancies special is that when they do occur, they can go undiagnosed for such a long time due to menstrual irregularity that women are told to anticipate as an effect of the method. Inability to detect an early pregnancy, combined with failed expectation of an almost perfect efficacy based on the manufacturer’s literature, makes women feel betrayed.

And there’s nothing the media likes more than a betrayed woman.

Unintended Consequences and Unintended Pregnancies

While I don’t wish to belittle or diminish the individual impact that an unexpected pregnancy has for any individual woman, especially when she has done all she can to prevent from becoming pregnant, I do have concerns about all this media attention to Implanon failures.

That’s because, unfortunately, media attention such as this, rather than informing, tends to lead women to mistrust hormonal contraception. And when women distrust hormonal contraception, they tend to discontinue it and move towards less effective barrier methods, or worse yet, no contraception.

The end result? Unintended pregnancy.

Thus, one consequence of all this media reporting about the contraceptive failures with Implanon could actually be even more unplanned pregnancies.

Great.

Bottom Line

Implanon remains an extremely effective contraceptive, when inserted properly and at the right time in the cycle in women not taking medications that interfere with its efficacy. New generation devices will hopefully have less insertion issues among practitioners, who must be properly trained in its insertion.
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What’s Wrong? It’s a Rip Off, That’s What’s Wrong

Cute packaging and product placement in the check out lane at Duane Reade will get you generic Tylenol for a price equivalent to 25 bucks for 100 tabs*, as opposed to $6 per 100 count in the usual package.
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* Ignore Duane Reade’s unit price sticker up there. The math is wrong, as was pointed out to me by Help’s founder Richard, in the comments section. Unfortunately, the pills are still overpriced as far as I’m concerned.

Vaginal Steam Baths – A Douche By Any Other Name…

A spa in California is offering vaginal steam baths , in which spa-goers squat or sit on open stools over a tub of hot steam, as a cure-all for menstrual disorders, digestion and mood –

The V-Steam. Inspired by an ancient ritual practiced for many years in Korea. The steam from the herbal tea rises and absorbs into your skin & orifice. This steaming treatment stimulates the production of hormones to maintain uterine health, aids regular menstrual cycles, helps correct digestive disorders while soothing the nervous system. The natural antibiotic and anti-fungal properties are said to help maintain internal health as well as keeping your skin looking young.
30 min. $50 Series of 6 for $180

It’s a douche, folks.

A $50 douche made with mugwort and 13 other herbs and having a fancy Korean name – Chai-Yok. True, the water gets up there as steam, and if you don’t squat just right over the steam bath, I imagine it may not get up there at all. But in the end it’s a douche.

We docs strongly advise against douching, since we know that women who do it have higher rates of vaginal and pelvic infections. Not to mention that the vaginal mucosa is highly absorptive surface, meaning anything you put in there is likely to end up in the rest of your body. And so I ask – what herbs are they using, at what doses, and what side effects might they have?  Not to mention what might be growing in those wooden tubs they have you squatting over…

Fertility aid? Right – Prove it.

The Koreans aren’t the only ones who use vaginal steam baths. In South American cultures it is called Bajos, and it’s being promoted all over the web as a “rainforest” fertility aid, using every possible herbal combination under the sun.

No surprise then, that the owner of the California spa credits Chai-yok for her pregnancy achieved at age 45 after “trying for three years”.  I notice she does not say how she “tried” to get pregnant, which makes me wonder if she is leaving out some little detail that may have led to her reproductive success, something like, oh I don’t know, maybe… fertility treatments? Not to mention, she may just have a little itsy-bitsy conflict of interest in making her claim, since she’s the one selling the V-steam? This, however, has not stopped websites from using headlines like “Vaginal Steam Baths Could Cure Infertility and Bad Periods“. Dumb.

The thing that upsets me is that the owner of this spa is an orthopedic surgeon. I can forgive his Korean wife for buying into unsubstantiated folklore medicine, but what’s his excuse? He and his wife can V-steam all they want in the privacy of their home, but where does he get off offering unproven, and potentially harmful, treatments for infertility and menstrual disorders? Shameful.

Bottom Line

I’d avoid the vaginal steam spa if I were you.  Especially if you are prone to yeast infections, since yeast love a warm moist environment.

Regarding Vagina Jokes

Now, before you start posting your funny vagina steam comments here, head on over to the Yelp spa review site, where someone has probably already posted your joke. It’s one of the more hilarious comment threads I’ve ever read. And if you do post a comment here, keep it clean, okay? Oh wait….
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More on V-steam from around the web

  • Orac weighs in on what he calls “Steamed Vajayjay Woo”, and wonders when Oprah will try it.
  • Dr Manny Alvarez at Fox News calls the V-Steam ludicrous and says its health claims “Don’t hold water with me”. Was he trying to make a little joke? You go, Dr Manny!
  • Dr. Lisa Rankin starts off on the right side of Medicine and tells us that Wormwood, one of the ingredients in the V-Steam, can be neurotoxic. But then she goes on to tell her readers to ignore her concerns and listen to their bodies instead…. C’mon Dr Lisa. You can’t have it both ways.  Are you on or off the wooden stool?

Image from Wikipedia

Roasted Cauliflower and Quinoa Salad

Thanks to sister-in-law Joan, who I like to call the Quinoa Queen, for instructing and encouraging me on using the wonderful grain.  I’ve tried to make it on several occasions, but found myself with mushy quinoa. Turns out I was peaking and stirring, a real no-no if you want fluffy quinoa. Now that I finally got the cooking technique right, I expect I’ll be using this delicious grain much more.

Roasted Cauliflower Quinoa Salad

I just made this recipe up so I could use a nice little cauliflower I found today at Gourmet Garage. The rest of the ingredients were things I found while poking around the fridge to see what else I had on hand. Making it is quicker than it looks. While the quinoa is cooking, you can start the cauliflower roasting and prep the rest of the ingredients. It would make a nice lunch served on a bed of lettuce with a little Greek Yogurt on the side.

1 head cauliflower
2 tbsp olive oil
kosher salt
1/4 tsp red pepper flakes

1/2 cup quinoa
1/4 tsp kosher salt
1 cup water

2 sticks celery, cut into small dice
1/4 large red onion, diced
2 tbsp capers, drained
1/2 cup chopped parsley
8-10 sun-dried tomatoes, diced
1 cup canned chick peas, drained
Juice of one lemon or lime (I happened to use a lime today)
Additional olive oil if needed

Roast cauliflower
Preheat oven to 475 degrees fahrenheit. Slice cauliflower into 1/4 inch thick slices – don’t worry if pieces fall apart. Toss with olive oil on large cookie sheet, sprinkle with salt and red pepper flakes. Cover baking sheet tightly with foil and place on lowest rack of the oven. Cook 10-15 minutes. Remove foil and continue to cook until bottoms of cauliflower are golden, 8-12 minutes. Carefully flip the cauliflower and bake another 8-12 minutes. set aside to cool.

Make Quinoa
In a medium saucepan, combine quinoa, water and a dash of salt. Cover and bring to a boil, then lower heat as low as possible and let cook for 20 mins (don’t peek, don’t stir!). Remove from heat and let stand, covered, for another 5 minutes.

Make salad
Toss veggies with lemon juice in a large bowl. If it seems dry, add a dash more olive oil Add quinoa, toss again lightly and serve.

Mary Courtney and An Beal Bocht – Magical

There’s a new kind of music playing in the soundtrack of my life, and it’s coming from a wonderful little pub in Riverdale called An Beal Bocht Cafe, where Irish singer Mary Courtney holds court on Friday nights from 6:30 to 8:30 pm. Mr TBTAM and I celebrated our 25th wedding anniversary at An Beal Bocht with dear friends this past September, and last night I joined a few old and some new friends there to help Mary and her band Morning Star celebrate the release of their new CD (and, coincidentally, my birthday)….

An Beal Bocht is a magical place – a real Irish pub, without a TV (except during the World Cup), with a house theater troupe (The Poor Mouth Theater Company) and with waiters and waitresses whose names you learn your first night there and who might even plop down next to you for a little chat. There’s always a small kid or two dancing or sitting on a parent’s shoulders, and everyone seems to know one another. I’ve only been twice, but I feel like I belong there too, thanks to my friend Tony, whose Dad’s Irish ancestry, barely a generation removed, gives us all membership to Mary’s inner circle. Of course, being the green-eyed daughter of one Patsy Ford, that place in the circle feels just a little bit like home to me.

A steady string of performers grace the place on weekends, including a Sunday afternoon set by John Redmond that I hear is fabulous. But it’s Mary Courtney who gives An Beal Bocht its heart, lighting up the room with her smile, easy conversation and welcoming ways that make you feel as if you’ve come into her living room for an evening. We’re all in her inner circle when we’re listening to her music, and no one is left out. Everyone at the bar seems to have a favorite song that she’ll play for them from her repertoire that ranges from the Irish ballad to sailor and soldier’s tales, with the occasional drinking song or wild Irish reel. Hang around for the whole set and she might even treat you to a Beatles tune or two, or my personal favorite, Where Do You Go To, My Lovely?

The beer on tap at Al Beal Bocht is Bass Ale, and there are no fries here, folks, just chips and salad with your burger. Of course, there are the standard Irish staples, including Shephards Pie and Bangers and Mash.

Bangers and Mash

But my favorite were the baskets filled with tiny Irish bangers that Mary and her band sent over to our table last night. Steaming hot, cooked to perfection, with a crisp skin and moist innards that went perfectly with a beer. And if you hold the little banger just right, you can double dip without getting the bitten part into the ketchup.

Now that I’ve celebrated both an anniversary and a birthday with Mary, I feel like she’s family, and that no upcoming significant event will be complete without a Friday night visit to An Beal Bocht. Next time I’m bringing the lyric sheets I’m working on so we can join in on the choruses to Dingle Bay and Tom Crean. I’ll let you know when I’m going, and maybe you’ll join me there!
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You can listen to a few songs from Mary and Morning Star at sonicbids.com

Who Killed HRT ? or “Stick a fork in the WHI – it is so done”

The Warren Commission reconvenes to discuss the WHI findings

I swear, if I read one more article rehashing the Women’s Health Initiative, or one more theory to explain its findings, I’m going to ask the Warren Commission to reconvene and settle this thing once and for all.

The latest WHI rehash, reported in this week’s NY Times, comes from a researcher at the San Antonio Breast Cancer Symposium who is using the WHI findings to state that estrogen protects against breast cancer.

…among 8,500 women with no family history of the disease, use of estrogen lowered breast cancer risk by 32 percent, compared with similar women taking a placebo. Among the 7,600 women with no history of benign breast disease, like lumps or cysts, those taking estrogen had a 43 percent lower risk of breast cancer.

This is not news, folks.

We knew it in 2004 when the findings from the estrogen-only arm of the WHI were published.

We talked about it again in 2006, when a detailed analysis of breast cancer findings from the WHI found a reduction in early and in situ ductal, but not lobular cancers among estrogen-only users. They also found a possible protective effect of estrogen in women without a family history, but no reduction in risk for women who had prior history of ert use. In addition, estrogen only users had a higher risk for breast biopsy and when breast cancer did occur, it was larger and more likely to be node positive.

Not exactly a resounding affirmation of breast safety, but still not what we would have expected given what we thought we knew about breast biology and estrogen, and certainly contrary to years of previous data suggesting that estrogen use should uniformly increase breast cancer risk.

The Gap Time Theory

The best explanation I can find for the parodoxical effect of estrogen-only use on breast cancer risk in the WHI is the so called “gap time” theory, which is not about how blue jeans seem to shrink at the rate of one size per year, but goes something like this –

The Gap Time Theory  – If you wait to start estrogen until 5 years or more after menopause, you will see a lowering of breast cancer risk, compared to estrogen use starting at menopause, which increases breast cancer risk.

Scientists think this is because breast cells that have been deprived of estrogen for a long time become sensitized to the apoptotic effects of estrogen (the ability of estrogen to induce cell death or apoptosis). Since the WHI participants were, on average, about 10 years post-menopausal, they would certainly have had a few years of estrogen deprivation prior to starting ERT, so the Gap Theory seems plausible enough.

But I know what you must be thinking right now – How does the Gap Theory differ from the Window Hypothesis?

The Window Hypothesis

One cannot talk about the WHI findings these days without talking about the Window Hypothesis, which was designed to address the other unexpected WHI finding, which was that HRT use did not protect women against heart disease. This again was contrary to years of prior research suggesting just the opposite – namely, that HRT reduces heart disease risks.

The Window Hypothesis goes something like this –

Window Hypothesis – There is a window of opportunity in the perimenopause for estrogen to be started in order for it to be beneficial for the cardiovascular system and the brain. If you wait too long to start it, estrogen actually becomes harmful to the heart and the brain.

Since the average age of the WHI participants was 64, and about 10 years post menopausal, the window hypothesis would tell us that they were too old to benefit from HRT.  And, when we do subgroup analysis on those women who were in their 50’s at the time they start HRT, we not only do not see a negative effect of hormones on heart disease, we see a possible benefit to its use. So, the window hypothesis seems plausible enough.

Which begs the question –

What if both the Gap Time Theory and the Window Hypothesis are correct?

This would mean that women who start HRT in the perimenopause, which is when we tend to prescribe it most, would experience a reduction in heart disease risk, a benefit to memory and an increase in breast cancer risk.

If women wait for more than 5 years post menopause to start HRT, they will see no benefit in terms of heart and brain. But if these same women also happened to have had a hysterectomy and take estrogen alone, they would see a reduction in breast cancer.

Women who take both estrogen and progesterone, no matter when they start, will have an increased risk of breast cancer.

Hmmm… this is exactly what the WHI seems to have found.

HRT and Menopausal Symptoms

It is important to note that the WHI was never designed to study the benefits of HRT on menopausal symptoms. Because we already know that HRT works extremely well for this.

What the WHI did, and continues to do, is to inform women about the potential risks they might be accepting in return for this benefit from HRT.  These risks are not large, but they are real.

So, who killed HRT?

The biggest objection to the WHI is that its participants were too old, and that the group that should have been studied was women who start HRT at menopause.

I happen to agree with this, so let’s accept it and focus on the WHI findings in this younger group, which at this point is that there may be (the operative word here is “maybe”) some cardio-protective effects of estrogen that we have yet to define, but that might surface in new studies being conducted in this area.

Of course, that leaves us with the risks of estrogen on blood clots, which I have not yet mentioned but which seems consistent across all arms of the WHI. However, this may be mitigated by using low doses of transdermal estrogen, which is what most of us are preferentially prescribing these days anyway.

Okay, now that that’s settled, let’s talk about the deal breaker with HRT – breast cancer. Because, at least among patients in my practice, this is what killed HRT – not worries about heart disease and blood clots.

And, since everyone is supposed to be getting HRT around menopause and not 10 years later, there will be no “gap” to give protection against breast cancer, will there? So can we just stop talking about breast cancer protection from HRT, and accept the breast cancer risk?

After all, it’s not a big risk – 7 per 10,000 per year, or as I tell my patients –

If you take estrogen replacement for 20 years, you should accept a 1% increase in your odds of getting breast cancer.

Now, when I explain all this to my patients, I find they tend to make one of four choices –

The HRT Choice

  • No – For many women, particularly those whose menopausal symptoms are mild, HRT’s small breast cancer risk is high enough to outweigh any theoretical cardiac benefit, particularly if they are doing other things to protect their heart – like eating well, staying in shape and exercising – and so they say “No, thank you” to HRT. Which is totally fine with me.
  • Yes – For some women who may have severe menopausal symptoms, the breast cancer risk may seem a small price to pay for a return to a quality of life they lost with the menopausal transition, particularly when they realize that they will probably only need HRT for a few years. So they say “Yes” to HRT. Also a fine choice.
  • Never – Some women, particularly those with a family history of breast cancer, will never say Yes to HRT, no matter how miserable they may be with hot flashes. Not an unreasonable decision, in my mind, and I have other options to offer them – none as good as estrogen, but perhaps good enough.
  • Yes/No/Maybe – Some women start off in the Yes camp and transition to a No when their symptoms lessen over time, or when a friend gets breast cancer, or when someone famous like Elizabeth Edwards dies of breast cancer – both of which makes any risk, not matter how small, seem too large. Fine by me, I say. Some try to go off, and end up back on hrt again. That’s okay, too. I’ll ride it out with them.

What I don’t appreciate, and why I am so tired of this whole WHI rehashing, is folks trying to use the limitations of the WHI to convince women they should or should not take HRT. Or worse, to use the limitations of the WHI to try to sell hormones – be they Big Pharma-made or bio-identically-hyped.

Could we all just stop telling women what they should or should not do, and let them decide?

Bottom Line

It’s your menopause, not mine, not Suzanne Somers‘ or Oprah’s, and certainly not Big Pharma’s.

Be wary of anyone saying that no woman should ever take HRT because it is too dangerous, and of anyone saying that every woman should take HRT because it is so safe. Reality lies somewhere in between.

Like everything in life, HRT has risks as well as benefits. Do your best to get informed about both and make your decision based on what is most important to you.

And by the way, I’ve always thought that there was a second gunman…

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(For those interested in reading more about HRT risks as well as benefits, I point you to a marvelous review of postmenopausal HRT by the Endocrine Society.)

Warren Commission photo from Wikimedia.org.

Grand Rounds with a Seasonal Shift

I don’t know what I enjoyed more today – reading all the wonderful med blogger posts at this week’s Grand Rounds at Dr M’s blog, or looking at the beautiful images of spring and summer posted alongside them.

Why not head over and see for yourself ?

Clotting Up Office Hours with Talk about Clots

Thanks to the lawyers and the media, this is the conversation I had recently in my practice –

Patient: My mother has been seeing lawyers’ ads on TV about Yaz, and says I should stop taking it. I don’t want to get a blood clot.

Me: Are you experiencing any problems on the Yaz?

Patient: No.

Me: Is there a particular reason why you are taking Yaz vs another pill? (Looking through EMR) I think you had tried another pill and didn’t like how you felt, and wanted to try Yaz, correct?

Patient: Right. My room mate was on it and liked it. But now she’s worried too.

Me: So – let’s run the numbers, shall we?

Patient: OK.

Me: With some variation depending on which study you look at, the background annual risk for blood clots is around 3 per 10,000.

Patient: (nods) OK.

Me:According to one study, women who took Yasmin had a clot risk of about 8 per 10,000. We can probably assume the risk with Yaz is about 20% lower than Yasmin, since the estrogen dose is lower, so let’s call your risk 7 per 10,000. That’s a bit less than a tenth of a percent.

Patient: OK.

Me: Now, if that risk concerns you, we could change you to an older pill containing levonorgestrel. In that same study, women who took that pill had a risk of about 5 per 10,000.

Patient: (silence)

Me: But wait  –  You’ve been on Yaz for what, three years?

Patient: Four

Me: Okay, then, four. Now the biggest risk for blood clots is in the first year of pill use, so you’ve already established yourself as lower risk.  That would lower your risk to around 3 per 10,000. But if we change your pill, your risk will be about 2 per 10,000. So I guess the question is, is the excess annual risk of 1 per 10,000 , or one hundreth of a percent, enough to make you want to change your pill?

Patient: I’m just worried…

Me: Well, you could change to a progesterone only pill, or POP. That has no increased clot risk over the background rate. However, it does have about a 2% higher chance of pregnancy, and is more likely to fail if you miss a pill than the pills containing estrogen. So you need to be pretty perfect taking a progesterone only pill.

In addition, your acne was better on the combination pills – I can’t guarantee it will stay that way on the POP, but we can try. You can always go back. Most patients are pretty happy on POP’s.

Patient: I don’t think I want a POP.

Me: Do you want to go back onto condoms? or be fitted for a diaphragm?

Patient: No way! And I don’t want an IUD.

Me: So what shall we do?

Patient: What do you think I should do? I’m just worried…

Me: Okay, let’s change you to a pill containing one of the older progestins and see how your acne is. It’ll probably be just as good. But if you’re not happy, we’ll change you back.

Patient: (brightens) I like that. My mom will be happy.

Bottom Line

All estrogen containing birth control pills have a small but real increase in blood clot risks. How that risk compares between different pills is complicated, depends on which study you read, and none of the studies are perfect or definitive. In fact, the FDA has yet to make a distinction between standard dose pills (20-35 micrograms) based on clot risk, because the data are so problematic.

Meta-anlayses suggest that pills containing the older progestins such as levonorgestrel and norethindrone have lower clot risks than those containing new progestins gestodene, desogestrel and drosperinone. All of these studies to date have problems, but the data appear to be consistent across analyses. Few of the studies have included norgestimate, but those that have place its clot risk nearer to the older than the newer progestins.

Researchers are now looking at APC resistance as a surrogate marker of clot risk to help us better differentiate pills from one another, but this approach has not been universally accepted.

How to use this information clinically?

We really have no randomized trial data to inform contraceptive choice when it comes to clot risks. All of the studies published to data are problematic in that they do not consistently control for prescribing and diagnostic bias, and varying doses of estrogen between pills, another factor that strongly influences clot risks.

For most women, the choice between pills is made based on factors such as cost, convenience, cycle preferences, side effects and how you feel on one pill versus another. And advertising. At the moment, Yaz is the biggest selling pill, probably due to a large DTC campaign when it first came out.  (Bayer rightly got slapped by the FDA for over-hyping Yaz’s benefits in that campaign.)

If clot risks is your primary concern, there are non-estrogen methods you can use instead – Depo Provera, the IUD, condoms, Diaphragm and implanon. (But even some of these carry clot risk on the package insert, despite clinical trial data to support it.)

The bottom line is that no matter which combination birth control pill you use, you will have to accept a small increase in risks of clots.

What can you do to lower your risk of clots?

Since plane travel and long car rides can increase blood clot risks in anyone, consider wearing knee high travel socks for long plane flights and car rides. Ask for an aisle seat, stay hydrated and move about the plane frequently to avoid clotting. (You can more on avoiding clot risk from plane travel from the CDC.)

If you are at increased risk for clots, you should avoid all the estrogen-containing pills, no matter what dose or brand. 

And by the way, the risk for a blood clot in pregnancy is 1 in every 500-2000 pregnancies.  So it’s pretty much always safer to take a birth control pill than to be pregnant.

Mom

She died in the early hours of Monday morning, surrounded by her girls and her husband of 57 years, in a bed at the wonderful nursing home where she spent the last months of her life, the victim of intractable, unremitting post herpetic neuralgia (nerve pain resulting from shingles) and dementia.

She loved life, yet prayed for its end for almost three years, aquiesing as we tried treatment after treatment, unwilling to accept the futility of our efforts until we had exhausted all possible avenues of therapy that might allow her to live her final days, however long they might be, at least without pain.

How much of her dementia was due to her pain? How much to the medications we tried? A good part to both, I believed, as we saw miraculous awakenings with hydration and cessation of drugs, only to see her return to somnulence, anorexia and confusion when yet another pain med was tried. Even pediatric doses of medications were too much for her fragile mental status, teetering as she was between confusion and remarkable lucidity.

And yet, she maintained her wisdom, kindness and sweet spirit to the end. “How are the kids?” she’d ask me when I called, proceeding to give me the advice I needed to be the kind of mom I wanted to be.

“What am I keeping you from?” she would ask us when we stopped in to visit. “Can I offer you something? The candy is in the drawer there.”

And sweetest of all –  “Do you have enough room?” to my daughters as they took turns cuddling next to her in the bed on their last visit with her a week before she died. (We all fought for that spot next to her, even to the end…)

We tried every conventional pain treatment, some more than once, in varying doses and combinations, all without success. Like so many desperate families, my parents also turned to alternative therapy – in this case acupuncture – which failed. A case report in the literature even led us to try botox injections – also with failure and possibly worsening of her pain. After that, unable to push her any farther, we elected to forgo the latest greatest pain med that had just appeared on the market.

For by then, she was barely eating, accepting only tiny spoonfuls of her favorite foods after much coaxing and cajoling, and then not even drinking. And so, on the advice of her doctors, we turned to hospice to give her relief from her pain. Increasing – but still by most measures tiny – doses of morphine, and finally, ativan and atropine graced her exit. And in her last hours on this earth, thanks to these medications, she was finally comfortable and pain free. Thankfully, she was also conscious enough to let us know it, and to enjoy those moments with us, and we with her.

We tried, Mom. We tried so hard.

In retrospect, we probably tried too hard and over too long a period of time.  Now I understand that Mom knew what we did not – that she would leave this earth with this pain. We kept her longer than she wanted, but being the mother and the wife that she was, she stayed until we were all ready to let her go.

I do not know what lessons, if any, there are for us in her suffering and death, any more than I know how the God she so loved and to whom she prayed could allow her to suffer so.

The only lessons I can take are those she taught us by her life – to live it fully, with kindness, grace and love for others.  In this, I can only think of the beautiful Prayer, written by Mother Theresa and put to music by Rene Clausen, that I could not sing this summer in Cuba without thinking of my Mom, for it embodies everything that she was –

Prayer by Mother Theresa

Help me spread Your fragrance wherever I go.

Flood my soul with Your spirit and love.

Penetrate and possess my whole being so utterly that my life may only be a radiance of Yours.

Shine through me and be so in me that every soul I know will feel Your presence in my soul.

Let them look up and see no longer me but only You.

Bone Density Testing – How Often Should It Be Done?

Not as often as you think, even though Medicare may be willing to pay for it every two years.

Now a new study led by Margaret L. Gourlay, MD, MPH of the University of North Carolina at Chapel Hill School of Medicine finds that women aged 67 years and older with normal bone mineral density scores may not need screening again for 10 years.

“If a woman’s bone density at age 67 is very good, then she doesn’t need to be re-screened in two years or three years, because we’re not likely to see much change,” Gourlay said. “Our study found it would take about 16 years for 10 percent of women in the highest bone density ranges to develop osteoporosis. That was longer than we expected, and it’s great news for this group of women,” Gourlay said. (Via Science News)

The researchers suggest that for T scores > -1.5, repeat testing needn’t be done for 10 years. Women with T scores between -1.5 and -2.0 can be re-screened in 5 years, and those with T scores below -2.0 can have every other year testing as is done now.

To be honest, I’ve been spacing out bone density testing in woman with good baseline scores for some time, but not knowing how long I can go. This is great information for me and for my patients.
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Image from Wikimedia Commons