I get this question all the time.  So, as we age, the ovaries produce less estrogen, progesterone, and testosterone.  Hormone production across the board decreases.  Why does this happen?  A woman is born with a finite number of eggs which are in the ovaries.  As time goes by, most of these eggs are released for ovulation in hopes to achieve a pregnancy.  During this process the ovaries produce estrogen, progesterone and testosterone.  As the number of eggs diminishes, there are no more left to ovulate, and without this process hormones are not produced.  This is why the production of hormones significantly decreases with menopause. 

With this decrease in hormone production, women approaching menopause can experience the following changes- insomnia, mood swings, hot flashes, vaginal dryness, changes in libido, weight gain, changes in hair/skin, the list goes on and on.  For some women, these symptoms can be really severe and negatively affect their quality of life.  For others, they barely notice the difference. 

So, do I need any extra lab tests or hormones checked to confirm this?  The answer is most likely no.  If you are approaching menopause and having symptoms consistent with menopause, then you are probably in menopause.  If you were to check hormones- they would all be low because your ovaries have now decreased production of them as you approach the menopause.  There are no guidelines that recommend this testing, and often insurance does not cover routine hormone testing.  So, you could easily be out $500 for a blood test.

Will checking hormones help guide my provider to providing me the right dose of hormones?  The answer to this as well is no.  We titrate the dose until your symptoms are better.  Some women require only a small amount of hormone replacement and some require a larger dose to help with their hot flashes and other menopausal symptoms.  If you are 55, your hormones across the board will most likely be low, and knowing this does not help me determine what dose of hormone replacement is best for you. 

If you are approaching menopause and have noticed severe hot flashes, moodiness or other symptoms, talk to your provider about options.  It is important to know both the risks and benefits of hormone replacement therapy as well as the best option for you.
​
Dr. Pam

Every winter I get lots of questions from patients about skin changes, and while some of them are definitely pregnancy related, a lot of the more annoying skin conditions actually start with the weather.  So, when the snow starts falling, here are a few tips to keep your skin from flaking.

1.  Healthy skin starts from the inside out.  Drinking extra water, even when you’re not as thirsty because of the cold, is an important first step to maintaining good skin health.  Fish oil and flaxseed oil both provide omega fatty acids that can be beneficial in severe conditions, too.
2. Stay warm, but not too warm.  While it’s tempting to crank the heat on a cold day, anything above 72 begins to zap the moisture from the air and can in turn dry out your skin.  If you really must turn the heat higher, then consider investing in a humidifier to offset the moisture loss from the heat.
3. The same goes for showers and baths, too.  Warm (not hot) water is best for keeping the moisture in your skin, and time in the water should be limited to less than 10 minutes.
4. As soon as you get out of the shower, moisturize while the skin is still damp, and be sure to use a heavy-duty moisturizer rather than simply a lotion during the winter months.
5. Limit exfoliants, toners, astringents, and scented skin products during the winter.  Even if they don’t usually cause skin sensitivity, the more fragile state of your skin during the winter can allow problems to develop.
6. Be wary of scented detergents and those with dyes, too.  Exposure to even small amounts of these chemicals left in clothes can potentially result in irritated skin.  That being said, don’t forget to wash new clothes before wearing as excess dye left in new clothes can also cause skin issues.
7. Warm clothes can sometimes be an issue as well.  For those with sensitive skin, wool can lead to rather profound itching, and other types of heavy clothes are often made of more coarse materials.  Be sure to layer with lighter, more comfortable clothes protecting you from the rougher texture of your winter garments.  Heavy clothes also tend to hold moisture longer than lighter layers, so if you do end up with snow falling into your jacket or boots, try to change as soon as possible as wet clothes can be even more irritating to skin than dry ones, and in turn, make you that much itchier.
8. Don’t forget your sunscreen!  Even on bleary days, UV damage is quite possible (as anyone who’s ever come home from a ski trip with goggle outlines can attest).  A combination of moisturizer and sunscreen can limit the number of skin products needed during the winter.
9. Lastly, at the end of the day, don’t forget to gently wash your face before bed to rinse of any accumulated products, oil and grime accumulated during the day.  A gentle nighttime moisturizer is a good investment in protecting your skin before bed.

Skin dryness and itchiness is a very common problem during the winter, and some irritation over the colder months may not be avoidable.  Still, a good skin care regimen for winter weather can go a long way toward making things better.  In turn, that healthy skin allows for even more enjoyment of peaceful, snowy days, whether you’re carving turns on the ski hill or admiring the snowfall while enjoying hot chocolate and a book by a crackling fire 😊

​Dr. Nick

Every now and again some major part of our diet gets attacked.  First it was fat- remember when low fat was the craze and every item in the grocery aisle had “low fat” on the cover.  Later carbohydrates were the scapegoat, and everything had to be “low carb”.  Next it was gluten’s turn: it was the nefarious culprit for every disease known to man.  Then we were encouraged to eat like cavemen with the paleo diet or like Greeks with the Mediterranean Diet.  Most of these nutritional theories have been debunked.  Depriving people of all carbohydrates or gluten or fat has been shown to be harmful and not necessarily the answer to what’s tipping the weight scale.  

The newest nutritional offender is sugar.  So, is sugar really the devil?  The answer to this one is mostly yes.  There are two different kind of sugars- naturally occurring sugars in fruit and dairy and then there is added sugar.  Added sugar is exactly what it says- extra sugar whether it is brown or white or in the form of honey or maple syrup added to whatever you are eating.  Added sugar has no nutritional value and is just empty calories that will make you fat and contribute to all sorts of chronic diseases like diabetes and heart disease.  How does sugar do this?  In additional to spiking insulin (causing insulin resistance) and being sent to fat cells for storage (this is how you gain weight), it produces an inflammatory response.  This inflammatory response is what is responsible to causing chronic diseases like heart disease and diabetes.

So, is all sugar bad?  No.  Eating foods with naturally occurring sugars like fruits and vegetables that also contain vitamins and fiber is probably beneficial to your health.  However, eating foods with lots of added sugars can lead to obesity and many other chronic disease states that will affect your long-term quality of life. 

How much sugar should I consume per day?  The federal dietary guidelines recommend no more than 10% of daily calories should come from sugar.  So, if you follow a 2000 calorie diet- that is 200 calories or 50 g (12 teaspoons of sugar).  To put that in perspective, a Grande Pumpkin Spice Frappuccino at Starbucks contains a whopping 73g of sugar- one beverage and you are way over the recommended amount!!

What can I do to control my sugar intake? 

1. Start by reading nutritional labels carefully.  Even your favorite flavored yogurt which is probably touted as healthy contains 15+g of sugar. 
2. Try to cook for yourself.  Even things like store bought marinara sauce has lots of added sugar that you would not suspect if you did not look for it. 
3. Stay away from sugary drinks.  A 12-ounce can of Mountain Dew contains 46g of sugar.  A 12-ounce container of Simply Lemonade contains 40g of sugar.  This is almost your daily allowance of sugar in a 12-ounce beverage.  

With the holidays quickly coming, making smart decisions about food can definitely be a challenge, but you can also look at it as an opportunity.  By using your knowledge of some of the negative effects of sugar limit your intake of overly-sweetened food, this time of year can actually be good motivation to take charge of your health.  For those planning to indulge for a cookie here or a slice of pie there, even decreasing the amount of sweets you eat can still be a positive step in improving your health.  We hope that everyone has a happy and healthy holiday season!

​Dr. Pam

Having a good social support group and friends can play a significant role in your  health.  A lot of these effects are good, but occasionally, there can be some negative effects as well.  Here Dr. Nick talks about the good (and some of the less good) consequences of these relationships.

First, let’s start with the good stuff.  Those who have quality relationships with friends tend to have a reduced risk of some significant health problems.  Better support tends to lead to less stress and in turn, lower blood pressure and decreased odds of developing diabetes.  It can also help keep your mind sharp as you age, and if you have good friends, then you tend to live longer to use that sharp mind, too.  Heart disease and depression are also less common in those with quality friendships.  Unfortunately for those who lack close friends, loneliness can have the same effect on health as smoking up to 15 cigarettes per day.

On the other hand, just like momma said, friends aren’t always good influences.  For instance, having a close friend who becomes obese increases your odds of becoming obese by 57-71%.  Is your best friend your spouse?  Having a spouse who becomes obese increases your chances by about 40%.  Now, obesity isn’t contagious in the sense that by being in the same place as obese person causes you to become obese, but sharing the same meals together can definitely have an effect on your health.  For example, eating out at work with friends increases your calorie intake, on average, by just under 1,300 calories per week.  Unless you and your colleagues also have intense workouts scheduled later, then that average increase in calorie intake could lead to over 20 pounds of weight gain each year!  With that amount of weight gain, you could now see higher chances of high blood pressure and diabetes as opposed to reaping some of those health benefits listed above.

So, in general, friendships are good.  Having friends who are there to help through life’s challenges and to celebrate life’s victories can lead to a healthier and longer life.  As long as you’re doing good things together, life with close friends to share it with can definitely be more fulfilling, and TWHC wishes you a happy holiday season with those friends.  Just remember to go easy on the stuffing 😉
​
Dr. Nick 

An IUD or intrauterine device is a little t- shaped device that is inserted into the uterus to provide birth control.   They are a great form of birth control because they are very effective and hassle free.  Once placed in the uterus they last for 3 to 10 years based on the one you chose to have and that’s it!  You don’t have to take a pill every day or remember to replace your Nuvaring.  No hassles or worries.  So, what are the different IUD’s, and which one is best for me?  The two types of IUD’s available are the copper IUD and the progestin-based IUD. 

​The copper IUD (tradename is Paraguard) has a plastic t-shaped frame with copper wire coiled around it.  The copper IUD releases copper ions which is toxic to sperm movement and egg fertilization. It also produces an inflammatory reaction which interferes with implantation.  It is 99% effective at preventing pregnancy and lasts for ten years.  This really is the best bang for your health care dollars.  This device costs about $1000 and is covered by most insurances.  If you use it for ten years- this comes out to about $8 per month for birth control.  Considering that most insurances cover it at a 100%, it likely won’t cost you anything.  However, there are some potential undesired side effects.  Because the copper IUD prevents pregnancy by producing an inflammatory reaction in the uterus, many women experience more painful periods and heavier bleeding than usual.  For some women these symptoms do improve over time, but this can take up to a year to notice improvement.  However, many do not notice any improvement over time, and for those women the only option is to remove the IUD. 

The progestin-based IUD (tradenames include Mirena and Liletta, among others) also has a plastic t-shaped frame that contains a progestin hormone.  Progestin is similar to the hormone progesterone which our bodies make naturally.  This type of IUD will last 5 years.  The progestin in the IUD prevents pregnancy by thickening cervical mucous which affects sperm motility and it thins the lining of the uterus preventing implantation.  Because the progestin acts locally in the uterus, many side effects that women experience with oral birth control like nausea, breast tenderness and mood changes are not experienced with the progestin- based IUD.  Also, it also does not affect breast milk supply if you are breastfeeding.  While copper IUD’s can worsen menstrual bleeding and cramping, most women with the progestin- based IUD experience less bleeding and 20% of women never have any bleeding while the IUD is in place.  Because of these non-contraceptive benefits, many women with heavy menstrual bleeding will use the progestin-based IUD just to control their bleeding.  However, some women can have irregular bleeding or spotting with the progestin-based IUD. 

So, this blog helps provide a basic framework about the differences between the copper and progestin-based IUD.  That being said, given your individual medical history, one of the options may be more effective or appropriate for you than the other.  Be sure to talk to your provider about your contraception goals, and together you can find what can work best for you. 

Dr. Pam

One of the most common questions I get asked every day is weight loss tips.  It’s frustrating to come in for your annual and notice that you have gained 15 pounds since last year.  I usually know the question is coming right when I walk into the room.  Obesity increases the chance of developing many chronic diseases- heart disease, diabetes, breathing problems, certain cancers, arthritis, high blood pressure and stroke to name just a few.   For the first time, we are actually seeing a decrease in life expectancy due to chronic diseases that can be easily prevented by lifestyle changes.  So, here are some tips on how to help with weight loss and improve your overall health. 

1. Rule #1: No snacking at all.  Snacking throughout the day causes continuous insulin releases.  This tells your muscle and fat cells to store all the fat and sugar you eat.  This is how you gain weight.  Also, more frequent insulin release leads to insulin resistance because your cells stop responding to the insulin produced.  I always tell patients to stick to only 2 to 3 meals a day and no more than that.  Only water in between.  This is the reason that fasting diets are so successful- they take advantage of decreased insulin release throughout the day and this is how they contribute to weight loss.
2. Rule #2: Stay away from processed foods: Anything that can survive in your refrigerator for more than 2 weeks is likely processed.  Again, the emphasis is on refrigerator.  Most things in your pantry other than dried spices are also processed.  In general, processed foods are high in sugar, salt, and artificial everything.  These foods were made in a laboratory somewhere and have an excessive amount of sugar, salt and flavor enhancers to encourage constant cravings.  They are very calorie dense and nutrient poor.  Start looking at nutrition labels on food and if you see things like MSG, natural flavoring, disodium guanylate, yeast extract, hydrolyzed protein, autolyzed yeast, aspartame, and other long chemical names that you can’t pronounce-don’t buy it or consume it.  This is not real food.  These are mostly chemicals manufactured in a laboratory that are high in calories and artificial flavors and packaged and then sold in a grocery store near you.
3. Rule #3: Try to cook your own meals: This will help you stay away from processed foods and allow you to have control over how much sugar and salt you consume.  I know this is time-consuming, but this is the only way to have control over your overall nutritional health.  This will also save you lots of money. 
4. Rule #4: Try to stay away from chain restaurants.  Oftentimes with these restaurants, the food is premade in some industrial place (again it is likely high in calories, low in actual nutrition and full of chemicals and artificial flavor enhancers to keep you coming back) and then shipped to the restaurant where it is simply reheated before serving.  This is a just a recipe for gaining weight.
5. Rule #5: Be wary of excessively fatty foods and diet fads.  Diets like the Atkins diet are popular because they allow you to eat fatty foods like bacon and butter.  The idea is that you can eat really yummy fatty foods and, as long as you restrict carbs, you will trick your body into seeking energy in stored fat.  This sounds awesome in theory- you can eat fatty foods and lose weight.  While patients do lose weight initially, most are unable to maintain such a low carb diet for long.  In addition, eating a lot of fat puts a lot of oxidative stress on your body and is what contributes to metabolic syndrome and other chronic diseases of obesity.  Unfortunately, the Atkins diet wasn’t even overly successful for its founder as Dr. Atkins was reported to weigh over 250 lbs when he passed away.

Hopefully this helps!  While discipline and lifestyle choices play a big role in weight gain, it’s hard to make informed choices about your health when you don’t have all of the necessary information.  The more I read about processed foods, the more I realize that these are calorie dense foods that are engineered to make you fat and instill cravings so that you keep coming back for more.  In addition, these foods are so poor in actual nutritional content that they make you even more prone to developing chronic diseases like diabetes, high cholesterol, and heart disease.  While I think restaurants and food companies should be able to produce and sell their products, I also think that they should be more transparent about the ingredients and content of the food that they produce.  Good luck with your weight loss goals!

​Dr. Pam

​As I near the end of the prenatal visits with patients, I often hear “Whatever you do, I hope I don’t need pitocin,” but when I ask why, there’s never really a clear answer.  It’s usually that they heard from someone who had a friend who had a cousin, or they read online that someone said it was bad.  With this blog, I hope to help sort some of the fact from fiction.
​
What is pitocin?  Here’s the fancy answer:  “it’s a nonapeptide protein.”  That’s the one you can use to sound smart.  Here’s the simple answer:  it’s the synthetic form of oxytocin, which is a hormone released by your very own pituitary gland.  Oxytocin is produced in response to labor and helps stimulate contractions, and it also is released during breastfeeding.  Those cramps you have while breastfeeding?  You can thank pitocin.

Why does your ob/gyn use this medication?  There are 2 main reasons:  it can be used to increase the strength of contractions, and it can also be given after delivery to help prevent bleeding (it helps the uterus contract and squeeze blood vessels closed).  During labor, you might think, “My contractions are plenty strong on their own, thank you very much,” but occasionally they aren’t.  Generally, the ideal strength of contractions that are strong enough to change the cervix in a timely manner without being so strong as to stress out your baby is 200-300 MVUs.  The strength of the contractions can be measured with an internal monitor placed beside the baby called an IUPC, and this monitor helps the nurse adjust the medication into the appropriate range to achieve the contraction strength noted above.  This can help the labor progress in the optimal timeframe to help minimize the chance of intrauterine infection and decrease the  chance of cesarean section once your labor has started or your water has broken.  Pitocin can also be used to stimulate contractions in order to initiate labor when medically indicated.  During inductions when the cervix is unfavorable (ie closed and not thinned), this is the time when we may  see an increase in the need for cesarean delivery with pitocin.  However, sometimes deliveries are medically indicated in patients with an unfavorable cervix, such as in patients with certain blood pressure issues, diabetes or other situations where to continue pregnancy has greater risk to mom/baby than ending it.  Without pitocin, though, medically indicated deliveries in patients with an unfavorable cervix would almost certainly have to be via cesarean delivery.

Is it safe?  Oxytocin is unavoidable during labor and breastfeeding, and your body has been designed to utilize this hormone in both cases.  When used at doses to obtain appropriate strength of contractions, both mom and baby tend to tolerate this medication well.  Even if the baby shows some element of stress, the half life of pitocin is only 3-5 minutes, so the effects end shortly after the medication is stopped.  Additionally, medications such as terbutaline can also be used to relax the uterus if needed.  Lastly, oxytocin used immediately after delivery decreases the chance of hemorrhage.  Postpartum hemorrhage is the leading cause of maternal death worldwide and the main reason that the maternal mortality rate is 239 per 100,000 in developing countries vs only 12 per 100,000 in developed countries.

Are there any other options?  At this time, pitocin tends to be the most effective and safest option that we have.  Some researchers have looked into the use of nipple stimulation to release natural oxytocin to stimulate labor, but at this time, there has been limited success, probably due to the fact the nurses’ hands must have gotten really tired ;)  Besides, there’s really only so much that lanolin can do for the breasts after a long labor like that!

So, while not all pregnancies require pitocin, it may be required during labor or after delivery.  When dosage is titrated to the optimal contraction strength, pitocin is often the most effective method to help obtain a safe outcome for mom and baby (not to mention decrease the odds of a cesarean section!).  And for us, this helps us to reach our ultimate goal, which is to conclude the pregnancy with a healthy, happy mom and baby :)

Nick

When you found out you were pregnant, you were probably expecting that healthy pregnancy glow.  Unfortunately, not all pregnant women are so lucky, and instead, your face is littered with zits even worse than during those awful teenage years.  So, now what do you do?!

1. I have not had bad acne in years, so why now? Acne can be very severe in pregnancy.  The increased hormone levels (particularly androgens) in the first trimester increases the skin’s production of natural oils, and many women have severe outbreaks in the first trimester.  

2. What products can I use for acne while I am pregnant?  Using small amounts of salicylic acid, benzoyl peroxide, and finacea is safe in pregnancy.  Large amounts can potentially be absorbed in the bloodstream, so please limit your use to small quantities.  This is especially true of salicylic acid, which is related to aspirin.  In LARGE doses aspirin and aspirin containing products can increase the risk of miscarriage and cause heart problems for the baby (That being said, do not be alarmed if your provider places you on baby aspirin as there are some medical indications for this medicine in pregnancy, and a small dose will not have this effect). 

3. Is Proactiv safe? Yes.  Proactiv is just benzoyl peroxide, salicylic acid and glycolic acid.  Again, as long as you use it in small quantities, it is safe in pregnancy.

4. Can I get facials for my acne while I am pregnant? Yes, for the most part facials are safe in pregnancy, and after the fun of early pregnancy (nausea, zits, etc) you probably deserve one :)  However, please make sure that your technician is aware that your are pregnant, so they can avoid the following: Retinol or Retin A containing products, Accutane and large amounts of salicylic acid.  If your technician is going to use a peel, please avoid salicylic acid peels as large quantities are not safe in pregnancy.  Peels that use glycolic acid, TCA or lactic acid should be safe in pregnancy.  Extractions are safe in pregnancy, but be careful because your skin may be more sensitive while you are pregnant.

5. Are my prescription antibiotic creams that I use for acne safe in pregnancy?  It depends on which antibiotic you are using.  Clindamycin or erythromycin based creams are fine while pregnant.  However, you should avoid tetracycline, doxycycline, and minocycline because they can damage your baby’s teeth.  

6. Accutane and retinoids.  Definitely, definitely don’t use Accutane if you may be pregnant or become pregnant.  It has been associated with multiple birth defects and also pregnancy loss.  If you use anti-wrinkle cream with retinoids and are pregnant, please stop because most of these creams all contain retinol-based products.  While absorption through the skin is much less than if you ingest these products, they still contain high amounts of vitamin A and are best avoided in pregnancy.

I promise you, your skin will get better!  Acne in pregnancy is usually worst during the first trimester and improves as the pregnancy goes on.  When washing your face, make sure you use a gentle, oil-free, alcohol-free, and non-abrasive cleanser.  Avoid over-cleansing as it can overstimulate your skin’s oil glands.  More than anything, resist the urge to pick or “pop zits”.  This can make your acne worse and cause unsightly blemishes or scarring to form.  ​ Just be patient, and you'll have your skin back to normal soon :)

Dr. Pam

It’s always interesting to address the concerns about epidural anesthesia during labor.  While there are a number of common questions, epidural anesthesia has taken on almost a mythical status for some patients, and it’s kind of incredible to hear what is attributed to this type of pain relief during labor.  Here I’ll try to offer some insight on epidurals, how they work, and how they do (or don’t) affect labor and delivery.

First, what is an epidural?  An epidural is regional anesthetic.  This means, as opposed to IV pain relief, it isn’t expected to go into the blood stream, make you loopy or cross the placenta to the baby and sedate him/her.  A simple way to think of the difference between an epidural and a spinal is that typically an epidural procedure involves placement of a small catheter attached to a pump for continuous, but usually lighter, anesthesia than a one-time injection in a spinal.  If you think about it, that makes sense.  Pushing and movement are required during labor whereas we don’t want you moving anywhere during a cesarean section.  Some techniques involve a combination of the two, but that’s probably best explained by an anesthesiologist.

So, does an epidural slow down labor and increase risk of cesarean section?  The answer to the first question is yes…sort of.  The first stage of labor (dilation of the cervix) actually has no significant difference in duration regardless of when an epidural is placed.  The second stage of labor (pushing and delivery of the baby) takes about 15 minutes longer on average with an epidural vs without.  That, too, makes sense as walking with feet that have fallen asleep is going to be a little slower going than on feet that aren’t a little numb.  As for increasing the risk of cesarean section, there is no apparent increased risk of cesarean section with epidural, although we do see slightly higher incidence of operative vaginal delivery, i.e. vacuum or forceps.

Can an epidural harm mom or baby?  More common side effects for mom can be nausea/vomiting, low blood pressure, itching and difficulty with urination.  While more severe effects such as infection and nerve damage are possible, they are fortunately very rare.  Backache or headache can also occur, but these are not expected to persist if they do.  Generally, sensation and ability to walk returns with a few hours after stopping an epidural.  As for effects on the baby, because the anesthesia is regional, we don’t expect it to cross the placenta into the baby’s blood supply.  Occasionally, we can see a decrease in blood flow to baby from mom if blood pressure gets to be very low, but if present, this is usually quickly corrected by treatment of mom’s blood pressure.  Otherwise, much like numbing a tooth for extraction doesn’t affect your toes, the effect on baby from epidural is expected to be rather minimal.
             
For some women, epidural anesthesia can be a very effective option for pain control during labor, delivery and any laceration repair (hopefully, you don’t have any vaginal tearing during labor, but if you do, numb is good!).  Other women either don’t need it or don’t want it.  I’ve had some moms say that better pain relief allowed them to be more in the moment and really enjoy their baby more, but others felt that abstaining from pain relief allowed them to be more present during labor.  Fortunately, unless there are medical reasons you can’t have an epidural, it’s a decision that you can make in conjunction with your OB and anesthesia providers.  Be sure to discuss with them any concerns that you may have, and also pay close attention to your anesthesia provider to clarify all of the risks, benefits, alternatives and indications prior to proceeding with any medical procedure.  Good luck with whatever decision is the right fit for you, and as always, we wish you your healthiest pregnancy, delivery and baby 😊

Dr. Nick