While gender transition medications/procedures aren’t services that our office offers, we still get questions from parents about the effects of these treatments on adolescents.  Based on these questions, we’ve looked into health implications for those who elect to undergo these treatments.  Here’s what we’ve found:
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Clinics that treat gender dysphoria have noticed some interesting trends in the number of adolescents identifying as trans in the last decade.  First, the number of adolescents identifying as trans has increased dramatically.  Second, gender clinics have seen a huge shift from primarily transfeminine patients (assigned male at birth) to a majority of transmasculine patients (assigned female at birth).  Historically, gender dysphoria presented in early childhood (ages 2 to 4) and was predominant in those born as boys.  Suddenly, we have seen a huge increase in individuals identifying as trans and instead of young boys with gender dysphoria, its adolescent girls with gender dysphoria.  So, what happened?  There are lots of possible explanations, from the influence of social media to the fact that it is more acceptable now adays to come out as trans.  The purpose of this blog is not to determine the reason behind this huge shift in demographics in the trans movement, but rather review the risks associated with medications for gender transitioning and surgery in adolescent natal girls.  What do these medications/surgeries do, are they permanent and what are the risks associated with taking them?

1. Puberty Blockers: When a girl enters puberty, her hypothalamus signals the pituitary which is a gland in the brain to send signals to the ovary to start producing hormones which will allow ovulation to occur (release of an egg from the ovary).  Puberty blockers usually a drug called Lupron, will shut down this entire process and prevent puberty from happening.  So, is this safe to do to a teenager who has not undergone puberty yet?  What are the risks?  First, these puberty blockers will stunt a teenage girl from growing in height and weight any further. She will likely be very short, as her longterm height will essentially be whatever height she is at time of beginning the medications.   It will also prevent breast formation, pubic hair/underarm hair and menstruation.  There is also concern that this will affect brain development and IQ as well.  Suppression of normal bone development also increases the risk of osteoporosis- her bones will be brittle, and she will more susceptible to fractures if she falls.  If a child moves from this to cross sex hormones like testosterone, the likelihood of becoming infertile is essentially guaranteed. 
2. Cross Sex Hormones: For teenage girls who have already been through puberty who are considering transitioning to male, the medication of choice is testosterone.  Testosterone does a lot of good things for mood, especially for someone who suffers from anxiety or depression.  It suppresses anxiety and lifts depression and produces a form of euphoria.  It makes you bold and unafraid.  It increases muscle mass and makes you stronger and increases your sex drive.  Testosterone redistributes fat away from the thighs and hips, and it causes body and facial hair to grow.  The girl will look like a boy.  It also causes severe vaginal atrophy (thinning, drying, inflammation of the vaginal walls that makes intercourse painful and can cause painful urinary symptoms as well).  After a few months on testosterone, the voice will crack just like an adolescent boy entering puberty), severe acne may follow, and even male pattern baldness.  It will cause the nose to become rounder and the jaw squarer.  Because testosterone thickens the blood, it increases the risk of having a heart attack by five times what a woman not on testosterone would have.  It also increases the risk of having a stroke, blood clots, and diabetes.  Testosterone also increases the risk of uterine cancer because of the effect it has on the lining of the uterus, and longterm use markedly increases the chances of permanent infertility.  Within several months after beginning testosterone, the changes to the body, like facial hair and voice changes, are all likely permanent.  These changes will persist even if she decides to transition back.    
3. “Top Surgery”:   For adolescents considering transitioning, the desire to proceed with bilateral mastectomy (removal of both breasts) is not uncommon.  One of the biggest misconceptions about this surgery, since breast augmentation is so common, is that if they change their mind, they can just get a “boob job”.  Unfortunately, this is not true.  Once the breast tissue is removed, if spacers are not placed at the time of removal (like we do for breast reconstruction following mastectomy for breast cancer), there is no way to do an augmentation that will look like real breasts again.  These individuals will also lose the ability to breastfeed it they ever decide to detransition or have a family.  Other risks include scar appearance, infection, seroma formation (where fluid accumulates and then drains), pain, bleeding, and distortion of the nipple. 

Hopefully, this blog helps to explain how gender transitioning medications and surgeries work as well as the risks involved for adolescent natal girls (born as a girl).  While we don’t feel that it’s our place to decide what’s best for your teen’s health, particularly regarding services that we don’t offer, we did want to provide patients and their parents (if the patients are minors) with information about the medical implications of these decisions.  Knowing about the potential side effects and being aware of the permanence of these therapies is important in making a well-informed decision that will affect their future. 
Dr. Pam

If you’ve been to a doctor’s office while planning or during a pregnancy, chances are quite good folic acid (to prevent neural tube defects), DHA (to promote baby’s brain development) and iron (for prevention of anemia) have been recommended.  These relatively universal recommendations have been shown to help promote health pregnancies, and safety of these supplements have been well established.  Unfortunately, as nutritional supplements are regulated by the FDA, there is a lot of misleading information or simply limited information about most nutritional supplements.  While some of these supplements may be beneficial, others may in fact be harmful in pregnancy, even some of the “natural” ones.  Here’s a short list of some of the more commonly asked about supplements and what information is available for them.

1. Tabacum – an herbal product used for nausea/vomiting in pregnancy.  Unfortunately, this tobacco-based supplement contains nicotine and should definitely be avoided in pregnancy as it can cause harm to a baby’s brain and lungs.
2. Melatonin – this supplement has actually garnered a lot of interest in pregnancy studies, and there are some ongoing studies to assess whether it may reduce risk of preeclampsia and growth restriction in pregnancy.  However, at this time, safety data in pregnancy is relatively limited, and since Unisom with doxylamine has an extensive safety profile (and can help with nausea in pregnancy), doxylamine is would typically be advised rather than melatnonin until further safety testing can be done.
3. Kombucha – often used as a source of probiotics, this fermented food can contain alcohol as a part of the fermentation process, so kombucha should be avoided as alcohol intake in pregnancy can be associated with birth defects and intellectual/behavioral disorders.
4. CBD – although many people may be aware of the potential for marijuana and THC use in pregnancy to affect a baby’s brain development and increase the risk for a smaller or preterm baby, it may be less well-known that CBD use in pregnancy should also be avoided.  In addition to potential for liver toxicity, there is also concern for negative effects on the developing male reproductive system.
5. Astragalus – used to boost immunity, energy or even milk production postpartum, it can cause irregular heartbeat, dizziness and may be passed along to the fetus during pregnancy and lactation, so it should be avoided during and after pregnancy.
6. Red raspberry leaf- taken as a tea to reduce labor pain, nausea and miscarriage while increasing milk production, it appears to be relatively safe, although it hasn’t been proven to be effective for treating any of the above claims.
7. Nux vomica – this herbal treatment for nausea should undoubtedly be avoided in pregnancy as it contains strychnine, which can be harmful to both mom and baby.  In fact, the primary use of strychnine today is as rat poison.
8. Vitamin A – one of the trickier supplements in pregnancy.  Very low levels can potentially be associated with growth restriction, hearing loss for baby, insulin resistance for the baby later in life, and some birth defects such as microcephaly or kidney defects.  Too much is also bad – increased risk of miscarriage and heart/nervous system defects.  A typical prenatal vitamin often helps walk the line between too much/too little, although supplementing with more than 5000 IU per day should be avoided during pregnancy, and intake should not exceed more than 25000 IU per week.

Supplement use in pregnancy can be complicated, and the limited or misleading information available can make the decision of whether or not to take them very confusing.  Unfortunately, your provider may have little to add to the conversation as most of these products don’t have controlled studies available to quote, and they aren’t regulated by the FDA.  Generally, it often makes sense to err on the side of caution as even if the supplements may not have inherent risk, these products are not infrequently contaminated by other products that may not be safe in pregnancy.  The bottom line is that all supplements used in pregnancy should be reviewed with your provider so that you can make the best possible decisions regarding supplement use in your pregnancy.

​Dr. Nick

Ever wonder how often other couples are “doing it?”  Turns out, there have been a number of studies to look into that very question (I guess researchers are curious, too!).  Based on the results of these studies, it looks like relationship status, age, financial status and maybe even access to digital distractions play a role.  Here’s what the results say:
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According to a 2017 study in The Archives of Sexual Behavior, the average couple has sex about once a week, or some 54 times a year according to one study.  As expected, age plays a role with 20 year-olds having sex around 80 times per year with 60 year-olds having sex about 20 times per year.  Another study from the Kinsey Research Institute in Indiana shows a similar trend in age, but with increased frequency across the board:  approximately 112 times per year for those under thirty and about 52 times per year for those over 50.  Either way, it looks like younger people tend to have more sex.

 Overall, the frequency of intercourse sharply declined between 2001 and 2012 after increasing between 1991 and 2001.  In fact, one British study shows that about half of people in serious relationships haven’t had sex in a year.  The biggest decline in sexual frequency seems to have occurred in married couples.  In the 90s, married couples had intercourse more frequently than never married individuals, but now never-married individuals have sex more often.  Overall, the frequency change of intercourse is much less pronounced for singles.  Some factors that may be responsible for this decline are financial stress, increased spread of work into the home, difficulty for younger individuals moving relationships from virtual to real life, social media distractions and increased access to/quality of online pornography with reduced need to find real life partners.  In fact, the development of the smartphone coincides rather closely with the decline in sexual frequency.

So, how often should you have sex?  While there’s no right or wrong answer for the best frequency of sex in relationships, a study in Social Psychological and Personality Science suggests that couples are happiest that have sex at least once per week.  Although there wasn’t an increase in relationship satisfaction with increased sexual frequency beyond once weekly, there was dissatisfaction for those having sex less frequently than once a week.  There are also some health benefits from sex that should be considered as well:  in addition to bolstering the immune system, sex can lower blood pressure and heart attack risk.  Also, sex can improve sleep, reduce chronic pain and reduce stress.  There are also gender-specific benefits:  for women, sex and orgasm can improve pelvic floor function/decrease bladder leakage, and for men who ejaculate 21 or more times per month, prostate cancer risk is reduced.

The bottom line is that sex should be fun (if done safely and with consent).  It can improve relationship quality and even provide some health benefits.  While work, kids, finances and phones can reduce desire for sex, it may pay off to try to have intercourse anyway.  Increased sexual frequency tends to increase libido, which in turn increases frequency and more desire for frequency.  Even scheduled intercourse counts and can lead to more spontaneous adventures.  If you’re interested in more sex, be sure to talk to your partner as over half of women and men in committed relationships want more sex.  After all, it’s springtime-don’t neglect the “birds and the bees.”

Dr. Nick

Poor Sleep is one of the most common complaints that I hear from patients.  Lack of restful sleep can lead to daytime sleepiness that affects our performance at work or school.  It can also affect our relationships with our families and can even lead to car accidents.   So, once you recognize that you are having a hard time falling asleep, what are some things you can do to help fix your sleep?  The first step is focusing on sleep hygiene.  What is sleep hygiene?  Sleep hygiene is taking control of your sleep behavior and your environment to help optimize your sleep.  Its like cleaning the house before you have guests over for dinner.  While not a necessity, if you are having problems sleeping it may make falling and staying asleep a much smoother process. 

1. Make your bedroom as dark as possible.  Our sleep cycles are controlled by circadian rhythms. Darkness causes the pineal gland to release melatonin which makes you sleepy.  Ridding your room of unnecessary light is an important step.  Start with making sure your curtains/blinds are blocking as much light as possible.  This also includes all screens: Televisions, cell phones, tablets, computers all emit light.  If you cannot eliminate all light from the room, invest in an eye mask to prevent light from reaching your eyes.
2. Back to screens, if you can’t turn your phone off or like to read e readers before bedtime, switch to the red-light predominant option under settings and lower the brightness as much as possible.  Most iPhones also have a setting where the phone switches to red light at a certain time.  There are also special glasses that block blue light and filters that you can purchase to place on devices to decrease blue light. 
3. Make sure your bedding is comfortable.  Some people like firm mattresses and some like it soft.  Whatever your like, make sure you have it, and it works for you. Also invest in your bedding.  Make sure your sheets are comfortable. If you are one of those people that gets really hot at night, invest in moisture wicking sheets (SHEEX is one company that makes these).  If you get really cold, then invest in extra blankets or flannel sheets.
4. Is your partner, kids or your pets preventing you from sleeping?  If you have a partner that snores loudly, just remember that you do not have to sleep in the same room.  Same goes for the pets and kids.  Ear plugs may also work. 
5. What to avoid before bedtime- Tobacco (nicotine is a stimulant), caffeine (also a stimulant and this includes chocolate ☹).  Also try not to eat 2 hours before bedtime.  This will allow for better digestion and help promote sleep.
6. Exercise promotes sleep but usually only if you exercise in the morning.  At the very least, try to wind down strenuous exercise at least a few hours before bed.  Its harder to shut down if you perform vigorous exercise in the evenings right before bedtime.

After trying all this, if you are still having difficulty falling asleep or staying asleep and don’t feel well-rested the following morning, it may be time to have a talk with your provider.  You may need a sleep study to determine the exact cause of your sleep problems.  Remember poor sleep increases the risk of Alzheimer’s disease, obesity, heart disease, mood disorders, and the list goes on and on.  Making sure that you can achieve restful sleep most nights is vital to your overall health. 
 
Dr. Pam

​If you’re the type to make New Year’s resolutions, you’re now over a month in.  At this point, it’s easy to get discouraged if your fitness starts to plateau and your weight loss has started to slow down.  You’ve been working out 5 days a week, and now you’ve been eating healthier than you ever have.  Or have you?  It’s not unusual for some creative marketing to mislead you regarding the healthiness of some of your favorite foods and snacks.  Here are some of the most common pitfalls of “healthy” eating.

1.  Gluten free – while eating a gluten-free diet can be very important to those with celiac disease or gluten sensitivity, it can also be a trap for those simply looking for healthy dietary alternatives.  Obviously, limiting carbohydrate intake by focusing on lean meats, non-starchy vegetables and some dairy is a great idea, beware of gluten-free bread and other gluten-free processed foods.  These gluten-free alternatives tend to be lower in protein as well as vitamins than the gluten-containing foods they replace.
2. Protein bars and breakfast bars – these easy meal supplementing or meal-replacement options can sometimes be misleading when touted as healthy food choices.  Some bars, in fact, have high protein, lots of vitamins and low carbs, and these can be helpful additions to your diet, especially when you’re short on time.  However, some have large amounts of added sugars and high levels of saturated fats and/or sodium.  Be sure to check out the nutritional content, and if there is a large amount of added sugar, then that protein bar is simply a candy bar masquerading as a healthy choice.
3. Low fat foods – while it seems intuitive to think that low-fat foods are inherently healthier than their full-fat replacements, this generally isn’t the case.  For instance, low-fat flavored yogurt and low-fat sweetened breakfast cereal have large amounts of added sweeteners for flavor.  This typically not only increases calorie content, but the fat of the non-sweetened alternatives is no longer there to help with satiety.  The bottom line is that you end up with more calories per serving, and you eat more because you’re less full.  Other low-fat traps can include frozen yogurt, low-fat peanut butter, low fat cereal bars, and low-fat pastries and cookies.
4. Diet soda – no calories and enough flavor to satisfy your sweet tooth?  Seems like a no brainer for a healthy diet alternative.  Unfortunately, that’s not exactly the case.  Studies suggest that these artificial sweeteners may still cause insulin release, and over time, sustained insulin release can develop into insulin resistance, weight gain and even diabetes.  Also, these artificial sweeteners are hundreds of times sweeter than sugar, which may make it harder to satisfy your cravings for sweets, and when taken at the same time as real carbs, can cause negative changes in how your body metabolizes carbs in the future.

The bottom line is that there’s no simple fix for healthy eating.  Eating non-processed foods means shopping for produce (that expires), meat and poultry (that can spoil), and dairy (that can go bad as well).  All of these choices typically require prep time, thoughtful shopping and meal planning, but if you’re serious about your weight loss goals, then it’s definitely the right choice.  By starting your 2021 with a new wellness routine, you can make the long-term changes in your health you’ve been striving for.
Dr. Nick

Blog contributed by Elena Stewart
Photo by Daria Shevtsova from Pexels
 
The end of the year approaches fast, and that means we need to determine what goals we want to accomplish in the new year and how we can foresee them getting done. Folks who want to consider investing their time and energy into forming healthy habits should also make sure they have a plan for sticking to them, especially as self-isolation continues into 2021. Maybe you want to create an exercise routine to stave off the chance of osteoporosis or eat healthier foods to improve mental health.
 
Let’s take a look at a few of your options for making healthy choices in the new year:
 
1. Take care of yourself first. 
The definition of “self-care” encapsulates mental and physical aspects, but it all starts with treating yourself kindly — because you should be your own number-one fan. Some easy mental health resolutions you can make this year include being grateful, asking for help when you need it, and giving yourself time to decompress from stressful events. Turning off your phone, taking a walk, and sitting quietly with a cup of your favorite tea or coffee are great ways to decompress.
 
Self-care also extends to paying more attention to every part of your body, and that includes your hair. Taking collagen for hair growth can help your hair become stronger and thicker. Collagen can even support retaining your hair color as you age. The science behind it is simple: Collagen helps your body produce the kinds of proteins and amino acids that create the compounds that strengthen hair and nails.
 
2. Listen to your body’s need for sleep. 
Another healthy habit that can greatly improve your mood and help you get more out of the new year is to make sure you’re getting enough sleep. This starts with creating routines and a more conducive sleep environment. For instance, you can incorporate a 30-minute wind down into your daily bedtime routine, or dim the lights as you get ready to go to bed. This will help signal to your body that it’s time to rest.
 
One thing you want to keep in mind, however: Adjust your sleep schedule incrementally. You don’t want to make huge changes all at once because it can throw your body off its rhythm. For instance, if your goal is to get more sleep, try to add only one or two hours per night at first. These kinds of smaller changes are more sustainable, which will contribute to helping you maintain them in the new year.
 
Taking sleep aids like melatonin could be something to experiment with as you continue your health journey in 2021. Melatonin, which is a hormone created to regulate the sleep cycle, is considered safe for short-term use as a supplement, so if you want to try this vitamin to see if it helps your sleep cycle, be aware of the limits.
 
3. Lose weight and keep it off. 
The so-called “Covid-19 pounds” is something impacting a lot of us, and the new year presents a perfect opportunity to reaffirm your weight-loss goals. There are several things you can do to get yourself back on track.
 
First — and this applies to all of the resolutions you may set this year — you want to focus on small victories. Small, achievable goals are easier to accomplish quickly, which gives you the motivation to keep it up. Put a number on how much weight you want to lose — for example, one pound per week in January.
 
Useful weight-loss tips go beyond simply eating healthy or exercising more. You can also resolve to shop at your local health food store for most of your groceries and change your main cooking oil to olive oil, which is full of omega-3 fatty acids.
 
Start small, dream big. 
Remember: Making incremental changes will improve your mindset and help motivate you to maintain your New Year’s habits. Give yourself a rest, take care of your own needs, and celebrate the small victories.
 
Are you thinking about having a baby soon or do you need to schedule your yearly checkup? Get in touch with the obstetrics experts at Teton Women’s Health Center at 208-523-2060.

Blog courtesy of Elena Stewart

In a world where so many people suffer from obesity and chronic health related diseases related to obesity like diabetes, hypertension, and cardiovascular diseases, sugar free products have become popular.  Nonnutritive sweeteners are advertised as “sugar free” or “no added sugar.”  Products that contain non-nutritive sweeteners are now so pervasive, that 56% of adults and 80% of children report using products that contain it daily.  Initial uses of these products were confined to tabletop packets and diet soft drinks, but now they are included in condiments, yogurts, fruit cups, baked goods, candies, desert products and the list goes on. 

The first question is- if I consume a product that does not contain sugar, will this help me lose weight or prevent me from gaining weight? This is of course what most consumers looking at packaging that says “sugar free” are thinking.  Unfortunately, this is not true.  These fake sugar products still trigger insulin secretion in humans.  Insulin secretion is what causes us to gain weight.  Non-nutritive sugars also alter the secretion of the gut hormone incretin which increases glucose absorption in the gut.  This means non-nutritive sugars will increase the amount of glucose your body absorbs, and this is how you gain weight.  Nonnutritive sugars also upregulate proinflammatory and adipose promoting pathways (this means it increases your chances of getting fat and developing chronic diseases). Finally, these non-sugar products can change the microbiome or bacteria that line your gut.  Studies in children of normal weight have shown that consuming products with non-nutritive sugars led to higher sugar intake and weight gain.  So, basically these kids did not lose weight but gained weight as they consumed more “sugar free” products. 

In pregnancy, women worry that gaining too much weight and consuming too much sugar increases the chance of developing gestational diabetes and all the problems associated with it.  Unfortunately, these fake sugar products will not save you from developing gestational diabetes.   These fake sugar products are also easily transported through the placenta to the baby and via breast milk.  The metabolites of these products can be found in amniotic fluid and the urine of newborns.  Their safety in pregnancy is not well established.  While the Academy of Nutrition and Dietetics states that non-nutritive sugars are safe in pregnancy, neither the American College of Obstetrics and Gynecology nor the Institute of Medicine have released any statements as to the safety of these products in pregnancy and lactation.  We have lots of animal studies, but very few good human studies in pregnancy to establish the safety of these products in pregnant women. 

The take home message from this is you are not likely going to lose weight or control weight gain with the use of fake sugars.  Also, the safety of these chemicals in pregnancy and breastfeeding are not well established because of the lack of good human studies in pregnancy and lactation.  You are better off moderating your regular sugar intake than you are using these “sugar free” products to control weight and optimize your overall gut health.

Dr. Pam

​The CDC recently provided some updates regarding COVID 19.  These numbers address both how transmissible the virus is as well as the severity of infection.  Keep in mind that these numbers are estimates, and there’s definitely been quite a discrepancy between computer modeling and actual outcomes in the past, although there is now 6 months of data to base these estimates on that wasn’t available before.  That being said, here are the current numbers from the CDC website.

1. Basic reproduction number – this is the number of cases, on average, that result from spread of a single infected person.  The current best estimate is 2.5, meaning that for every one person infected, he/she will spread it to 2.5 others.  The projected range is from as low as 2 to as high as 4.  In more densely populated areas, this number would be expected to be higher than in areas with lower population density.  If immunity develops following infection, this number would decrease over time to the effective reproduction number, which would be lower.  At the present time, there is no data on how masks and social distancing play a role in affecting this number.
2. Infection fatality ratio – the number of deaths from infection divided by the number of people with the infection, regardless of whether or not they have symptoms.  For age 0-19:  0.003% (so survival rate is 99.997%);  for age 20-49:  0.02% (survival rate is 99.98%); for age 50-69:  0.5% (survival rate is 99.5%); and for age >70:  5.4% (survival rate is 94.6%).  There is a caveat for the last age range as the CDC states that the data is only likely accurate for those up to age 79, so there are not specific numbers for those 80 and older, and those less than 2 years old carry the highest risk in the pediatric age group, despite being grouped with those up to 19.  Also, it is important to remember that certain medical conditions may also affect a person’s risk beyond simply the age-related risk so that he/she may be more vulnerable than statics suggest.
3. Percentage of infections that are symptomatic – the current best estimate is 40%, although it may be as low as 10% or as high as 70%.
4. Infectiousness of asympomatic individuals – again, this statistic has large variability with 75% being the current best estimate but a range as low as 25% or as high as 100%.
5. Percentage of transmission occurring prior to onset of symptoms – it is currently projected that 50% of viral transmission happens before the infected person has symptoms.  The range may be as low as 30% or as high as 70%.

This information is definitely a lot of numbers to digest, but it seems to show a virus that is pretty easily spread, and there does also seem to an increased risk as one gets older.  While it looks like for many people, especially a younger population (with 419 deaths in the age range up to age 24 vs 643 deaths from influenza in patients up to just age 17 during the 2017-2018 flu season), medical comorbidities such as obesity, high blood pressure and chronic lung disease may increase that risk.  That being said, according an Oxfam report, over 100 million people worldwide may be pushed to the brink of starvation with hunger-related deaths from COVID 19-related food shortage reaching 12,000 per day (vs peak COVID deaths at 10,000 per day earlier this year), and this doesn’t take into account financial hardships from job loss due to economic shutdown.  This is a tough situation, both from the health effects of the virus as well as the socioeconomic impacts.  Fortunately, investigation continues into potential treatment options (for instance, a new ICAM protocol may have some promise) in addition to vaccination studies.  At the end of the day, the information is there for you to draw your own conclusions, so if you’d like to check out the information yourself, here’s the link to the CDC website used for the statistics above.  https://www.cdc.gov/coronavirus/2019-ncov/hcp/planning-scenarios.html  The numbers are in Table 1.

With such dramatic changes on many people’s lifestyle this year from all the societal changes initiated by Covid, a good night’s sleep has become one of the first casualties.  For some, newfound downtime during the day has led to increased napping and difficulty falling asleep at night.  For others, stress plays a big role in keeping them up late or making getting up in the morning tough.  The temptation is often to try taking a supplement rather than to change behavior (it’s easier to swallow a pill than ignore the siren call of the snooze button), and one of the most commonly used is melatonin.  Here we’ll take a look at what exactly melatonin is and how it works.

What is melatonin?  Melatonin is a hormone produced by the pineal gland (a tiny gland in the brain) that helps regulate the sleep-wake cycle.  Production of melatonin generally increases as darkness increases, which in turn, helps make us sleepy as night approaches.  Production is generally suppressed by light, so we tend to be more awake during the day.  That cycle of sleepy and wakeful is referred to as our circadian rhythm.
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How does melatonin work?  By signaling the body that it’s time to sleep, the thought is that it may help with insomnia or delayed sleep phase disorder (trouble falling asleep before 2 AM) as well as shift work disorder (those who work night shifts) and jet lag.  That being said, studies have shown mixed results with regards to efficacy.  Perhaps for those who are truly deficient, they may see more improvement of symptoms than those who are able to produce adequate amounts on their own, but for now, there doesn’t seem to be a way to determine which individuals would be most responsive to supplemental melatonin.

Is melatonin safe?  Generally, melatonin is considered relatively safe for short term use, i.e. 1-2 months, although long term safety information is limited.  There are certainly those who should avoid melatonin use such as those on blood thinners, diabetes medications, immunosuppressants, dementia medications, and even birth control pills because melatonin can affect the efficacy of these medications.  Also, use in children should be discussed with a pediatrician as there is a question of whether or not melatonin, as a hormone, can affect hormonal regulation of growth and even puberty or menstrual cycles in those with immature endocrine systems.  As for those who are pregnant or breastfeeding, there is no quality data regarding safety for use of melatonin.  Common side effects can include daytime sleepiness, anxiety, GI distress, dizziness and depression among others.  Because it is considered a supplement in the U.S. (rather than a drug, which would be managed by the FDA), safety and efficacy data is limited.  In fact, a study of melatonin supplements from a few years ago showed that the amount of melatonin listed on the bottle varied significantly from the amount actually in the product in most of those products evaluated, and around a quarter were contaminated by serotonin.

In the end, reviews of safety and efficacy are mixed for supplemental melatonin.  The American College of Physicians recommends cognitive behavioral therapy as a first-line treatment of insomnia.  As for simple changes to make on your own, limiting daytime naps, having consistent bedtimes and wake times, exercising regularly and avoiding electronics (especially those emitting blue light) for several hours before trying to sleep can all be good places to start.  Often, the hardest part of making these changes is avoiding the temptation to catch up on some missed sleep at night with naps during the day, but by being more tired when trying to fall asleep at night, resuming (or starting) a more regular sleep schedule can be within reach. 

Dr. Nick

Since Marijuana has been legalized in many states, there is a general perception that it is a natural and safe drug unlike other drugs.  This perception is reflected in the number of pregnant women who use marijuana while pregnant.  In 2017, a study showed that 1 in 20 women used marijuana while pregnant.  In 2002, the number of women who used marijuana was 1 in 10.    

Now before we talk about marijuana use in pregnancy and autism, let’s review some stuff we already know about MJ use in pregnancy.  First it does cross the placenta.   THC crosses the placenta and can be found in fetal circulation at 10% of the maternal level.  Second, we also know that marijuana can bind to fetal cannabinoid receptors as early as 14 weeks of pregnancy.  Third, studies have shown that exposure to marijuana in pregnancy can disrupt normal brain development.  Children born to women who used marijuana while pregnant are more likely to have low birth weight at birth, hyperactivity, and attention, cognitive and behavioral issues.

So, a couple weeks ago a study out of Canada published in Nature showed that women who used marijuana while pregnant were 1.5 times more likely to have a child with autism. The researchers reviewed 500,000 births between 2007 and 2012 in Ontario, Canada.  They found an association between maternal cannabis use in pregnancy and the incidence of autism spectrum disorder in these children.  The incidence of autism spectrum disorder diagnosis was 4 per 1000 children who were exposed to marijuana and 2.4 among children who were not exposed to MJ in utero. 

So, while this study does not definitively prove that marijuana use during pregnancy causes autism, there does seem to be a strong association.  Based on these findings, as well as ACOG (American College of Obstetricians and Gynecologists) recommendation, we encourage our patients to avoid using marijuana during pregnancy and breastfeeding.  

​Dr. Pam