One question that I hear a lot from women either looking to conceive or at first pregnancy visits is “how will my weight affect my pregnancy?”  As weight can very often be a sensitive topic, it can be a tough topic for your provider to discuss with a patient.  That being said, weight has been proven to play a role not only in a women’s ability to become pregnant, but also her ability to have a healthy pregnancy and carry it to term.  Below are some of the most significant ways that BMI (and yes, I understand that for a select few BMI may not be perfectly accurate, but it’s what we’ve got) can affect pregnancy.
​
Starting with getting pregnant, obesity (a BMI over 30) is often related to increased adipose (fat) tissue, and this adipose tissue actually makes its own hormones that can disrupt ovulation.  If no egg is released, then pregnancy can’t happen.  Even with successful ovulation and pregnancy, the risk of miscarriage increases by 3%, and there is also an increased chance of birth defects such as neural tube defects (problems with the spine) as well as heart defects.  This can be associated with either a problem with chromosomes (genetic material) in the egg or during the development and growth of the pregnancy.

Unfortunately, there are also increased chances of maternal health issues during pregnancy with higher BMI.  For preeclampsia (blood pressure issues in pregnancy that may cause seizure/stroke, kidney/liver damage, or even death), the single greatest risk factor is obesity, which is present in about 1/3 of cases.  In fact, women with a BMI >30 are 3 times more likely to develop preeclampsia than those women who begin pregnancy with a BMI in the normal range.  Why do we care?  Blood pressure issues in pregnancy are the most common cause of maternal death in most developed countries, like the U.S.

Blood sugar issues are another problem that is more common in obese women during pregnancy.  Gestational (pregnancy-related) diabetes risk increases as maternal BMI increases.  While only about 2.5% of women with a normal BMI develop gestational diabetes, this increases to about 5% with a pre-pregnancy BMI of 30 and to more than 10% for a BMI >35.  While it’s certainly not enjoyable to watch one’s diet before pregnancy, having to prick a finger to check blood sugar and taking or injecting medicine during pregnancy would definitely be less fun.

Even delivering the baby can be tougher for obese moms.  Labor tends to last longer, the chances of needing a cesarean section are higher, and babies tend to be bigger.  For moms with a starting BMI >30, the chances of delivering an 8 lb 13 oz baby is as high as 15%, and the chances of having a baby weigh nearly 10 lbs or more is about 4%.  In comparison, mothers with a normal BMI have less than a 10% chance and about a 1% chance, respectively.  The issues with larger babies are that they often have to stay in the hospital longer as they can have trouble with their blood sugar or they can potentially get hurt if they get stuck during the delivery.  In fact, baby size alone increases the odds of needing a cesarean section to deliver the baby.

Of course, not all obese mothers have poor pregnancy outcomes, and not all normal weight mothers have good pregnancy outcomes.  Also, we’d definitely not advise intentional weight loss during pregnancy.  Still, working to attain a healthy weight prior to conceiving and monitoring weight gain during pregnancy do decrease the risk of pregnancy complications, and that happy, health pregnancy is what it’s all about 😊

Dr. Nick

CBD Oil seems to be the hot new product that cures all sorts of ailments: anxiety, depression, nausea, seizures, inflammation, and insomnia just to name just a few.  CBD oil is available in sorts of different products: gums, candies, lotions, hair products, capsules, vape oil.   At prenatal visits, I get asked all the time- Is it safe to use CBD oil products for my nausea while I’m pregnant?

1. So, let’s start with what is CBD oil?  CBD oil is made by extracting cannabidiol from the flowers and buds from Marijuana or hemp plants and then diluting it with a neutral edible oil.  It does not have an intoxicating effect because it does not contain THC which is what causes the “high” when you smoke marijuana. 
2. Is there any medicinal use for Cannabidiol?  The FDA has only approved the medication Epidiolex to treat a rare form of childhood epilepsy.   Of the research done with cannabidiol, this is the only indication where the evidence suggests there may be some efficacy for treatment with cannabidiol.  For all its other purported benefits, there is not enough evidence for the FDA to recommend it as a treatment modality.  Also, whenever any product seems to be the panacea for so many different symptoms, there is always a concern about it being the new snake oil. 
3. Is CBD oil safe to use during pregnancy?  So unfortunately like most things, there are not enough studies for us to be able to say with certainty that CBD oil is safe in pregnancy.  However, several studies have found that there is an increased risk of preterm birth, small for gestational age babies, placental abruption, and increased admission to the Neonatal Intensive care unit for moms who used marijuana while pregnant.  Long term neurologic studies in children whose mothers used marijuana while pregnant do show increased risk of attention and behavioral problems, impaired visual acuity, verbal reasoning and comprehension and short-term memory issues.  For these reasons the American Academy of Pediatrics, the American College of Obstetrics and Gynecology and the US Surgeon General all warn pregnant women not to smoke marijuana or use any of its byproducts.

So, at this point, the FDA hasn’t found CBD oil to be an effective treatment for pregnancy-related nausea, and the medical community is concerned about the safety of cannabinoid-based products as they may be related to negative pregnancy outcomes.  Also, while we are aware that the THC in marijuana is responsible for the “high,” there haven’t been any studies to determine which part of cannabis plants is dangerous in pregnancy.  Given the lack of proven efficacy and also the potential danger of these products, the safest course of action would be to avoid them in pregnancy until the FDA and the medical community suggest doing otherwise.

​Dr. Pam

Every year, over 90% of people make New Year’s resolutions, but typically, less than 10% of them achieve their goals.  Some of the most common resolutions often involve improving diet and exercising more.  While everyone knows that these lifestyle changes improve health, what they may not know is that exercise can also boost the quality of their sex life.

For women, a short, vigorous workout in the gym (as little as 20 minutes), can lead to a vigorous workout in the bedroom, too.  The hormonal boost from intense exercise can increase arousal by over 150%!  Not only are women more aroused after exercise, but they also experience increased genital bloodflow, which, in turn, can improve the quality of the intercourse that they have.  Just don’t wait too long to “workout” with your partner as these boosts are generally short-lived.

For men, exercise can increase testosterone by up to 15%.  Weightlifting is particularly beneficial for increasing testosterone production, especially with heavier weights.  In addition to improved sexual drive associated with testosterone production, testosterone can increase muscle mass and decrease adipose (fat) tissue.  When fat loss is from the abdomen, penile bloodflow increases as can erection length (less covered by adipose).  Men shouldn’t fully neglect cardio, though, as atherosclerosis and hypertension can result in erectile dysfunction if not prevented.

For both men and women, improved self-image from weight loss and increased muscle tone often results in desire to share their new, sexy look with their partner (how about lights on in 2020?).  By being more comfortable with oneself, stress from being intimate is often lessened, thus allowing for more enjoyment of (and desire for) sex.  Lastly, as fitness increases, insulin resistance decreases, and the suppression of sex hormones by high insulin levels also ends.  With normal sexual hormone function, arousal and excitement happen more readily, and now that strength and stamina are increased from regular exercise, a person often has more energy to act on those urges.

So, here’s to a healthier 2020.  Keep making those resolutions for a fitter you, but when your exercise routine gets a little stale or your life gets busy, a healthy heart or lower cholesterol isn’t your only reason to stay active.  Remember that getting sweaty in the gym can lead to getting sweaty with your significant other, too!
​
Dr. Nick

Antidepressants are one of the most commonly prescribed medications among women, with around 15% of all women taking an antidepressant, and one of the most commonly prescribed groups of these medications are SSRIs.  SSRIs are generally used to treat depression and anxiety, and while it’s generally thought that the risks of taking these medications during pregnancy are for the most part rather low, it turns out that these medications may make having a successful pregnancy harder.  Here’s a quick overview.

What are SSRIs, and how do they work?  SSRI stands for selective serotonin reuptake inhibitor, and includes medicines like citalopram (Celexa), fluoxetine (Prozac), ecitalopram (Lexapro), sertraline (Zoloft), and paroxetine (Paxil).  These medications work by increasing the level of serotonin in the brain.  Serotonin is a chemical messenger used by the cells in the brain for communication.

How would this affect my ability to become pregnant?  We've known for awhile that SSRIs can decrease libido, but a recent study by Dr. Sjaarda, et al presented at the American Society of Reproductive Medicine, suggests that using any SSRI while trying to conceive decreases the chances of becoming pregnant in a single menstrual cycle by 23%.  Additionally, patients specifically taking fluoxetine (Prozac) had an increased risk of pregnancy loss (34% vs 24%) compared with patients who weren’t taking Prozac.

So, should I stop my SSRI right away if I’m trying to conceive?  Absolutely not!  The decision of whether or not to continue a medication should always be discussed with your provider BEFORE stopping.  Not only should these medications generally be tapered prior to stopping, but everyone has a very individual health history, and the level of need for these medications can vary significantly from person to person.  Pregnancy at the cost of good mental health probably isn’t going to be worth it.

All medications have their both their benefits and their side effects.  For some, those benefits far outweigh the potential side effects, and quite frankly, safe day-to-day functioning may not be possible without a given medication.  For others with more mild symptoms, especially if the cause of those symptoms was temporary, their depression might be controlled with nonmedicinal options such as therapy, exercise, good social support, meditation or other coping strategies.  In those cases, gradually tapering an SSRI prior to pregnancy may be a good option, or if taking fluoxetine, another medication in the SSRI group may be a better option.  That being said, these decisions should always be made in conjunction with your healthcare provider, and if any severe depression symptoms develop during weaning these medications, it is always advised to go directly to the ER for help.  For all of those trying to conceive and taking SSRIs, we hope that you are able to make the best decision for you, and, hopefully, your growing family 😊
​
Dr. Nick

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