About James T. Breeden, MD

Dr. Breeden is president of the Carson Medical Group, a 26-physician multi-specialty group in Carson City, NV, where he has practiced ob-gyn for 35 years and for the past eight years has specialized in women’s office care and gynecologic surgery. Dr. Breeden was ACOG President from May 2012–May 2013.

Time Flies When You’re Having Fun

What a ride this past year has been! As I wind down my time as ACOG president, I’m proud of our accomplishments—we remained a strong and vocal supporter of women’s reproductive rights, made strides in standardization of care and patient safety, and moved forward in communication and technology, including the introduction of the new ACOG app for ob-gyns.

Two main themes during my presidential year have been the essentialness of contraceptive access for all women and the importance of having women in leadership roles. For the “grand finale” of my presidency—the President’s Program on May 6 at ACOG’s Annual Clinical Meeting (ACM) in New Orleans—I’ve assembled a roster of phenomenal speakers that will offer their unique spin on these topics.

I’m happy to welcome Malcolm Potts, MD, chair of population and family planning at the University of California Berkeley’s School of Public Health. Dr. Potts has studied extensively the positive societal changes that come when women can make their own reproductive health choices. In a recent speech, Dr. Potts said “If you’re working in cancer or orthopedics or pediatrics, you make people healthier by trying to relieve pain and suffering. What we’ve done in gynecology is change civilization.” His lecture “Sex, Ideology, and Religion: How Family Planning Frees Women and Changes the World” is one not to be missed.

Next, I’ve invited two exceptional leaders, colleagues, and ACOG vice presidents, Sandra A. Carson, MD, and Barbara S. Levy, MD, to present “Your Personal Path to Leadership: The Road Less Traveled.” They’ll discuss their own not-so-traditional journeys to becoming leaders in our field and the need for diversity in leadership.

Rounding out the program, Gary Chapman, PhD, author of The Five Love Languages, will present his speech “The Five Languages of Apology.” His insightful presentation will discuss the importance of apology in developing, maintaining, and repairing relationships.

Though my year as ACOG president is coming to a close, my involvement will continue. I’m looking forward to supporting our new president, Jeanne A. Conry, MD, PhD, in her endeavors and continuing to be an outspoken advocate for women. I’m also looking forward to more time for family and mountain biking in Nevada! Many thanks to ACOG Fellows and staff for your support and friendship throughout this amazing year.

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Guest Blog: How ACOG Sections Can Increase Member Advocacy

Holly S. Puritz, MD

Holly S. Puritz, MD

As women’s health continues to come under attack at the federal and state level the importance of advocacy cannot be overstated. We need educated voices to weigh in on key issues. It is only through continued advocacy that we can protect our patients’ access to care and preserve the sanctity of the physician-patient relationship.

Ob-gyns are getting the message: More than 330 ob-gyns attended ACOG’s annual Congressional Leadership Conference (CLC) in March—our highest attendance yet. During the CLC, we have the opportunity to meet with congressional leaders to call attention to key ob-gyn issues. We also learn about the importance of women’s health advocacy on the state level, where many laws that affect how we care for our patients are passed. Often, our expert testimony can be very meaningful when bills are still in committee.

In Virginia, we were struggling to find a way to have physicians available for these committee sessions, but we believe we’ve found a good solution. Each year, the Virginia Section sponsors approximately six members to attend the CLC. This year, to encourage state advocacy, we adopted a “pay it forward” approach to this sponsorship. We now expect our sponsored members to spend one full day during the legislative session in Richmond, ready to speak to lawmakers.

The Virginia General Assembly meets every year from January to March. The key committees meet on Tuesdays and Thursdays, and bills often come up without warning. Our lobbyist can testify on our behalf, but the message is always better received when delivered by a physician. In 2013, we aimed to have at least one ACOG Fellow or Junior Fellow attend each Tuesday and Thursday of the legislative session.

By implementing this new system, as bills came up, there was always someone who could testify. Our lobbyist knew she would have coverage, and we knew our voices would be heard. On days when testimony was not needed, the ob-gyn would accompany our lobbyist on “rounds” of key legislators to discuss women’s health issues from our perspective.

Our CLC group wasn’t large enough to cover every Tuesday and Thursday during the session, so we also asked other ob-gyns to volunteer, offering to reimburse them for mileage and lunch. Our ob-gyn representatives enjoyed their one-on-one experience and are looking to build on the relationships they formed in the off-season so that we can continue to be strong advocates for women’s health.

We found this new process to be a very effective way to encourage state advocacy, and we hope to expand participation in 2014 by increasing volunteer outreach at our annual section meeting. I invite other ACOG sections to give this formula a try. More voices in more states speaking up for women is a goal that we should all strive to achieve.

Holly S. Puritz, MD is chair of ACOG’s Virginia Section.

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Then Comes the Baby Carriage…Or Maybe Not

Infertility—the inability to conceive after six months to a year of unprotected sex—is a common problem in the US. More than 7 million people struggle to have a baby, often facing frustration and confusion along the way. Fortunately, many people who are treated for fertility problems are able to conceive after therapy.

Infertility affects men and women nearly equally. About one-third of cases can be attributed to the male partner, one-third are related to the female partner, and the remainder are caused by a combination of problems with both partners or by unknown factors.

In women, increasing age, irregular ovulation (release of eggs from the ovaries), abnormal anatomy, or scarring or blockages in the fallopian tubes are the main causes of infertility. Gynecologic conditions, such as polycystic ovary syndrome, endometriosis, and fibroids, can also make it difficult for a woman to conceive. Lifestyle factors, such as smoking, eating a poor diet, or being underweight, overweight, or obese, may also make it harder to get pregnant.

Male fertility also declines with age, but at a slower rate. Infertility in men usually involves problems with the sperm. Sexually transmitted diseases (STDs) or an injury to the testicles, such as overheating (from spending too much time in a hot tub, for example) or a reaction to medication, can lead to short-term fertility issues.

If you are having trouble getting pregnant, see your ob-gyn. Your doctor may order tests to understand what is causing the problem. You may also be referred to a doctor who specializes in infertility (reproductive endocrinologist) or to other counselors and specialists.

Standard fertility testing for women includes a physical exam and a health history survey that focuses on menstrual function and a woman’s history of pregnancy, STDs, and birth control use. Blood and urine samples may be analyzed to confirm that normal ovulation is taking place. X-rays or ultrasounds may be used to view and inspect the reproductive organs for any abnormalities. To test for male fertility, a semen sample will be checked for the number, shape, and movement of the sperm and for signs of infection.

Infertility can be treated in a variety of ways depending on the cause. If you are overweight or obese, losing weight may improve your chances of getting pregnant. Medications that stimulate the ovaries or regulate blood insulin levels (which can interfere with ovulation) may be prescribed. Your doctor can also help you decide if surgery or assisted reproductive therapies, such as in vitro fertilization, are right for you.

National Infertility Awareness Week is April 21–27, 2013. Learn more.

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Chlamydia and Gonorrhea Screening a Must for Women 25 and Younger

Each year, approximately 19 million Americans contract a sexually transmitted disease (STD). STDs are infections spread from one person to another during sexual activity. Chlamydia and gonorrhea are the most commonly reported STDs.

There are an estimated 2.8 million new cases of chlamydia and 700,000 cases of gonorrhea in the US each year. Both infections are most common in young women and both pose a serious risk to women’s reproductive health. If left untreated, gonorrhea and chlamydia can cause pelvic inflammatory disease (PID), an infection of the uterus, fallopian tubes, and other parts of the pelvis. PID may cause chills, fever, pelvic pain, infertility, and ectopic pregnancy.

Many women may never know they have an STD—the symptoms can be vague. Within two days to three weeks of infection, women may experience a yellow vaginal discharge; painful or frequent urination; vaginal burning or itching; redness, swelling, or soreness on the outside of the vagina (vulva); pain in the pelvis or abdomen during sex; abnormal vaginal bleeding; and rectal bleeding, discharge, or pain. Many women and men will experience no symptoms at all.

ACOG and the US Centers for Disease Control and Prevention (CDC) recommend that all sexually active women age 25 and younger be regularly screened for chlamydia and gonorrhea. Women over 26 should be screened for chlamydia and gonorrhea annually if they have multiple sexual partners or if their partner has multiple sexual contacts. Despite these recommendations, the CDC recently reported that only 38% of young sexually active women are screened for chlamydia and that more than 20% who test positive become reinfected within six months.

ACOG urges ob-gyns to talk to their patients about STDs and screen those at high risk of infection. Chlamydia and gonorrhea can be treated with antibiotics. To lower the risk of reinfection, ACOG suggests that ob-gyns write a prescription both for their patient and her sexual partner, who may be unlikely or unable to get treatment on his or her own. It is important that both partners are treated and take all of their medicine before resuming sexual activity.

Using a male or female condom correctly every time you have sex can also help reduce transmission of STDs. Practice abstinence or monogamy, or limit your number of sexual partners. And be up front: it’s better to have a frank conversation with your partner about your sexual histories beforehand than to be unpleasantly surprised down the road.

April is STD Awareness Month. For more information, check out the CDC’s STD Awareness Month page.

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Gynecologic Oncologist = Women’s Cancer Specialist

For many women, ob-gyns are their primary health care provider. It’s not uncommon for women to see their ob-gyn at least annually, and for good reason. Ob-gyns receive a comprehensive education in caring for women from adolescence through childbearing and into menopause. Our training includes care of both pregnant and non-pregnant women, surgery, pharmacology, and more.

Because we see our patients regularly, especially during their reproductive years, ob-gyns have the opportunity to build and maintain a strong patient-doctor relationship. We can observe patients when they’re healthy, establish a baseline of what’s normal, and potentially spot suspicious changes or health problems when they are most treatable.

When a patient reports out-of-the-ordinary changes and symptoms, an ob-gyn can perform diagnostic exams and tests to confirm the problem. He or she can treat changes that may lead to cancer and prevent cancer from ever developing. When invasive cancers of the female reproductive organs—cervix, ovary, uterus, vagina, or vulva—are diagnosed, ob-gyns will often consult with other ob-gyns with advanced training and experience, such as gynecologic oncologists. This can be especially helpful for cases that are thought to be more advanced.

Gynecologic oncologists are ob-gyns who have completed several additional years of training in surgery, treatment, and research on women’s cancers and received board certification in gynecologic oncology. They see patients with these cancers every day. Following diagnosis, gynecologic oncologists can perform the sometimes complicated surgical procedures (staging) necessary to improve a woman’s chances of controlling and beating cancer. They are experts in the timing and order of treatment and can also serve as the “traffic controllers” overseeing the coordination of nurses, primary care physicians, radiologists, and other health care professionals who will be involved in all aspects of the patient’s care.

Today, there are more than 1,000 board-certified gynecologic oncologists in the US. To learn more about these cancer specialists, visit the Society for Gynecologic Oncology website.

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To Supplement or Not to Supplement

Do you take calcium and vitamin D supplements? If you’re a woman over 60, chances are you do. More than half of women in this age range take these dietary supplements, and for good reason. Fully 80% of the 10 million people in the US with osteoporosis—a debilitating disease marked by porous, fragile bones—are women. Another 37%–50% of women over 50 have osteopenia (low bone mass). Both conditions put sufferers at risk for bone fractures, which can take longer to heal as you age and can cause major mobility problems, and sometimes death.

So when the US Preventive Services Task Force (USPSTF) recently recommended that postmenopausal women should stop taking calcium and vitamin D supplements, it caused some confusion. The USPSTF concluded that the small risk of kidney stones associated with taking calcium and vitamin D outweighs the protection against bone fractures that most postmenopausal women receive from the supplements.

ACOG and the Institute of Medicine recommend that women over 50 get 1200 mg/day of calcium and 600 IU/day of vitamin D (800 IU/day in women 71 and older). The National Osteoporosis Foundation has similar recommendations.

While the debate continues, there are a few facts we can all agree on:

  • Calcium is a nutrient that’s vital to bone health and vitamin D helps the body to use it efficiently
  • It’s important that women get enough of these bone-protecting nutrients
  • Supplements can help you reach optimal levels, but they don’t replace the need for eating a variety of foods with calcium and vitamin D

The average American only gets 500 to 750 mgs of calcium each day, far short of the recommended daily intake. You can increase your daily levels by eating calcium-rich foods such as lowfat dairy (yogurt, cheese, milk), dark leafy greens (kale, collards, spinach), and canned fish with soft bones (salmon and sardines). You can get more vitamin D by eating fortified foods such as milk or cereal, or aiming for 15 minutes of sun exposure on your hands and face or arms a few days each week. Weight-bearing exercise, such as walking, tennis, dancing, yoga, or tai chi, can help strengthen bones, too.

For some women, certain types of hormone therapy and other medications containing bisphosphonates, estrogen, and calcitonin can also help prevent fractures. Talk to your doctor. He or she can determine whether you’re getting enough calcium and vitamin D, suggest a supplement to make up for what you’re missing in diet alone, or help choose a medication that may work for you.

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With Delivery Times, Defer to Mother Nature

“Let nature take its course.” Over the years, I’ve found this saying particularly applies to the process of giving birth. My personal experience as an ob-gyn and reams of scientific research demonstrate that Mother Nature knows best when a child is ready to be born. The start of natural labor is the main sign, but we’re not always patient enough to wait for it.

Today, one in three babies in the US are born by cesarean—the delivery of a baby through an incision in the mother’s abdomen and uterus. The rate of labor induction is also at an all-time high. Unfortunately, many of these births occur before the pregnancy is considered “term” at 39 weeks. These upward trends have long been a source of concern in the medical community, especially considering the increased risks to a baby who may not be fully developed at delivery.

Among cesarean deliveries, an estimated 2.5% (more than 100,000 births each year) are scheduled on a designated date by the mother and her doctor. Some women cite reasons such as a lower risk of future incontinence, better sexual functioning after childbirth, and fear of pain as motivations to schedule cesareans. Inevitably, some cesareans (and labor inductions, too) are scheduled before a pregnancy is full term, increasing the risk of negative outcomes for the newborn, including respiratory problems and time spent in the neonatal intensive care unit. The fact remains that due dates are estimates, and you can never be sure that the infant will have reached optimal maturity at the time of a scheduled delivery.

Women should keep in mind that cesarean delivery is no walk in the park. While it’s a safe option, cesarean delivery is a major surgery and comes with a number of risks, such as placental complications in future pregnancies, problems with anesthesia, infection, and longer recovery times.

Certain urgent situations—such as preeclampsia, eclampsia, multiple fetuses, fetal growth restriction, and poorly controlled diabetes—may make it necessary to deliver the baby before the onset of natural labor. However, newly issued guidelines from ACOG remind women and ob-gyns that in uncomplicated pregnancies, a vaginal birth that occurs after the natural onset of labor is ideal. Additional new ACOG guidelines reaffirm that cesareans and labor inductions should only be performed when medically-necessary.

Delaying delivery until labor starts naturally may not make ob-gyns too popular with a patient who’s uncomfortable and near the end of her pregnancy, but it’s a decision that will pay dividends by giving the baby the extra time it needs to face the world.

Guest Blog: Every Reproductive-Age Woman At Risk, Every Time

Frances Casey, MD

Frances Casey, MD

Full implementation of the Affordable Care Act (ACA) will remove many of the financial barriers women face to obtain effective methods of contraception. While making contraception affordable for every woman is a good first step toward improved prevention of unintended pregnancies, it remains the responsibility of health care providers to counsel women about all methods of contraception and help them find the one that may be the most effective.

The CHOICE project demonstrated that removing financial barriers related to the most effective methods of contraception decreases rates of unintended pregnancy and abortion. But the CHOICE project also did something many of us ob-gyns do not. Every reproductive-age woman eligible for the study was read a script about the effectiveness of long-acting reversible contraceptives (LARC), such as intrauterine devices (IUD) and hormonal implants.Instead of discussing LARC with their patients, many providers continue recommending less effective contraceptive methods based on misconceptions that adolescents, women who have never been pregnant, or women they estimate are at high risk for sexually transmitted infections (STIs) are not good candidates for LARCs. However, according to ACOG, LARC is the most effective form of contraception available and safe for use in all of these groups.

Because LARCs don’t require ongoing effort by the user, continuation and correct usage rates are higher. This could significantly reduce unintended pregnancy among teens and women if widely adopted. Additionally, women at high risk of both STIs and unintended pregnancy can be screened, obtain a LARC method the same day, and receive treatment without removing the device. Women with medical conditions and physical and mental disabilities can also benefit from both the pregnancy prevention and the non-contraceptive benefits of LARC.

Other women may also benefit from a longer-acting option. Without strict breastfeeding, postpartum moms are at risk for ovulation and repeat pregnancies even earlier than six weeks after delivery. LARC methods can be inserted immediately following delivery or at four weeks postpartum. Despite slightly higher expulsion rates, the benefits of immediate postpartum insertion of LARC methods may outweigh risks for women who are unlikely to receive postpartum care.

Minimizing financial barriers will make contraceptive methods more accessible for women at risk of unintended pregnancies, but it is up to us, as their partners in prevention, to counsel them on the most effective methods, including LARCs, at every opportunity.

Frances Casey, MD, is a Family Planning Fellow at Washington Hospital Center in DC.

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Big HIV News and An Important Reminder

Earlier this week it was reported that a Mississippi toddler born with human immunodeficiency virus (HIV) apparently cleared her HIV infection and is now disease-free. The story of her innovative medical treatment and remarkable results is truly exciting. However, as an ob-gyn, I can’t help but think that this entire situation could have been avoided.

Today in the US, mother-to-child transmission of HIV is a rare occurrence. HIV-positive women have roughly a 2% chance of passing along the virus to their babies. This is due in large part to increased HIV screening among pregnant women. Those who test positive for HIV during pregnancy can begin treatment with antiretroviral medications before they give birth. These medications significantly reduce the risk that a child will be born with HIV. The earlier the medication is given during pregnancy, the better, but it can still have a positive effect when administered just 24–48 hours before delivery and/or to the newborn within the first two days of life.

ACOG recommends that all pregnant women be screened for HIV as a part of routine prenatal care. Repeat third-trimester testing is also recommended for pregnant women in areas with high HIV prevalence. Not all women receive prenatal care, and it’s not uncommon for ob-gyns to see women for the first time when they come to the hospital to deliver. In this case, rapid HIV testing can confirm a woman’s HIV status. If she tests positive, she may still be able to receive medication in time to protect her baby from infection.

I cannot stress enough the importance of knowing your HIV status. Screening is the best method we have to both head off HIV transmission to infants and stop the spread of the disease to people of all ages. In addition to the screening recommendations for pregnant women, ACOG also recommends that all women ages 19–64 be routinely screened for HIV, regardless of individual risk factors.

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Guest Blog: Fighting Violence Against Women Together

Susan M. Lemagie, MD

Susan M. Lemagie, MD

Every day news from around the world highlights acts of egregious violence against women: the rape and murder of a female medical student in India, acid throwing and subsequent suicides of women in Central Asia, and the Taliban bullet to the brain of a 15-year-old girl in Pakistan who was targeted for promoting education for girls and women. While the scale here at home may be different, women in the US are not immune to violence.

Today, 1 in 4 women in the US has been physically or sexually assaulted by a current or former partner. Homicide is a leading cause of pregnancy-associated mortality in the US, with the majority being committed by an intimate partner. And as demonstrated in the last election, there are still many people who attempt to dictate a woman’s relationship with her doctor and her ability to make her own reproductive health choices. These efforts teeter on the edge of reproductive and social coercion.

In defense of women, ACOG has issued several recent documents—including committee opinions on reproductive and sexual coercion, sexual assault, intimate partner violence, and human trafficking—to raise awareness of the abusive treatment that some women in the US regularly face. ACOG has also developed patient outreach materials that provide information and resources to women in need.

ACOG has partnered with Futures without Violence on a guide titled Addressing Intimate Partner Violence, Sexual and Reproductive Coercion, which encourages ob-gyns to screen patients for domestic violence and recognize the signs of abuse. It also provides tools for health care providers to help women build healthy relationships and be safe in their own homes. Many thanks to ACOG’s Committee on Health Care for Underserved Women and the ACOG National staff for their ongoing efforts to advocate for women.

Now it is our turn as ob-gyns to speak up for our patients and their families. At this year’s Congressional Leadership Conference, March 3–5, 2013, more than 300 ob-gyns will lobby Congress to support ACOG’s Women’s Health Resolution. The resolution lists 14 non-negotiable rights that every woman in the US should be allowed, including the right to be free from gender-based violence. We will also convey to our legislators that our highest professionalism emerges when we base our care on the best scientific evidence, without legislative interference in our role as women’s health care physicians.

As we prepare for our lobby day, I’m filled with both a sense of duty and of pride. We can once again stand up as supporters of our patients and champions of women. It’s what we signed up for as ob-gyns, and it’s the right thing to do.

Susan M. Lemagie, MD, is an ob-gyn in Alaska and a member of ACOG’s Executive Board.