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.

Guest Blog: Cultural Sensitivity Is a Must in Patient Communication

Sarah Ward Prager, MD

Sarah Ward Prager, MD

Have you ever gone to the doctor and felt like he or she just wasn’t understanding you? You’re not alone. Many women have their own beliefs about health, medicines, and other treatments. Sometimes those beliefs don’t match up with what doctors recommend, even though the doctor’s suggestions are based on research proving they work. When patients bring their own cultural beliefs, sensitivities, or fears about health and health care to their appointment, they may need more explanation than just the evidence.

In some cases, doctors just need to listen better and avoid making assumptions about patients. For example, ob-gyns may believe all young women are at risk for an unintended pregnancy, but that’s not the case for women in committed same-sex relationships. Other times, doctors may need to be more clear in explaining the reasons for certain tests or medications, using words and examples that fit into the patient’s own cultural framework.

ACOG understands that approaching patient encounters with cultural awareness and sensitivity creates a more satisfying and caring relationship. To help ob-gyns become more aware of health-care related issues and beliefs in different cultures, ACOG has developed resources that address the traditions and cultural norms common among women of certain backgrounds. ACOG’s cultural sensitivity committee opinion offers typical doctor’s office scenarios with examples of sensitive vs. non-sensitive approaches to a patient’s culture and background. Additionally, ACOG will soon release a video training series that includes clinical vignettes demonstrating a wrong way and a right way to communicate with a patient, taking her heritage and beliefs into account.

Your ob-gyn wants to understand you and communicate with you effectively, and using these ACOG’s cultural sensitivity resources can help make that happen. Also, remember to tell your doctor about the cultural beliefs that are important to you. In the end, sharing what you value is one of the most helpful tools for facilitating better two-way communication.

Sarah Ward Prager, MD, is an ob-gyn at the University of Washington and is a member of ACOG’s Committee on Health Care for Underserved Women.

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With Routine Medical Tests and Procedures, Choose Wisely

Hal C. Lawrence III, MD, ACOG Vice President, speaking during the press briefing.

Hal C. Lawrence III, MD, ACOG Executive Vice President, speaking during the press briefing.

Open lines of communication are the basis of successful doctor-patient interactions. However, when it comes to medical tests and procedures, doctors and patients alike can easily slide into cruise control without taking the time to discuss what’s truly needed, appropriate, supported by evidence-based research, and in the best interest of the patient’s care.

With this in mind, ACOG has teamed up with the Choosing Wisely campaign—an initiative that aims to spark a conversation about commonly performed tests and exams in different areas of medicine. By taking a critical eye to routine health care practices, we can make better decisions on how to provide thorough and comprehensive care while avoiding unnecessary, redundant, or even risk-increasing procedures.

Today, at a joint press conference with 16 other partnering organizations, ACOG made the following recommendations:

1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.
Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.
Ideally, labor should start on its own initiative whenever possible. Higher cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

3. Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age.
In average–risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at 3-year intervals. However, a well-woman visit should occur annually for patients with their health care practitioner to discuss concerns and problems and to have appropriate screening with consideration of a pelvic examination.

4. Don’t treat patients who have mild dysplasia of less than two years in duration.
Mild dysplasia (Cervical Intraepithelial Neoplasia [CIN 1]) is associated with the presence of the human papillomavirus (HPV), which does not require treatment in average–risk women. Most women with CIN 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment.

5. Don’t screen for ovarian cancer in asymptomatic women at average risk.
In population studies, there is only fair evidence that screening of asymptomatic women with serum CA-125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits.

Learn more.

Guest Blog: With the ACA, Many Ounces of Prevention

Barbara S. Levy, MD

Barbara S. Levy, MD

Have you ever heard the phrase “an ounce of prevention = a pound of cure”? It’s an often-used mantra in the medical community and a message we continuously repeat to our patients. That’s because intervention through prevention makes good sense. In many cases, catastrophic illness can be avoided by nipping small problems in the bud or diagnosing and treating disease early. In addition to living a healthy lifestyle, regularly visiting your doctor for routine screenings and counseling is paramount to achieving this goal.

As women, we are often the primary (or sole) caregiver for our families—not to mention the cook, head nurse, and chief financial officer among many other roles. Without a second thought, we may put the needs of others before our own. This is especially true if money is tight and it’s a decision between getting an annual well-woman exam, paying $50 for a birth control prescription, or meeting the needs of a child, spouse, parent, or friend. But this philosophy doesn’t serve women well—if you’re sick, who will look after the people you care about?

The Affordable Care Act (ACA)—the new US law that expands health care coverage by making health care more affordable and accessible—focuses on expanded access to preventive services. Making preventive services available for little or no out-of-pocket cost makes it easier for women to do the right thing for their health and put themselves first. As I discussed in my last post, a growing number of women are now eligible to receive contraception and other preventive health services without a co-pay.

Preventive services that are now covered include:

  • Annual well-woman visit
  • Human papillomavirus (HPV) testing
  • Preventive vaccinations including HPV, flu, hepatitis A & B, shingles, and chicken pox
  • Sexually transmitted disease prevention counseling
  • Obesity screening and counseling
  • Smoking cessation
  • Depression screening

The ACA chips away at many of the barriers to access and care that women have faced for years. Here at ACOG, we’re closely monitoring the implementation of the law and will continue to advocate for comprehensive care for the women we serve. I believe this legislation is a major step in the right direction to improving women’s health and improving health outcomes for all Americans.

Check out these links to learn more about ACA and how it will affect you:

Prevention, Wellness, and Comparing Providers (HealthCare.gov)

Benefits for Women and Children of New Affordable Care Act Rules on Expanding Prevention Coverage (HealthCare.gov)

Effective Date: Women’s Preventive Health Coverage Requirements (ACOG)

Barbara S. Levy, MD, is vice president of health policy at ACOG.

Guest Blog: The Co-Pay Question—Contraceptive Access Under the ACA

Barbara S. Levy, MD

Barbara S. Levy, MD

If you’ve been to the pharmacy or doctor’s office lately, there’s a good chance that you noticed something different about your bill—there may not have been one. Depending on what type of insurance you have, you may now be eligible to receive all FDA-approved contraception and other preventive health services without a co-pay. This is due to the Affordable Care Act (ACA), a law with a lofty goal: overhauling our current health care system to provide the majority of Americans with affordable access to health care. While the intricacies of the ACA—and health insurance policies—are complex, it’s important for women to understand these most recent changes because they so specifically apply to us.

Whether or not you still have a co-pay for contraceptives depends on where you get your health insurance. More than half of people in the US get their insurance either through their job or by purchasing an individual insurance plan. Currently, the contraceptive coverage provision applies to most of these private plans. Insurance companies that adopted ACA policy changes early on may have already updated their plans to offer free contraception beginning in August 2012. As time passes, more plans will comply. However, there are some exceptions—some plans have grandfathered status that gives them more time to meet the terms of the new requirements, and some religiously affiliated organizations are currently exempt from providing this coverage.

State Medicaid programs already provide no-cost contraception to enrollees. The ACA expands Medicaid’s reach, potentially decreasing the number of uninsured women ages 19–64 from 20% to 8%. Many states are still hammering out exactly how Medicaid provisions will be implemented. ACOG is following this issue closely and supports the adoption of the ACA’s Medicaid expansion in all states.

So how can you find out whether your plan has changed and what new services are covered? You’ll need to ask a few questions and then update your records to be sure your health care team (you, your insurer, pharmacy, and your doctor) is on the same page:

  • Ask your employer or your health insurer whether the ACA has caused any significant changes to your plan. If so, what are they, and specifically, is contraception now covered without a co-pay?
  • If there are updates to your plan, be sure to notify your pharmacy and your doctor’s office and report any problems to your plan administrator or insurance company. It’s up to you to be sure you’re being charged correctly based on what your policy covers.

As an ob-gyn, I am thrilled by the increased availability of no-cost contraception that the ACA provides. Contraception is a basic health necessity for women. More access puts women in the driver’s seat, helping us avoid unintended pregnancy and take control of our reproductive health.

Learn more about contraceptive coverage and the ACA.

Barbara S. Levy, MD, is vice president of health policy at ACOG.

Guest Blog: 40 Years After Roe v. Wade—Politics or Patients, Who Is Winning?

Colleen McNicholas, DO

Colleen McNicholas, DO

This week marks the 40th anniversary of the Roe v. Wade decision—the US Supreme Court ruling that protects a woman’s right to have an abortion. In the years since, state legislatures have been primarily responsible for the laws that have at times validated and secured this right, and at other times severely limited it. However, in recent years, there has been a troubling trend. We have seen an unprecedented number of legislative attempts by politicians and government officials to interfere with women’s reproductive rights and with medical practice.

According to the Guttmacher Institute, 17 states now mandate that women undergoing abortion be given factually inaccurate information such as links between abortion and breast cancer and abortion and mental health. Eleven states have seen bills that attempt to limit medication-induced abortion, including some that specify the dose and route of such services. These laws completely disregard the meticulous and thorough process of scientific investigation that has been the cornerstone of medical advancement.

At least two states have proposed or enacted legislation that allows physicians to withhold information from a woman about her pregnancy if they feel the information would result in her choosing to terminate, essentially permitting reproductive coercion by the physician, which I believe is a universally deplorable form of violence against women. At least 18 states have introduced some version of legislation that not only requires an ultrasound for women seeking abortion but often dictates who can perform it, how and when it is performed, and what the provider must say to the woman undergoing it.

No matter where you stand on the abortion debate, this invasion of politics into medical practice should concern you. This scripting of patient-doctor interaction is unacceptable. The commitment we made when choosing to become women’s health care physicians was to promote the health of women through the execution of the best science. Our education and training tell us that these laws have not been created in the spirit of promoting the health of our patients.

As we reflect on this anniversary, consider the burden these laws pose for the girls, women, and families we care for. I hope that the 41st anniversary will be marked with something to celebrate: widespread comprehensive sexual education, improved access to the most effective contraceptive methods, and, ultimately, a reduction in unplanned pregnancies.

Colleen McNicholas, DO, is a Family Planning Fellow at Washington University in St. Louis.

Guest Blog: A Changing Tide—Have New Pap Test Recommendations Taken Hold?

David Chelmow, MD

David Chelmow, MD

If you’ve been following women’s health news, you know that a lot’s changed recently with Pap screening. Over the last decade, health organizations including ACOG, the American Cancer Society (ACS), and the US Preventive Services Task Force (USPSTF), have been reviewing research to determine how we can best prevent cervical cancer without excessive testing and unnecessary medical intervention.

The latest round of recommendations issued by each of these groups in 2012, building on guidance from ACOG in 2009, is generally consistent. All three organizations agree that for most women, cervical cancer screening should:

  • begin at age 21
  • stop after age 65 or following a hysterectomy in which the cervix has been removed
  • be performed every three years (Pap test only) OR every five years in women over 30 who’ve received negative results on a simultaneous Pap and human papillomavirus (HPV) test

The Centers for Disease Control and Prevention (CDC) recently published two studies looking at the use of Pap testing from 2000 to 2010. Much of what they found was good news and strongly suggests that doctors and patients are increasingly following the new recommendations. Fewer women younger than 21 were tested, and there was less Pap screening of women who had hysterectomy.

Unfortunately, there was also disappointing news. Many women continued to receive unnecessary Pap tests, including more than half of women younger than 21. Given the frequency of HPV infection in this age group, these young women are at significant risk for harms of testing without any expected benefit of cancer prevention. A much better strategy for prevention in this age group is HPV vaccination, but data from other sources suggest only a small portion of eligible women are receiving the full three-shot course of the vaccine. Additionally, 60% of women age 30 and older who had a hysterectomy continued to get Pap testing over this timeframe, according to CDC. Only a few of these women will need continued testing.

The studies also found that women age 22 to 30 who have never been screened increased from 6% to 9%—disturbing data considering most cervical cancer occurs in women who have never been screened or have not been screened in more than five years. Women age 30 to 64 who did not have health insurance were also less likely to be up to date with Pap screening in 2010 than in 2000.

For women to get the best protection against cervical cancer, they should get the HPV vaccine and be screened using the Pap and HPV tests according to ACOG recommendations. Let’s hope that the 2010—2020 summary finds that more women are getting screened according to the recommendations.

David Chelmow, MD, is professor and chair of the department of obstetrics and gynecology at Virginia Commonwealth University Medical Center in Richmond. Dr. Chelmow is a member of The American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Gynecology.

A Healthy Weight for Pregnancy

It’s no secret that the US has a weight problem. Roughly two-thirds of us could stand to lose a few (or more) pounds. Today, more than half of all pregnant women in the US are overweight or obese. Maintaining a healthy weight is always important to overall health, but it becomes an even more important vital sign when a woman is pregnant or planning a pregnancy.

Carrying too much weight can throw a wrench in a woman’s reproductive works. Not only can it interfere with getting pregnant, but it can also make pregnancy more difficult once achieved. Overweight and obese women are at increased risk of a number of complications during and after pregnancy, such as high blood pressure, preeclampsia, gestational diabetes, and cesarean delivery. They are at a higher risk of problems related to cesarean delivery—including complications with anesthesia, excessive blood loss, blood clots, and infection. Overweight and obese women also have increased odds of miscarriage, stillbirth, premature birth, or having a baby with a birth defect.

So what’s a woman struggling with weight to do if she wants to achieve the best pregnancy outcome? Losing weight before becoming pregnant is ideal, but that doesn’t always happen. According to new ACOG recommendations on weight gain and obesity during pregnancy, some overweight and obese women may be cleared to gain less weight than typically recommended to reduce risk factors. Gaining less weight during pregnancy may also help with losing extra pounds post-delivery.

If you’re considering getting pregnant in 2013 and are currently outside of a healthy BMI range, it’s not too late to make a New Year’s resolution to lose weight. There are many resources and articles focused on eating right and getting fit at this time of year, so investigate and develop your plan of attack. If you’re already pregnant, be sure to ask your doctor about a healthy amount of weight gain and an exercise plan to help you stay active.

Reach Your Fitness Goals with Health Apps

Nearly half of people in the US make a New Year’s resolution each year. We often vow to lose weight and be more healthy—both noble and important aims to strive for. But if you’ve ever made a resolution, you probably won’t be surprised to find that by the end of January, many people have abandoned their newly set goals.

If you think that expensive trainers or diet plans are the only thing that will help you stick to your resolution, you may want to explore your smartphone first. There are apps aimed at keeping you honest and focused—or at least get you moving in the right direction. Many fitness apps are available to help you track your calories, log daily activity levels, and tailor your routine to get results.

Food tracking apps allow you to keep a detailed log of what you’re eating, often helping you spot patterns in your eating that are sabotaging weight loss (eg, that daily mid-morning doughnut or the twice-weekly buffalo wings at happy hour that regularly push you over your recommended calorie goals). Calorie trackers give you a recommendation for the number of daily calories you need in order to reach your weight goals alongside the actual number of calories you take in on a given day. Some food tracker apps have extensive databases of foods, which make logging calories easier and faster than ever.

To help you maintain your exercise goals, give fitness trackers a try. With these apps, you can log your routes, pace, miles, and different types of workouts. Many allow you to share your activities and progress on social media sites such as Facebook and Twitter, allowing you to engage your support network (friends and family) for encouragement and accountability.

Not sure which app to try? Check out the Huffington Post’s list of the best fitness apps. You can also see what ACOG Fellows have recommended on our Facebook page. Or if you have a food or fitness tracking app that you love, please share it with us in the comments section. We’d love to hear what you’re using and what’s working for you.

Here’s to a healthy and active 2013!

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The Battle of the Bloat

For many people, rich and decadent foods are a hallmark of holiday celebrations—and while we all know that egg nog and cookies are not health food, a holiday treat here and there is not the end of the world. But eating too much heavy fare can wreak havoc on the digestive system, especially in women.

Digestive problems such as constipation, diarrhea, heartburn, and gas occur more frequently in women than in men and may be made worse by changes in hormone levels caused by menstruation and pregnancy. Women are also more likely to develop irritable bowel syndrome (IBS), a common digestive disorder marked by persistent abdominal pain and bowel changes. IBS sufferers may have a strong digestive reaction to stress, large meals, caffeine, dairy products, and large amounts of alcohol—typical staples of the holiday season.

Look out for these common problems:

Too many large meals and not enough fiber can lead to constipation. Symptoms may include having fewer than three bowel movements a week, firm or hard-to-pass stools, abdominal swelling or bloating, straining during bowel movements, and a full feeling after a bowel movement. The Fix: Eat at least 25 grams of fiber each day, drink plenty of fluids, exercise, and use the bathroom when you have the urge. Your doctor may also prescribe laxatives or other therapies.

A case of diarrhea—defined as having three or more loose bowel movements in a day—may develop after eating or drinking foods that contain harmful viruses or bacteria. Dairy products, caffeine, artificial sweeteners, certain additives, or medications such as antibiotics can also be a cause. The Fix: Eat hot foods hot and cold foods cold. Skip foods that have been sitting out too long. Drink fluids to keep hydrated, and if diarrhea lasts more than a few hours, drink liquids that contain salt, such as sports drinks or broth. Avoid drinks that include dairy products, caffeine, or sugar, which can make diarrhea worse.

Heartburn—a burning feeling in your chest and throat—can be caused by rich, fatty, or acidic foods; chocolate; coffee; alcohol; mints; and big meals. The Fix: Avoid overeating. Instead of lying down after a meal, try taking a walk.

Gas and bloating can be triggered by hard-to-digest foods, such as beans, broccoli, cabbage, and dairy products (for lactose-intolerant people). The Fix: Pay attention to which foods give you gas and avoid them. An over-the-counter treatment may also help.

It’s OK to enjoy your favorite holiday treats in moderation, just remember to eat a healthy, fiber-rich diet at non-party times. However, if you’ve experienced digestive discomfort or symptoms for at least 12 weeks out of the last 12 months, talk to your doctor. It may be a sign of IBS or a more serious condition, such as colon cancer.

Over the River and Through the Woods = A Good Winter Workout

It’s the time of year when schedules are full of holiday parties and meals, and opportunities for food-and-alcohol-centered merriment abound. It’s also the time when the average adult packs on a sneaky, often unnoticed, pound or two that has a high chance of lingering on your waistline long after the calendar changes over. This is one of the many reasons why it’s so important to make time for fitness.

You may already know the benefits of regular physical activity such as a reduced risk of heart disease, stroke, some cancers, type II diabetes, osteoporosis, high blood pressure, and high cholesterol. It can also improve your ability to perform daily tasks, keep you mentally sharp, and help you avoid injuries. Winter fitness is especially beneficial because it helps with health concerns specific to cold weather:

It boosts immunity. During cold and flu season, exercise can help you dodge the seasonal sniffles. Regular activity appears to boost the immune system, making it easier for your body to handle wintertime germs. Flu vaccination and frequent hand-washing also help keep you healthy.

It staves off holiday spread. Weight gain during the holidays can contribute to the 20–30 pounds that most Americans gain during adulthood. Exercise can help you balance the number of calories that you eat with the number of calories you burn, so you can enjoy some treats without the negative consequences.

It improves your mood. The shorter days of fall and winter cause some women to experience seasonal affective disorder, a condition marked by symptoms such as tiredness, irritability, cravings for complex carbohydrates (such as bread and pasta), and depression. For others, a hard day at work or holiday visits with family and friends can be very stressful. Exercise is one of the best natural antidepressants around and can help relieve stress and anxiety, improve your mood, lower levels of stress hormones, and boost levels of feel-good hormones.

ACOG recommends at least 30 minutes of moderate-intensity exercise (eg, brisk walking or bicycling) on most days of the week to lower your risk of chronic disease, 60 minutes on most days of the week to maintain weight, and at least 60 to 90 minutes a day to lose weight. If you can’t get a full workout in every day, try going for a walk after meals, raking leaves, vacuuming, or taking the stairs. Or winterize your workout with cold weather activities such as ice skating, snow shoveling, or skiing. Any physical activity helps, so fight your inner couch potato this winter and get moving.