Gynecologic Oncologist = Women’s Cancer Specialist

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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

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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

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“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

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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

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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

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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.

Guest Blog: Cultural Sensitivity Is a Must in Patient Communication

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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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