Tag: obstetrics

Everything Has Risks

I am a fierce supporter of informed choice and autonomy in healthcare. I have worked for 23 years to give my clients and patients the freedom to choose what they feel is best for them. That means carefully educating to avoid bias, coercion, intimidation, or the appearance of authority.

“Every choice we have made leading up to that moment has created outcomes that pertain only to us and only to that moment.“

Informed choice involves the review of the risks and benefits of options and is not solely a medical treatment issue. It often impacts the choices we make in our daily lives that have little to do with healthcare. Additionally, the choices we have made before this point, especially the choices we have made with our bodies, and our lifestyle, impact our options and the risks of those options.

This is the risk-benefit ratio.  These are the options and choices where you have to consider the risks versus the benefits and is highly individualized.  My risks and benefits pertain to my circumstances and center around previous choices and outcomes. This is the reason why routine care policies and standard practices can be harmful. Every choice we have made leading up to that moment has created outcomes that pertain only to us and only to that moment.  It is our risk-benefit ratio, and no one has the right to tell us what risks are too much, and what benefits are too few or vice versa.

I have had clients/patients who want their nurse or provider to make their care decisions. In those cases I take that responsibility very seriously and try to consider the risks and benefits within their treatment.  I then introduce options with the least risk first, ask their preference, and continue to involve them in their care as much as they desire.  I never want to be responsible for making decisions for a human who can choose for themselves. Even as a parent, the “because I said so” was very rare, and there were almost always two choices and an explanation of why. I’m not going to let you run into the street and get hit by a car or grab a hot pan, but if you try to do those things, we will talk about the risks.

“We don’t get to choose the risks or consequences, as they are a part of the natural order of humanity.“

The fact is, everything has risks, even those choices that do the most good or have the highest reward, we perceived the benefit so greatly outweighs the risks that we do not consider there to be negatives.  We don’t get to choose the risks or consequences, as they are a part of the natural order of humanity, and even when we only see the benefits or positives of our choice, there will be a negative aspect.

“My risks and benefits pertain to my circumstances and center around previous choices and outcomes. “

For those that do not want children, either temporarily or permanently, the risk of pregnancy is so high that they will do everything to prevent it.  They accept the risk of their decisions, namely birth control or surgery, because the risk of a pregnancy is much higher. For those who want children, they view pregnancy as a positive without risk, or the benefits so greatly overshadow the risks they are minimized to the point of null.  However, the risks still exist, and usually show up to be dealt with; such nausea and vomiting, fatigue, stretch marks, bone and joint aches, and ultimately birth. 

“However, the choice is ultimately ours, and no one has the right to remove our ability to choose which risks and benefits are acceptable to the individual.“

When we generalize healthcare and create an environment where everyone has the same interventions, we take away informed choice and force negative impacts creating a high risk, low benefit care environment.  This is especially true with “you will” interventions – and often these are presented as you will have or we will be doing this intervention, and the options are often timed.  For example: at 20 weeks you will have an ultrasound – at 37 weeks you will have a GBS (beta-strep) swab – we will break your water at 3 pm. These are suggested as interventions without risk, or where the benefit is assumed and the risk minimized, yet no one but us can assess the risks and benefits, and there lies the problem.  For me, the option presented may carry acceptable risks, but for you the risks may outweigh the benefits and carry more harm.

“Additionally, the choices we have made before this point, especially the choices we have made with our bodies, and our lifestyle, impact our options and the risks of those options.“

I live the consequences of my choices.  Yes, some of those choices impact others around me, and that should be considered in the assessment of risks and benefits.  However, the choice is ultimately ours, and no one has the right to remove our ability to choose which risks and benefits are acceptable to the individual. As patients we have the right and responsibility to question, investigate, research, and expect feedback regarding our options.  As providers we have to acknowledge that we do not fully know the risks or benefits for our patients, and since we do not live their life, we have to defer to their personal assessment.   This means taking the time to listen and educate without the bias or our belief system or personal experiences. 

*Sometime the options available are outside of the providers skills or ethical beliefs.  The solution is referring or deferring to a different provider that can meet your patient’s needs.*

Polycystic Ovarian Syndrome/Disease

I wrote this paper several years ago, and sadly as I review current PCOS treatments I find not much has changed. We are still utilizing many of the same medications and focusing on fertility and symptoms. In fact, over 13 years later and nothing has changed.  In healthcare, women are still second-class citizens and sit behind in medical advances.

For more information visit

www.mayoclinic.org/diseases-conditions/pcos/diagnosis-treatment/drc-20353443

And

www.pcosaa.org

Introduction

Polycystic Ovarian Syndrome is a lifetime health issue that affects only women. Initially, it was connected to infertility; however, scientists now know that the effects of Polycystic range from puberty to death.  Polycystic is currently considered an endocrine disorder and not just an infertility issue.

What is PCOS?

Barber (2006) states, “Polycystic Ovarian Syndrome (PCOS) is a heterogeneous (women only) condition that affects approximately 6-10% of U.S. women and is associated with metabolic syndrome, which very often coexists with an overweight or obesity health issue.”  PCOS seems to come in two forms, hormone-resistant and insulin-resistant.  While the results seem to be the same and are treated similarly, each has different symptoms initially.  PCOS usually manifests itself when a young woman gets her first period or after her first pregnancy.

In women with hormone-resistant PCOS, the ovaries do not make enough hormones to mature the waiting egg for ovulation.  Instead, the egg accumulates fluid, and a cyst forms, ovulation does not occur, and the body does not produce the hormone progesterone.  The primary symptom is anovulation in these women, or a menstrual cycle spanning greater than 45 days.  The lack of ovulation and the lack of progesterone creates infertility, which creates an imbalance in the endocrine system, leading to further hormone imbalance and eventually insulin resistance.

In women who have insulin-resistant PCOS, the body does not respond to insulin.  To combat this, the body creates an excess amount of insulin, dropping blood sugar levels.  Insulin balance is essential to hormone balance and production, leading to carbohydrate craving as the body attempts to balance the low blood sugar levels.  As the blood sugar level comes up, the insulin level again rises.  A vicious cycle of high caloric intake, weight gain, and eventually hormone resistance and infertility.  Barber (2006) says, “The presence of insulin resistance in women with PCOS (largely reflecting impaired glucose disposal in skeletal muscle) was established initially in 1980 by Burghen et al….There is some controversy regarding the presence of insulin resistance in lean women with PCOS.  Possible reasons for this controversy include the use of variable definitions of PCOS and differences in ethnicity, family history of type 2 diabetes and personal history of gestational diabetes in women with PCOS and controls between studies.”

Symptoms of PCOS

Polycystic is a complex syndrome.  The symptoms are often variable, broad-based, and similar to other syndromes and disorders, making PCOS intricate and sometimes difficult to pinpoint.  The list of symptoms is hugely generalized, and many symptoms are directly connected to obesity.

Durso (2004) states that women with PCOS often have many of the following symptoms:

~ anovulation (absence of ovulation) or infrequent menstruation with heavy periods.         *Note menstruation may occur in the absence of ovulation.

~ infertility because of anovulation

~ Hirsutism on the face, chest, stomach, back, thumbs, and toes

~Acne, oily skin, or dandruff

~ Balding, voice deepening, increased muscle mass, decreased breast size due to the overproduction of testosterone.

~ Abnormal weight gain or obesity

~ Type 2 diabetes

~ High cholesterol

~ High blood pressure

~ Thickened dark brown or black skin on neck, arms, breasts, or thighs

~ Skin tags in armpits and neck areas

~ Sleep apnea or excessive snoring

Diagnostic Tests

The process of diagnosing PCOS is complicated and depends on the level of understanding and knowledge of Polycystic by the primary care provider and the technology available in the patient’s area.  Because the field of symptoms varies so greatly, testing should be comprehensive as well.

Tests that are conducted to confirm or rule out the presence of PCOS are:

~ Thorough medical history should include the age of the first period, length of time between periods, and quantity of flow in teens.

~ Physical examination including Body Mass Index and checking for excessive body hair, signs of Acne, loss of hair (balding).

~ Pelvic ultrasound including level 2 doppler color imaging of ovaries.

~ Comprehensive hormone panel blood workup including a pregnancy test, testosterone levels, DHEA-S levels, androstenedione levels, prolactin levels, thyroid levels, and 17-OHP levels.

~ Fasting glucose tolerance test or comparable insulin/glucose blood level test.

Treatment

The treatment options for Polycystic in the past have primarily depended on both symptoms and desired results.  Until recently, the assumption of PCOS as a fertility problem lead to treatment by combined oral contraceptives.  Snyder (2005) states, “For many years, oral contraceptive pills have been the mainstay of therapy for women with PCOS not desiring pregnancy.  The best choices are the combined oral contraceptives (COSs).  This hormonal therapy can regulate grossly irregular cycles, as well as decrease testosterone, thus decreasing the occurrence of Acne and Hirsutism.”

However, scientists now understand that uncontrolled PCOS can have lifetime health effects, and therefore treatment options have expanded to include hormonal, insulin, and weight treatments.  Treatments currently available include:

Insulin regulating medications such as Metformin (Glucophage), used in patients with type 2 diabetes and those with insulin-resistant PCOS, is given to regulate insulin levels, decrease testosterone production, slow abnormal hair growth, and initiate ovulation.  Many women who use Metformin for PCOS conceive within 2-6 months and use an insulin-regulating medication prior to conception and during the first months of pregnancy and may reduce the risk of gestational diabetes.

Although not the recommended first course of treatment, ovarian drilling surgery is available and can induce ovulation if the goal is pregnancy and not a PCOS treatment.  While increasing the chance of conception, this surgery carries those risks associated with major surgery and is only suitable for one treatment cycle.

There are medications used to treat the symptoms of Polycystic such as Vaniqa, which slows hair growth, or Aldactone to treat hypertension and decrease free circulation testosterone levels.  However, Snyder (2005) points out that “Currently, there are no FDA approved medications indicated for the treatment of PCOS.  Any drug that is used in clinical practice is used off label.” 

Currently, the most popular treatment for Polycystic is lifestyle changes and weight loss.  Barber (2006) states that “Even modest weight loss of 5% of body weight has been shown to result in significant improvements in both symptoms of hyperandrogenism and ovulatory function in women with PCOS.  There is no doubt, therefore, that adiposity plays a crucial role in the development and maintenance of PCOS and strongly influences the severity of both its clinical and endocrine features in many women with the condition.”

Without treatment, women are at risk for serious health problems.  (NICHD 2004) states, “Women with PCOS can be at an increased risk for developing seral other conditions.  Irregular menstrual periods and the absence of ovulation cause women to produce the hormone estrogen but not the hormone progesterone.  Without progesterone, which causes the endometrium to shed each month as a menstrual period, the endometrium becomes thick, which can cause heavy bleeding or irregular bleeding.  Eventually, this can lead to endometrial hyperplasia or cancer.  Women with PCOS are also at higher risk for diabetes, high cholesterol, high blood pressure, and heart disease.”

Conclusion

Scientists now know that Polycystic Ovarian Syndrome is no longer just a fertility issue but a lifetime health issue for women.  The consequences of ignoring this disease are severe and life-threatening.  Because acknowledgment of PCOS as a health issue is relatively recent, many women have gone untreated and are now dealing with the long-term health effects of this disease. Women who suspect PCOS in their family or who are experiencing any of the symptoms of Polycystic should seek out a provider who is knowledgeable about the syndrome and its health risks to obtain current and comprehensive treatment.

Reference:

Barber, Dr. T. (2006). Obesity and Polycystic Ovary Syndrome.  Clinical Endocrinology, 2006;65(2):137-145. Retrieved October 2006, from http://www.medscape.com

Durso, Nancy (M.D.).  (2004). What is Polycystic Ovarian Syndrome (PCOS)? Retrieved October 2006, from http://www.4woman.gov/faq/pcos.htm#3

Kusku, Naci K. (MD), & Koyuncu, Faik M. (MD). (2002). Insulin and Oral Antidiabetic Agents for Treatment of Polycystic Ovary Syndrome.  Medscape General Medicine, 4(4).  Retrieved October 2006 from http://www.medscape.com/viewarticle/440584_1

Legro, Richard S. (M.D.). Diagnostic Criteria in Polycystic Ovary Syndrome. Seminars in Reproductive Medicine, Med 21(3):267-275, 2003.  Retrieved October 2006, from http://www.medscape.com

Snyder, Barbara S. (2005). Polycystic Ovary Syndrome (PCOS) in the Adolescent Patient: Recommendations for Practice.  Pediatric Nursing, 2005;31(5):416-421.  Retrieved October 2006 from http://www.medscape.com