pregnancy

Notes on Thiamine and Pre-Eclampsia: The Sugar Connection

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If you have read any of the articles on this website or anything relative to modern thiamine deficiency, you are aware of the connection between sugar consumption and thiamine deficiency. The more sugar, in any form, that one consumes, the more thiamine one needs to process it. This is because thiamine is the rate-limiting step in the metabolism of glucose into ATP. This pathway can be overwhelmed easily by the high sugar and low nutrient content of modern foods. The mismatch becomes particularly evident during pregnancy, where increased energetic demands may lead to insufficient thiamine independently of sugar intake if one is not careful, but also may be compounded by sugar intake. A study published in 1969 looking at thiamine and pre-eclampsia elegantly illustrates this point. Pre-eclamptic women, it appears, have a problem with sugar metabolism and the logjam is insufficient thiamine.

Pre-eclampsia

Pre-eclampsia, which affects up to 6% of all pregnancies, is marked by dangerously high blood pressure, edema, proteinuria with kidney damage and potentially damage to other organs. There is a high risk of stroke and other serious, even fatal complications, for the mom. For the fetus, because of the impaired functioning of the placenta, placental abruption is possible along with growth restriction and pre-term birth. There are few useful treatments, beyond bedrest and early delivery, but even then mom’s health may continue to be at risk. Postpartum spikes in blood pressure, called postpartum pre-eclampsia, affect up to 27% of women. As bad as these numbers are, they are likely even worse, given that most women are seen in the emergency rooms where the association with pregnancy is not regularly tabulated.

Metabolic Disturbances, Thiamine, and Pre-eclampsia

Pre-eclampsia has long been associated with metabolic derangements leading to poor energy metabolism of the placenta and mom alike. Although some have considered the role of thiamine in pre-eclampsia, the research has been mixed, generally decades old involving non-Western populations where food insecurity and not excess drives deficiency. In all, the research is sparse at best.

Although this particular study is older, its unique design merits discussion. Specifically, it shows that the activity of a thiamine-dependent enzyme that is responsible for a key aspect of the metabolism of glucose into ATP is impaired or overwhelmed in women with pre-eclampsia. This impairment then, leads to both maternal and placental energy deficits, which in turn, result in poor maternal kidney and cardio-metabolic function and all of the negative sequelae associated with pre-eclampsia.

Depending upon the severity of the impairment though, the problems with thiamine and subsequently glucose metabolism may not be noticeable unless challenged. That is, early on in the disease process, despite symptoms of pre-eclampsia, the metabolic dysfunction associated with insufficient thiamine are hidden with typical testing. It is not until the patient either faces a metabolic challenge, such as the one devised by the study below, and/or the disease has progressed sufficiently in severity that the thiamine issues may be detected.

Study Details

Backing up just a bit, let us look at this study more closely. Here, three groups of pregnant women were recruited: a healthy control group, a mild pre-eclampsia group (BP >160/100, plus edema and albuminuria) and a hospitalized eclampsia group. Instead of measuring thiamine directly, which has a high rate of false negatives, the researchers devised a challenge test wherein blood pyruvic acid concentrations were measured fasted and then 30 minutes following the administrations of dextrose.

Recall, thiamine is required for pyruvate dehydrogenase (PDH), the gatekeeper enzyme within the mitochondria, responsible for taking pyruvate (derived from glucose) and converting it into acetyl CoA, so that after a series of reactions, ATP can be produced. This pathway is called oxidative phosphorylation or OXPHOS, because the reactions require oxygen. With OXPHOS and sufficient thiamine, for every molecule of glucose, the mitochondria synthesize 30-38 units of ATP. This is compared to only 2 units of ATP produced via glycolysis, the intracellular pathway that converts glucose into pyruvate.

Pyruvate or in this case, pyruvic acid, is inversely associated with thiamine concentrations such that when thiamine is sufficient, pyruvic acid concentrations are low, even in response to the ingestion of sugars. When thiamine is low, however, pyruvic acid skyrockets. This means that a higher than expected pyruvic acid in response to the ingestion of dietary carbs or in this case dextrose, would indicate a logjam at the PDH, likely associated with low thiamine. Since the PDH enzyme also utilizes riboflavin and lipoic acid, it is possible that these nutrients may also be involved. Similarly, if any of these nutrients are severely low or this enzyme is more completely overwhelmed, we would expect to see elevated pyruvic acid even when fasted and even higher concentrations after the dextrose challenge. And that is exactly what these researchers found.

Compared to the healthy group, fasting pyruvic was similar but increased significantly after the dextrose challenge in the less severe pre-eclampsia group. For the hospitalized eclampsia group, however, both fasting and challenge pyruvic concentrations were elevated significantly. The healthy range for pyruvic acid is .5mg-1mg. Pyruvic concentrations in pre-eclampsia fell within the range while fasted but their numbers shot up, in some cases over 2mg. The average was 1.62 (SD .4). For the hospitalized group, pyruvic was elevated both when fasted (r=1.05mg) but especially with the dextrose challenge (r=1.93mg, SD .26).

Whoa.

Let’s put this in context. We use sugars (and fats, but that is another story) to make ATP. ATP is the energy currency produced by the mitochondria and used by all of the cells to do the things they need to do. Not enough ATP means not enough energy. Imagine trying to grow a new organ like the placenta and a new human without sufficient ATP. It just will not work out very well. Something will have to give. In this case, maternal kidney and heart function suffer. Both require huge amounts of ATP.

Getting pyruvate though PDH is the rate-limiting step. If the PDH does not have its cofactor nutrients, it will not work well and if it is not working, not much else will either. I should note that there are several other thiamine dependent enzymes in this and other pathways that control the metabolism of fats and proteins as well.

So, if pyruvate cannot get into the mitochondria and be worked on by the PDH, not only will ATP production decline and pyruvic build up at the gates of the mitochondria, but in an effort to rid the body of the excess pyruvate, some of it will be transported to another enzyme called lactate dehydrogenase or LDH. LDH and PDH work together to generate back up energy by converting pyruvate to lactate and back again. If one is healthy, lactate can be used as a fuel source and fed back into the mitochondria but only if one has sufficient thiamine to run the PDH. If thiamine is lacking, all of that pyruvate and lactate build up and that is what we see here. The PDH is not working well and so concentrations of pyruvic acid and likely lactic acid, though not measured, increased especially in the presence of a dextrose challenge and as the disease processes progresses in severity.

Final Thoughts

What this study tells us is that there is problem in this pathway that may not be readily apparent biochemically unless stressed appropriately, in this case, with dextrose but I imagine any high carbohydrate diet might produce the same reaction. And since, thiamine is involved in other metabolic pathways, I suspect had the researchers devised challenges to test them as well, we would likely have seen a similar pattern. While this study looked at pregnant women specifically, this pattern holds across all populations. The body adapts for as long as it can, but the chinks in the system are there. We simply do measure them appropriately in the early stages of disease – with challenge tests.

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More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, like it, please help support it. Contribute now.

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Childbirth in America

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I recently gave birth to a beautiful baby boy on February 14, 2020. He is my second child, but this pregnancy and delivery were nothing like the first. Both my son and I almost died during the delivery, and physician negligence during the pregnancy could have left me paralyzed and without bladder and bowel control. We both survived, thanks in part to a nurse who happened to walk in just as my child fell out of me with his cord tangled around his neck, and a spinal surgeon who took my pain seriously and rushed me into emergency surgery a few days later.

Childbirth with Herniated Discs and Physician Negligence

Over the course of my pregnancy, I developed severe back pain. It had become so bad that by week 39, I could no longer walk on my own, needed assistance bathing, and couldn’t even I couldn’t reach my own bum to wipe anymore. After months of being ignored by my OBGYN and leaving her office sobbing because she wouldn’t take me seriously, I finally called her and made her induce me on Thursday, February 13th. I thought once my son was delivered, the back pain would be resolved. It did not. In fact, it got worse and I required emergency surgery to fix two herniated discs just days after I delivered my child, but I am getting ahead of myself.

I grabbed my bags and headed to the emergency room where they took me up to labor and delivery to get checked in. During this long process, it was difficult to even lay on my own bed without moaning in pain. They wouldn’t supply me with a walker because the hospital doesn’t supply them to patients without prescribing physical therapy even though they knew my back was bad and I was at risk for falling (I had started falling for two weeks because my back couldn’t support my own weight) and as a result, I had my father and brother bring me my walker from home so I could go to the bathroom on my own. The nurses up until that point just pushed me around on a stool with wheels. The doctor never really checked on me but the nurses were really sweet.

All day my son was kicking my belly so hard the monitors would move and the nurses would come back into the room and find his heartbeat again then would leave. They kept calling my son the perfect textbook baby because of his vitals and activity. I started on a pill that slowly induced me and then put on Pitocin when the pill wasn’t working quickly enough. Most of my first day was a blur filled with tons of pain and being moved from room to room. I saw my doctor maybe a total of twice and had no idea the crap show that was about to go down.

My best friend and my auntie showed up sometime during the day on February 14th, 2020, and gave me company and support. My son’s father wasn’t in the picture my entire pregnancy. He ran when he found out I was pregnant – kinda like Forrest Gump. I had family and friends take over loving me unconditionally through my hard times. My mother was right by my side the entire time; every single doctor appointment and every contraction. My mother was always there.

Throughout the day, my son would kick the monitors off because he was strong and active. The nurses would come in and find the heartbeat and leave. Like usual. After a while, the Pitocin started doing its job. The contractions became more and more intense. At this point, I had only seen my doctor twice and would see her only four times in over 24 hours. Most of the updates came from the nurses over the phone to my OBGYN. It seemed like when the OBGYN checked on me it was a burden to her because she had to induce me, and didn’t stick around to talk to me or really see how I was feeling. It was a wham bam thank you ma’am scenario.

By late afternoon the contractions were terrible and they moved me to my final room for delivery. They made me walk. I could barely get to my room using my walker. A grumpy nurse rolled her eyes at me. I know she was thinking I was being dramatic. By the time I got to my room I was in some of the worst pain I had felt in years. I could barely stand and it felt like breathing was a chore. The nurse told me to take a shower because I stunk and needed to clean up. I remember just standing in the shower praying. Hoping that my pain would stop in my spine sometime soon. My contractions shot through my spine, down my left leg, and into my foot. I was just thinking about how every contraction I go through would just be that much closer to seeing my sweet son’s face for the first time.

Something Was Wrong

After hours of breathing through my contractions and holding my composure, I started to panic. The pain became unbearable. I demanded an epidural, which took hours to get. I remember screaming how it felt like the baby was going to fall out. My friend and my aunt kept trying to tell the nurses. Nurses would tell me that since I didn’t feel like I had to poop or push I was just fine. I was finally given my epidural two hours later. The entire time I was repeating myself, “I’m serious it feels like he’s going to fall out!!” The doctor came in and checked me. I was dilated to 7, and then right after the OBGYN decided since it was Valentine’s Day she would go have dinner with her husband. The nurses had to tell her to stay. I could tell she was irritated.

Not too much longer after I received my epidural and the pain had almost completely subsided and they drained my bladder. I rolled to my side, a nurse slid a giant peanut-looking pillow/ball filled with air between my legs and I started to close my eyes. I didn’t sleep the entire time I was there. Not even thirty minutes go by and one of the residents that was learning comes in to find my son’s heart on the monitor. She couldn’t find it. Minutes passed and another nurse of 35 years came in and asked the resident if she needed help. She said yes. After minutes go by and both of them couldn’t find the heartbeat I started to sense their panic. I remember the nurse said, “That’s weird. I wonder if…”

Then she threw back the blanket that was covering me, I also just then felt something brush against my thigh very lightly. I heard a gasp from both of them. My mother and best friend stood up and I watched in horror. The nurse hit the button for code blue. My son had fallen out of me with the cord wrapped around his neck twice. I don’t know how long he had been there because they hadn’t checked me in some time and I couldn’t really feel anything since the epidural. The nurse didn’t even have time to put on gloves and immediately was yanking at the cord to get it loosened from around his neck.

My son was completely blue. He wasn’t responding or breathing. The nurse then yanked my placenta out with force, which then caused me to start bleeding to death. I remember watching a river of blood cover the bed and was flowing onto the floor. I looked up and saw my mother and best friend just holding each other, terror on both of their faces. I remember my body going cold like I stepped into a freezer. My body tingling all over, and I was seeing black dots almost like fireflies that buzzed around the room. I went into shock and I couldn’t stop saying how my son was blue. I couldn’t stop repeating myself. “My son is blue. He is blue. Why is he blue?” I was eerily calm and it was hard to think. I vaguely remember blinking hard a few times to try and wake up. I thought this was just a nightmare.

A bunch of nurses poured into my room and as they were trying their best to bring my son back, they were also weighing my blood loss. My doctor had come into the room and was upset because I didn’t tell anyone I felt the need to push. We had told them for two hours how it felt like my son was “falling out” when in fact that is just what he did. No pushing at all. They stopped my bleeding eventually. I was so tired and woozy, but I finally heard my son cry. He was alive. Purple, red, and face bruised, but he was alive and I was alive.

Another Rough Night

After things had settled down my best friend headed home and my mom was by the baby and my side all night. The nurses decided with my past issues with seizures, they would put padded bumpers around my bed making it impossible for me to get out, especially with my excruciating back pain. By then, I could barely move and my adrenaline was still going. I was freaking out. My son had swallowed fluid before falling out and so his lungs had suffocated him throughout the night multiple times. All night, nurses would rush in to clear his airways. I was worried he would have brain damage through everything he had gone through. I had issues getting out of bed to help my son and had to rely on the nurse’s button and my mom to pretty much run in the room to assist my son. I couldn’t sleep. I felt like if I closed my eyes for one second my son would die. It was a constant issue throughout the night and kept praying that my son would be okay and healthy.

They kept my son an extra day to monitor him and get his jaundice under control. It was weird watching my son turn yellow before my eyes. Even his tiny nose was yellow. I just wanted to take my son home and lay down next to him. Both my mother and my friend said that not only did they think they were witnessing the worst day of my life, they thought I was going to die too. My mom thought she was going to lose us both. If that nurse didn’t walk in when she did, the chances of my son surviving was very slim to none. She saved my son’s life and for that, I am blessed. The Lord was watching over us.

Emergency Back Surgery Just 3 Days After Delivery

After my son was checked by his pediatrician for his jaundice that Monday and he had given us the thumbs up for recovery, I gimped into the hospital to find out that I had two herniated discs and I was to have emergency surgery. I was taken by ambulance to the hospital to have surgery the very next day. My spinal doctor had informed me the damage was so bad he believes I was almost paralyzed. He was surprised that I hadn’t lost bladder and bowel control already. All through the pregnancy, I complained to my OBGYN about my back and she ignored me, even when I could no longer walk by myself.

Recovering From a Traumatic Delivery

After the surgery, I am doing much better. Although my back is sore, I still achieved my goal to go back to breastfeeding my baby and I am able to walk on my own again with no assistance. I wouldn’t wish what I have gone through on my worst enemy. I thought I carried my son to full term just for him to die in front of me. Now I just stare at his sweet little face feeling undying love. I have two healthy boys and God is so good.

Due to the complications and trauma, I have experienced, I have issues still today sleeping. My brain doesn’t want to shut off and when my son sleeps I make sure he is breathing all night, waiting for one of my family members to take watch so I can get rest. It has been a difficult few months and the delivery was especially scary. I am grateful that both of us made it, but what I went through shouldn’t happen to anyone else.

We Need Your Help

More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, like it, please help support it. Contribute now.

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This story was published originally on March 6, 2020.

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Vitamin D’s Role in Preventing and Treating Multiple Sclerosis

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Modern lifestyles are countering nature’s intentions to keep us healthy. Since the advent of the Industrial Revolution in the late 18th century, we have migrated from farms to factories and office buildings. Nature intended for us to live and work outdoors in the sun—without sunscreen. Today most of us live and work indoors—often wearing sunscreen, or cosmetics containing sunscreen. By doing so, we have denied our bodies one of the most fundamental sources of health: the ultraviolet B (UVB) rays of the sun that initiate vitamin D protection in our skin.

Compelling scientific evidence over the past century indicates the significant role vitamin D plays in protecting us from developing a wide variety of medical conditions including autism, autoimmune disorders, cancer, cardiovascular disease, diabetes, and thyroid disorders. It is not a coincidence that the prevalence of these diseases has emerged during “modern” times. These medical conditions, many of which are serious, chronic, and life-threatening, frequently result in health, financial, and social burdens to the patients and their families.

What is Multiple Sclerosis?

Multiple sclerosis (MS) befits a disease of modern civilization. First identified by French neurologist Jean-Martin Charcot in 1868, MS is a chronic, neurological autoimmune disorder that damages the myelin sheath, the multiple layers of fatty tissue that surround and protect the nerves in the brain, spinal cord, and optic nerves. When the myelin sheath is intact, electrical impulses are carried through the nerves with accuracy and speed. When the myelin sheath is damaged (sclerosis is the scar tissue formed by damaged myelin), the nerves do not conduct electrical impulses normally. The impulses are distorted or interrupted, resulting in a range of symptoms including numbness, blindness, paralysis, and brain damage. MS also can result in death.

Who is at Risk of Developing MS?

Despite the identification of MS almost 150 years ago, MS has no cure. Over 2.5 million people around the world have been diagnosed with MS including about 400,000 Americans. Women are to two to three times more likely to develop MS than men. Although MS is usually diagnosed between the ages of 20 and 50, the disease can strike at any age. In addition, Caucasian women of Northern European descent are more frequently diagnosed with MS than African Americans, Hispanics, and Asians.

As part of the Environmental Risk Factors in MS Study (EnvIMS), researchers at the University of Bergen in Norway sought to understand better the association between MS and sun exposure measures by studying a total of 1,660 MS patients and 3,050 controls from Norway and Italy. The researchers’ findings included significant connections between infrequent summer outdoor activity and sunscreen use and an increased risk of MS. Published in the January 10, 2014 issue of Multiple Sclerosis, the study’s conclusion stated, “Converging evidence from different measures underlines the beneficial effect of sun exposure on MS risk.”

It is not surprising that incidences of MS in the equatorial region occur much less frequently than at the higher latitudes. Epidemiological studies over the past several decades however indicate that women who live at higher latitudes have an increased risk of developing MS. For example, University of Oxford researchers studied MS patterns in Scotland by examining hospital admissions throughout the country between 1997 and 2009. The research team discovered a “highly significant relationship between MS-patient-linked admissions and latitude” across Scotland. This study was published in a 2011 issue of the Public Library of Science (PLoS) One journal.

In addition, a seasonal risk factor also exists for MS. Researchers at Queen Mary University of London conducted a systematic review of data for 151,978 MS patients to ascertain the link between month and location of birth, and the risk of developing MS. They found that babies born in April had the highest risk of development of MS, and infants born in October enjoyed the lowest risk of MS. The researchers also noted a direct correlation between the latitudinal location of expectant mothers and MS risk. The study, published in a 2012 issue of the Journal of Neurology, Neurosurgery, and Psychiatry, suggests the importance of maternal vitamin D supplementation in particular during the winter season.

What Causes MS?

The definitive cause of MS remains unknown but medical research suggests genetic and environmental factors influence one’s risk of developing MS. Interestingly enough, science has demonstrated that vitamin D plays a role in influencing environmental and genetic factors that may affect how likely one is to develop MS.

A landmark study at the University of Oxford, published in a 2009 issue of Public Library of Science (PLoS) Genetics, examined how genes and the environment interact in MS. A gene variant called HLA-DRB*1501 is associated with an increased risk of developing MS. The research team discovered how vitamin D influences the HLA-DRB*1501 gene variant. As we know, the amount of vitamin D synthesized by UVB sunlight exposure fluctuates from season to season. Therefore, women who give birth during the spring, carry the HLA-DRB*1501 gene variant, and have low vitamin D levels are more likely to produce children with a higher risk of developing MS.

The study’s author Dr. Sreeram Ramagopalan suggested that adequate vitamin D3 supplementation during pregnancies may decrease the risk of children developing MS in later life. The combination of carrying the HLA-DRB*1501 gene variant and lacking adequate vitamin D levels may impair the ability of the thymus, an immune system organ, to delete rogue T cells, a type of white blood cells, that play an important role in maximizing the immune cells. The rogue cells would attack the body, causing demyelination of the central nervous system.

How Can Vitamin D Protect Against MS?

MS is a neurological autoimmune disorder. Scientific research over the past few decades solidifies the connection between vitamin D and autoimmunity. Vitamin D plays an integral role in the regulation of the adaptive immune system.

Adequate vitamin D in our bodies can protect us from autoimmunity because adaptive immune cells contain vitamin D receptors (VDRs). These receptors are attached to the surface of the adaptive immune system’s antibodies and sensitized lymphocytes. When the VDRs receive adequate amounts of vitamin D, they enable the adaptive immune system to function properly by attacking new and previous invaders.

When the VDRs attached to the adaptive immune system’s cells do not contain sufficient vitamin D to attack invaders, autoimmunity may kick in, causing the death of healthy immune cells. Thus, vitamin D deficiency can contribute to the development of autoimmune disorders such as MS.

How Can Vitamin D Treat MS?

The scientific community is delivering hope to MS patients by investigating vitamin D intake as a treatment for the disease. Research suggests that higher vitamin D levels are associated with reduced disease activity in MS sufferers.

Dr. Alberto Ascherio of Harvard University’s School of Public Health and colleagues recently concluded that vitamin D appears to be connected with MS disease activity and progression in patients who experienced an initial episode suggestive of MS and were treated with interferon β-1b. The researchers found that 20 ng/mL-increases of vitamin D levels within the first 12 months of experiencing an initial episode predicted a 57 percent lower rate of new active lesions as well as a lower risk of relapse. In addition, the results included a 25 percent decrease in annual T2 brain lesion volume and a 0.41 percent lower yearly loss in brain volume over four years. The Harvard study was electronically published on January 20, 2014 in JAMA Neurology.

According to a study published in a 2012 issue of the Annals of Neurology, a University of California, San Francisco research team examined 469 male and female MS patients over five years to ascertain how vitamin D affected disease progression. The researchers discovered that for each increase of 10 ng/mL in vitamin D levels, the MS patients benefited from a corresponding 15 percent decrease in new brain lesions as well as a 32 percent lower risk in inflammation of the myelin sheath.

A Finnish study, published in a 2012 issue of the Journal of Neurology, Neurosurgery, and Psychiatry, concluded that vitamin D3 supplementation significantly reduced the number of brain lesions in MS patients undergoing interferon β-1b treatment.

Paving a Way to Better Health and Quality of Life

Adequate vitamin D levels in our body may indeed protect us from developing MS. If you have experienced a possible initial episode or have been diagnosed with MS, please consider how vitamin D3 supplementation may decrease the severity of your symptoms.

We must take ownership of our health by understanding the importance of vitamin D as well as other micronutrients. Why wait years, or decades, to garner the results of further studies and clinical trials to define the exact relationship between vitamin D status and MS. We can be proactive by taking daily vitamin D3 supplements and enjoying moderate sunlight exposure to increase our vitamin D levels.

It is imperative to take enough vitamin D so this essential nutrient will be stored in your cells to help regulate your immune system. The greater your vitamin D level (easily obtained from a simple blood test called 25(OH) vitamin D), the more likely you will benefit from a stronger immune system that will protect your body’s cells from attacking one another.

No one wants to endure the health, financial, and social burdens of a chronic debilitating disease. By empowering yourself with adequate vitamin D, you may not only reap lots of health benefits but enjoy a better quality of life.

We Need Your Help

More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, like it, please help support it. Contribute now.

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Image credit: Stephanie021299, CC BY-SA 4.0, via Wikimedia Commons
This post was published here originally on March 4, 2014. 

Copyright © 2014 by Susan Rex Ryan. All rights reserved.

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Treating Infertility with Specialized Pelvic Therapy: A Natural Approach That Works

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In a 10-year study of 1392 infertile women, manual physical therapy yielded high pregnancy rates for women in three categories of hormonal infertility. Subsets of participants showed success for women with endometriosis, polycystic ovarian syndrome (PCOS), and high FSH (follicle-stimulating hormone).
The therapy was originally designed to treat pain due to the adhesions that form when the body heals. Adhesions tend to remain in the body, acting like an internal glue after healing has occurred. Adhesions can act like tiny straitjackets, causing pain or dysfunction – including infertility.

Endometriosis adhesions

Endometriosis, Infertility and Adhesions

Endometriosis is considered both a mechanical and a hormonal condition, with adhesions frequently accompanying endometrial implants. The therapy is designed to decrease the cross-linking, the tiny but powerful white attachments shown in the drawing. In the 10-year study, 43% (128/299) of the women diagnosed infertile with endometriosis became pregnant after receiving the therapy. This rate compares well to surgical success rates, but without the costs or risks of surgery.

PCOS and Infertility

In the study, 54% (15/28) of women diagnosed infertile with polycystic ovarian syndrome (PCOS) achieved pregnancy after therapy. While this is a smaller subset, this rate is encouraging; it is much higher than the 22% to 33% pregnancy rates achieved after surgeries cited in the study. In surgery for PCOS, the physician will either drill holes in the ovary or remove a wedge-shaped portion of the organ. One reason for the low pregnancy rates after PCOS surgery may be the new adhesions that form as the body heals from the surgery.

High FSH Infertility

pregnancy rates for women with high FSHOne of the biggest surprises in the ten-year study was in women who were diagnosed hormonally infertile due to high FSH (follicle-stimulating hormone). As a woman approaches menopause, her ovaries demand more and more FSH to stimulate egg growth in older follicles. Measured early in the menstrual cycle, most physicians feel a woman’s FSH levels should be at or below 10 mIU/mL. When a woman’s FSH is above 10, she is considered unlikely to conceive. At FSH of 25, the woman is generally considered to be menopausal.

In the 10-year 2015 study, a surprising 39% (48/122) of women diagnosed subfertile or infertile due to high FSH became pregnant after receiving the therapy; 43 of the pregnancies were natural, and five were by follow-up IVF.

“The data with these women has been absolutely remarkable” said Belinda Wurn, director for Clear Passage Physical Therapy. “Before this study, nothing in medicine has been shown to improve FSH and fertility naturally. Until now, none of us imagined that a manual therapy could have such profound effects, without surgery or drugs.”

The therapy (Clear Passage Approach™) is available at a dozen locations in the U.S. and the United Kingdom. Treatment consists of 20 hours of hands-on care described as “feeling like a deep, site-specific massage.” The therapy is often given 4 hours a day for 5 days. For more information, visit clearpassage.com.

We Need Your Help

More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, like it, please help support it. Contribute now.

Yes, I would like to support Hormones Matter.

Feature image: Tulia Colombia Torres Hurtado Pixabay

This article was published originally on August 15, 2017. 

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Reframing Maternal Health: How Do We Know What We Think We Know?

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I had the great pleasure of speaking to the Washington Alliance for Responsible Midwifery (WARM) recently about re-framing the concepts around maternal health and understanding the biases in medical research. One of the great questions that has been occupying my time lately is understanding how the frameworks for understanding medical concepts emerge. Shorthand: how do we know what we think we know? Below is an annotated and somewhat edited (for publication) version of the talk I gave. Enjoy.

What is Health?

When we think about health and illness, we all think we know what they are. We can see, touch, and measure health and illness in some very discrete and obvious ways. For example, in Western culture thin is good, fat is not good. If one is skinny, one must be healthy whereas if one overweight, one must be unhealthy.

Weight is a key parameter by which we all shorthand our assessment of health and illness. Indeed, weight, along with other visible qualities, like pallor and disposition, and some less immediately visible but easily measurable qualities like blood pressure, glucose, and other standard labs are key indicators that define health versus illness.

More often than not, however, our definitions of health and disease have been guided by external forces and systems of thought that are inherently biased, even though they claim the objectivity of science and evidence. These biases not only impact our views on health and illness, but in many ways, define what questions are acceptable to ask about health and disease.

Perinatal Mental Illness: An Entrenched Framework for Maternal Health and Illness

In my own research on perinatal mental illness, the prevailing wisdom was and still remains focused on questions that frame the discussion incorrectly. What I mean by that is the original ideas that initiated our notions of what causes postpartum mental illness – the change in progesterone and the estrogens – have become entrenched. Indeed, the ideas that the symptoms are a standard clinical depression or somehow a more serious degree of baby blues and tearfulness are well established.

When you think about pregnancy and postpartum, there are huge hormone changes, progesterone and estriol and estradiol being the most obvious, so it was reasonable to begin looking there. The problem is that, more than not, these hormones were never measured and when they were measured in association with depressive symptoms there were only weak correlations, if any correlations at all. After a while, one would think researchers would begin looking elsewhere, other hormones, other symptoms, but they didn’t. They just dug in deeper. The framework for perinatal mental health issues had already be set and to deviate was difficult at best, impossible for many.

I came to this conversation as a lowly graduate student. I thought, let’s look at other hormones and other symptoms, not just depression, and see what happens.

Lo and behold, other hormones were involved, as were other symptoms. But again, the framework was established and so the idea of expanding definitions of perinatal mental health, especially by someone who wasn’t a named researcher, was not a positive one.

The research was rejected over and over again and the politics of the maintaining the framework and only incrementally changing it were made quite clear to me, repeatedly. So much so that those controlling the dialogue were willing to dismiss where the data pointed to in order to frame the conversation as conventionally accepted – that progesterone and estrogens caused varying degrees of depression postpartum. Even though this made no sense logically; if this were the case, all women would be suffering and they were not. There was no supporting data, but it didn’t matter because as one reviewer commented about my research – ‘that is not the direction the hormone research is going’. So much for unbiased science.

This experience, added to my already disquieted disposition, led me to always dig deeper and look at the frameworks through which the research or ideas were being proposed. These are more philosophical questions, and yes, I have a degree in philosophy so I am naturally inclined towards these – but I think it is important to question how you know what you know and how others know what they know; those rules of knowledge determine, in large part, what can be known in a public sense, and will lead to tremendous insight in your practice – especially when what is accepted as standard clinical practice – doesn’t quite mesh with the patients in front of you. Dig and figure out what the framework was that developed those particular guidelines. Was it valid, was it commiserate with modern patients and current health issues or was it something that was skewed to begin with and has become increasingly more skewed – but we’re holding on to the practice anyway because it has become just the way we do things.

It’s a big topic – one where women and childbirth should play central roles but historically, we have been left out of the conversation.

Historical Frameworks for Maternal Health

To give you some context about how the frameworks impact clinical practice, let us consider the evolution of modern medicine. Historically, medicine has asserted the primacy of the physician’s ability to ‘see’ and thus, identify illness, over the subjectivity of the patient’s perspective about his or her health. So much so, that patients need not even speak unless spoken too and may only aid the physician to the extent they can answer those questions that the physician is interested in.

To say this has been a paternalistic approach is an understatement. Within this model of the physician as ‘seer’ and interpreter of signs and symptoms there is no room for the patient and his or her interpretation of the illness – especially her interpretation.

Despite its flaws, however, in many ways, this was a net positive for medical science. It allowed medicine to progress, for diseases to be systematically recorded and discussed – amongst other physicians of course – but still a critical step forward in medicine. Most importantly, this framework allowed medical science to begin developing treatments to specific diseases.

On the most basic level, one cannot manage a condition unless one can measure it, and to measure it, we have to be able to identify it and distinguish it from other diseases. And herein, lays much of problem with general women’s health and maternal health: what to measure, how to measure and what those measurements meant were largely decided by men who had no lived experience of ‘women’s health’ save perhaps, an observed experience with mothers, wives, sisters – which for all intents and purposes because of the political and cultural norms – women were separate.

So, the framework for women’s health, and most especially, maternal health was fundamentally flawed and inherently biased – from the onset. No matter that midwives had been delivering babies for generations and had built a wealth of knowledge – their influence, and power was usurped by physicians and that knowledge was summarily rejected. In its place practices and technologies that, in many cases, did not benefit women. Indeed, from the early 20th century onward, obstetrics considered childbirth a pathogenic condition requiring medical intervention.

Since within this model the patient had no role in either diagnostics or treatment consideration, but lay simply in front of the physician for him to ‘see’ and interpret the signs and symptoms of disease, the definitions of women’s health and disease and most especially maternal health – were obviously skewed. How could they not be, looking from the outside in – framing the questions from a distance?

Consider that not only were the very questions asked about women’s health defined by men, but the research subsequently, if it included women at all, was guided by the false presumptions that women were simply men with uteri.

And I should note, that women were summarily excluded from research until the late 1990s – so everything we know about medications prior to the 90s was based upon research with men, generally, young, healthy men at that.

It was believed and still held by many, that except for reproductive processes, men and women were fundamentally the same. Once we isolate those specific functions, there is no need to address women’s health any differently than men’s health. Or is there?

Is a Woman Simply a Man with a Uterus?

As women, I think we would all argue in favor of assessing women’s health differently than men’s health.

From a physiological and biochemical standpoint, male and female bodies are quite distinct, far beyond differences in reproductive capacity. In fact, these differences are exactly because of reproductive capacity and more specifically, the hormones that mediate those abilities.

If men and women are different – and of course they are – how do we know that what we know about women’s health is in fact accurate when most of women’s health research was defined by men? Do we really know anything, beyond the most basic assessments about women’s health?

I would argue that what we know or rather what we think we know, pretend to know, especially in western medicine, may not be accurate. The questions were framed incorrectly – from the perspective that women’s reproductive capacities, organs and hormones had no impact on the rest of her health. We could probably make the same argument for men, as their reproductive organs and hormones were dissociated from the rest of their health too – but because men controlled the research, defined the research, and importantly, had personal insight regarding their own physiological functioning, health knowledge is likely more accurate than what has been conveyed about women.

Shifting Frameworks Means Changing Definitions of Maternal Health

This isn’t just about differences in human physiology. If we dig into the framework by which we understand health, if we dig into the systems at play, we can see trends in how, as that power structure, as the lens, the framework for understanding health and disease shifts, so to do the definitions of health and disease and so too does the range of acceptable and unacceptable questions to ask.

If we look at recent decades with advent of HMOs and other payer contracts, along with the growth of hospitals, we see ever changing health and disease models. The model with physician as the central and all powerful seer and knower has shifted quite significantly by financial interests producing a factory like approach to healthcare.

With any factory, efficiency and cost cutting are key indicators of success. Instituting those efficiencies, however, largely removes the physician’s authority by shifting the primacy of his views towards the more efficient and less authoritative matching of symptoms to medications and billing codes. Cookbook medicine.

If symptoms reported by a patient don’t fit the ascribed to criteria, for all intents and purposes, the illness does not exist.

The physician, in many ways and recent decades, has become no more than a well-educated, technician answering not to his or her patients, but to the factory bosses – the insurers, the hospitals, and the regulators – the bean counters.

The physician is no longer central to medical science and clinical care. He/she is in many ways an administrator of care – a provider, not a healer, not even a scientists or medical researcher, save except to proffer funding from pharma or device companies.

Physicians have no power, no say in patient care, except to the extent that they can dot the i’s and cross the t’s according to billing codes. If their gut, or more importantly, if the data tell them that a particular treatment is dangerous, or conversely, is needed, but it doesn’t fall within the ascribed treatment plan, the physician has little recourse but to comply or risk losing his/her livelihood and, in more extreme cases, his/her reputation.

We see the barrage of reputation ending slanders hurled at physicians and researchers who dare to speak up and say that perhaps pesticide laden foods are not as safe as chemical companies make them out to be or that perhaps vaccines or other medications are neither as safe nor as effective as pharma and governmental institutions funded by pharma suggest. When physicians speak up, they risk their careers and reputation.

And while, you might be thinking there might be some positives to this shift, it is no longer such a paternalistic system where the physician has total power, in reality, this shift in healthcare towards efficiency still leaves women’s health high and dry and pushes the patient’s experience of his/her illness even further from the ‘knowledge base’ of western medicine.

Who Determines What We Know about Health and Disease? The Folly of Evidence Based in Women’s Health

So, back to this idea of frameworks, if neither the physician nor the patient is central to our definitions of health and disease, who is?  Who determines what we know about health and disease?

In recent decades, clinical practice guidelines have emerged from what are called evidence-based claims. Evidence-based clinical guidelines sound like a perfectly acceptable and reasonable approach to medical science. Research should be done on clinical decisions and outcomes, the data paint a picture of the safety and efficacy of a particular treatment or approach.

Evidence-based is certainly far better than consensus based – which means the ‘experts’ agree that this approach or that approach is optimum – something that has been the norm in women’s health care for generations.

Indeed, most medications were (and are still) never tested on women, pregnant or otherwise, so clinical practice guidelines that involve medication use are developed by ‘consensus’ and what many doctors like to call ‘clinical intuition’.

But since the long-term effects of these intuitive decisions are rarely seen by the clinician whose intuition guided the initial decision, and rarely shared with others, the notion of consensus based medical decision-making becomes sketchy at best, dangerous at worst; unless, you are lucky enough to have a highly skilled and thoughtful practitioner who is able to discern and act upon the best interests of his patients, even if it means going outside the parameters of what the rest of the profession says is appropriate. Most of us are not that lucky and as women we are faced with a medical science that doesn’t quite fit our experience of health and disease.

Of Weight and Health: The Obesity Paradox

If we go back to the shorthand measure of weight as a marker of health – how many of us tell ourselves if we just lose 10lbs we’ll be healthy. Every one of us, at some point or another has fallen into the weight = health trap. While it is true on extreme ends of the weight continuum that weight is related to disease, everywhere else and for everyone else, weight has little to do with ‘healthiness’.  Weight loss has been noted to reduce blood pressure and type 2 diabetes, but the relationship is not as straightforward as it seems. Being of normal weight does not necessarily equal low blood pressure or increase your longevity. Weight is not correlated positively with mortality – death by heart attack or stroke. In fact, the relationship between weight and surviving a life-threatening disease is almost always inverse – the heavier you are, the better the chance for survival. Those fat stores come in handy when we are deathly ill.

Wait, what did I just say that?  We should all go get fat and live longer – well, not really. Rather, I think we should look beyond weight as measure of health and to more appropriate measures like fitness, quality of life and the nutrient density of the diet. If you are eating well, active and feeling good, without any need for medication, then you are healthy.

Back to our evidence based approach – How can it be that the evidence behind what are gold standards of clinical practice be incorrect?

That is a big question that involves a little more background.

We all want our physicians to make healthcare decisions based upon the best available evidence and we can all think of ways that evidence is better than consensus, but each of these methods have their flaws.

Defining the Gold Standards in Clinical Care

When we look at the gold standards in clinical practice, those that align with evidence-based care, we have ask ourselves, from where did that evidence emerge, what were the variables, populations, and other factors studied and how were the outcomes determined.

How we define a good outcome versus a bad outcome determines how we design a particular study and what we results we will show.

Recall my example of the postpartum depression discussion – if we only ever measure progesterone and the estrogens (or don’t measure the hormones at all, simply assume those changes are at root of mood and psychiatric changes) and if we only measure depressive symptoms – then we have narrowed the framework such that we will only find associations or as the case may be – a lack of associations. And if there are no associations in the data – well then the disease must be made up and not real – all in the patient’s head.

The lack of questioning of one’s own biases, of the lens through which the research was designed or the parameters of what fits within that framework necessarily limits the understanding, making it easy to blame the patient. But if we step outside the framework, and listen to the patient’s experience, believe the patient experience and let it guide us, then we can break through the limitations of any particular framework and move science and healthcare forward. It sounds simple, and it is, but only if you recognize your biases and the biases of others and begin questioning, how you know what you know. And if that is not on solid ground, re-frame the questions.

Lies, Damned Lies and Statistics

You’ve all heard the phrase ‘lies, damned lies and statistics’   – it comes from the notion that research design, and particularly, the statistics can be swayed, intentionally or unintentionally, to prove or disprove anything. In medical science, this is especially true. Pick any medication for any disease and ask yourself how we determine whether it is effective or not?

First to mind, ‘it reduces symptoms’

Sounds reasonable – but dig deeper – which symptoms? All of the symptoms? Some of the symptoms?

And then if we dig even deeper…

Who decides which symptoms are important or even which symptoms are associated with a particular disease process? Over recent history, these decisions have been controlled by the pharmaceutical companies, insurance companies and hospital administrators – each with a specific bias and vested interest. The pharmaceutical companies want to sell products, the insurers and hospitals want to reduce costs and make more money. These should be counterbalancing agendas, but unfortunately they are not. The pharmaceutical companies have brilliantly controlled this conversation, defining not only the disease, but also, by controlling the research and defining the symptoms and prescribing guidelines. (I should note they also create new symptoms and disease processes to re-market old drugs to new populationsantidepressants for menopauseantidepressants for low sex drive in women, for example. The symptoms for both of these conditions are made worse by the very drugs being prescribed.)

If institutions or organizations with a vested interest are allowed to define the disease and the research by which a therapy is considered successful, how do we judge the validity of evidence-based guidelines?

Are the assumptions about the disease and the symptoms correct? Do these symptoms apply to all individuals with the disease or only those of certain age group? How about to women versus men?

Treatment Outcomes Determine Product Success or Failure

Take for example the case of statins, like Lipitor or Crestor, some of the most highly prescribed drugs on the market designed to lower cholesterol – because cholesterol was observed to be associated with heart disease in older men, particularly those who have had a heart attack previously.

Reducing cholesterol in this particular patient population might be beneficial to improved longevity (although, that has been questioned vigorously). However, does the rest of population benefit from cholesterol lowering drugs? It depends upon what outcomes are chosen in the research. If we, look at decreased mortality and morbidity as an outcome, then the answer to the question is no, statins are not good for the entire population with high cholesterol. A healthy diet and other lifestyle changes would be better.

Indeed, in women in particular, these drugs are dangerous because they increase Type 2 diabetes, increase vitamin B12 and CoQ10 deficiencies, among other nutrients (which initiates a host of devastating side effects), and most importantly, statins may increase the risk for heart attack and death in women.

So the drug promoted as one that prevents heart disease, may worsen it in women. Not really a tradeoff I would take.

This is problematic if one’s job is to maximize product sales. What do you do?

Let’s change the outcomes to the very simple, lowering of cholesterol. No need to worry about extraneous details like morbidity and mortality, keep it simple stupid.

Also, no need to compare the health of women versus men. Indeed, outcome differences between women men and women are rarely conducted, since statins decrease cholesterol in both women and men. Outcome achieved, evidence base defined, built and promoted.

A couple of points here…

He who defines the research design, controls the results. Across history, patients, especially women, have had no impact on these variables.

First it was the physicians, mostly male, and more recently, the product manufacturers have controlled the very definitions of health and disease, which in turn, determine treatments. To say evidence-based medicine is skewed is an understatement.

Now what?

While I’d argue that we have to re-frame the entire conversation about women’s health and include more voices in that conversation, voices that may not have been heard previously. I would also argue that we are never going remove biases from research and decisions about health and disease, but we can understand them and maybe even use them more effectively.

Revisiting the Foundations of Maternal Health – Enter Obstetrics

In maternal health, consider the Friedman curve and the failure to progress, though certainly not a product based bias as discussed previously, the Friedman curve, created in the 50s by a male physician at the height of hospitalized birth, where hospitals had a vested interest in understanding the progression of labor and its relationship not only to physician efforts, but time and outcome. For generations, this one study has guided OBs in their decisions to expedite labor – and as much research has found – has led the unheralded increase in cesarean delivery. Why?

One could argue that the study was flawed – it was – but most research is flawed in some way or another. I think the important thing is to understand the biases, how the question, and therefore, the answer were framed, and as importantly, who made the decisions about what was important in the framing of question?

Begin with the study population, was it skewed? Yes, it was.

For the Friedman study, more than half of the women had forceps used on them during the delivery (55%) and Pitocin was used to induce or augment labor in 13.8% of women. “Twilight sleep” was common at the time, and so 23% of the women were lightly sedated, 42% were moderately sedated, and 31% were deeply sedated (sometimes “excessively” sedated) with Demerol and scopolamine. In total 96% of the women were sedated with drugs. What might these drugs do to the progression of labor – stall it perhaps?

Digging deeper, consider the framework within which this study was conducted. Hospital births in the 1950s were predominantly drugged, sterile (or presumed sterile). Efficiency and scientific prowess were on the rise. Time was of the essence and there was very strong impetus to gauge decisions based upon the most advanced medical science – drugs, interventions – and an equally strong pull not to allow women to progress more naturally – because then science would not have intervened.

How did this one study become the guiding factor in obstetrical care? Why did we think that this particular study group was representative of the entire population of birthing women? The obvious answer was that women had no voice in this conversation or in the birth itself. It was medical science and intervention from a place of ‘all-knowingness.’

There was never any question that these results could be skewed, until recently. It was accepted, and perhaps the only reason questions have arisen, I suspect, is because of the links between the medical management of birth and the increasing rates of cesareans and maternal and infant mortality in the US over recent decades. Would this study have become so entrenched if the patients – the women – had a voice in the conversations about childbirth or the outcome was not so closely tied to hospital efficiencies? We’ll never know, but one could postulate that under different circumstances the study might have been framed differently and netted different results entirely.

Maternal Hypertension

Another, more recent example of how the framing of the question determines the conclusions of the research, involves how we view high blood pressure in pregnant women. Hypertension during pregnancy is dangerous for the mom – but what do we do? Treat it with non-tested anti-hypertensives, for which we know nothing about the potential side effects to the fetus short or long term ? Do we change diet? Do we simply monitor and hope for the best? What do we do? We don’t know. There is limited research on the topic, including on commonly used interventions.

With such limited research, I had high hopes for recent study, Less-Tight versus Tight Control of Hypertension in Pregnancy.  It was a huge and well-funded study with a wonderful opportunity to determine the risks/benefits of anti-hypertensive therapy, but by all accounts, and in my opinion, it failed because the questions it asked were framed incorrectly. (Or were they? For pharmaceutical companies, the study was success. More on that in a moment).

That is, rather assessing the safety and efficacy of anti-hypertensive medications used during pregnancy (remember safety data for medication use during pregnancy is severely lacking), this study investigated a very narrowly defined and essentially meaningless question. The study asked whether controlling maternal blood pressure strictly within a pre-defined and arbitrary range of blood pressure parameters provided better or worse maternal or fetal outcomes compared to a more flexible approach that allowed broader range of accepted blood pressure metrics.

It did not analyze maternal or infant complications relative to particular medications to determine whether some medications were safer than others. It did not look at dose-response curves relative to those medications and outcomes or sufficiently address the role of pre-existing conditions relative to medications and outcomes. All it did, was ask whether or not managing maternal blood pressure more or less tightly with medications (that were not assessed in any meaningful way) was beneficial or harmful to maternal or infant outcomes. Since both groups of women were on various medications, varying doses and had a host of pre-existing conditions, the results showed that both groups had complications. It did not tell us which medications were safer, what doses of these medications were more dangerous or anything useful for clinical care. It just told us that anti-hypertensive medications during pregnancy, reduce blood pressure (we knew that) and cause complications (we knew that too). My review of the study.

Now, because of way the study was framed and especially how the conclusion was framed – that both tight control and loose control of maternal blood pressure show equal numbers of complications – the message will, and already has, become – blood pressure medications during pregnancy are safe.

The study found no such thing. In fact, the study found nothing really, but because of how it was framed it now becomes shorthand evidence of drug safety during pregnancy. Only those who read the full study with a questioning mind will know that this is not accurate. Most of the population, including physicians, will see only the shorthand PR surrounding the study and assume drug safety.

Conclusion

In conclusion – I want you to go back to practices and think about how you know what you know and if something doesn’t quite mesh – dig deeper – look at the framework from within which that guideline came to be. Look at the original research and decide for yourself.

I think it is time for women, midwives to have a much stronger voice in maternal health care, but to do that, we have to speak up and speak out and not accept the ‘gold standards of care’ just because they are the gold standards. While it is true, sometimes those standards will align well with maternal healthcare, other times, I think you’ll find that because of how the questions were framed, the solutions were skewed and do not match the reality of maternal health and disease.

Thank you.

We Need Your Help

More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, like it, please help support it. Contribute now.

Yes, I would like to support Hormones Matter. 

Image by StockSnap from Pixabay

Originally published March 31, 2015.

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Mommy Brain: Pregnancy and Postpartum Memory Deficits

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Pregnancy and postpartum memory problems are common complaints amongst new moms. Are they real? Some research says yes, other research says no.

In graduate school I studied this issue and completed several studies on pregnancy and postpartum mood and memory changes. In one such study, I ran a full battery neuropsychological tests on a group (n = 28) of highly educated, healthy, medication free, first-time moms. We tested in late pregnancy and within 10 days following the delivery of the child. We also measured a range of hormones (progesterone, DHEAS, testosterone, estrone, estradiol and estriol) to determine what relationship the radical hormone changes of pregnancy and childbirth had on a woman’s cognitive ability. We knew from animal research that steroid hormones could affect learning in very significant ways. It wasn’t that difficult to suspect the same would be true of human women.

The study was never published, rejected from at least three, maybe four journals and has been sitting in a file ever since (along with a number of other studies). With the open access and open science movements growing, I decided it was time for this research to see the light of day. I will be self-publishing much of my research over the coming weeks and months. Here is the first study. Understanding Maternal Cognitive Changes: Associations between Hormones and Memory.

Is the Mommy Brain Real?

More importantly, are hormones to blame?  The answer is yes on both counts. We found that pregnant and postpartum women exhibited detectable cognitive deficits across multiple domains. The deficits were worse in late pregnancy and mostly improved postpartum. These memory problems were linked to both the excessively high hormones of late pregnancy, the low hormones following delivery, and the large changes in hormone concentration from pregnancy to postpartum.

What Types of Cognitive Deficits?

Pregnant and to a lesser degree, postpartum women had difficulty sustaining focus – this may be the mommy brain fog that many women complain of. We also found that during pregnancy especially, women were unable to manipulate and organize incoming information effectively. This presented as poor performance across a number of tests that assessed both short and long term memory.

In the case of verbal memory, these highly intelligent (estimated average IQ was 114 – 119) and educated (average years of education was 16 years) women tested in the low single digit to the 20th percentiles across multiple IQ-adjusted verbal recall measures. Even when estimates of IQ were not used to adjust scores, the participants performed poorly compared to normative standards. This was surprising given that many of these women had advanced degrees and were working in professional capacities.

The verbal tests involved remembering lists of words; words that could be grouped into meaningful categories that would improve memory significantly. Most of the study participants had difficulty grouping the words into categories. Instead, they would attempt to remember by rote sequence, which is always much more difficult. They also exhibited high numbers of intrusions – recalling words that were not in the original lists and repetitions – repeating words.

Similarly, and more strikingly visible, visual- spatial memory was marred by the inability to group bits of information and perhaps even to see the groupings in the first place. In this test, the study participants were given a complex figure to copy (shown below). They were not told that they would be asked to recall and redraw the picture later. When asked to redraw the figure, the inability to see the totality of the picture, to group bits of information was apparent.

Visual – spatial memory deficits as assessed by the Rey Complex Figure Test. Marrs et al. 2013, © 2013 Lucine Health Sciences, Inc. All rights reserved.

Does Memory Improve Postpartum?

Interestingly, while spatial memory improved significantly from pregnancy to postpartum, verbal memory did not. And this is probably what troubles women the most, the perceived deficits in verbal memory. Most of us think in words, when our ability to find words, retain words, organize information effectively is compromised, we notice.

Hormones and Memory

Both high levels of late pregnancy estrogens, (estrone, estradiol and estriol – we measured all three) and the low levels these estrogens postpartum were correlated with multiple measures of diminished memory, attention and processing. Additionally, the larger the change in the circulating levels of estrogens from late pregnancy to early postpartum was associated with poor memory postpartum. Indeed, women who had higher postpartum estradiol and estriol specifically, performed better on measures of verbal memory than those who did not.

Progesterone, long thought to be associated with cognitive function, primarily because of its sedative properties, was not associated with any measure of cognitive function at either test time, although large changes in progesterone were associated with some performance measures. DHEAS and testosterone, not often measured in pregnancy, postpartum or even in women’s health in general, were also associated with a few measures of cognitive functioning.

What This Means

Ladies, you are not imagining the pregnancy memory problems. They exist and they are related to the hormones. Most women knew this already, but it took a while for science to catch up. Not to worry though, the memory problems do resolve as the hormones stabilize (my next study to be self-published – a long term follow-up). Read the full study for all the details: Understanding Maternal Cognitive Changes: Associations between Hormones and Memory.

We Need Your Help

More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, like it, please help support it. Contribute now.

Yes, I would like to support Hormones Matter. 

This article was originally published on Hormones Matter on March 26, 2013.

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Infertility Faux Pas: 5 Things Not to Say to Someone Struggling to Conceive

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Infertility is really, really hard. It’s harder than I’ve ever even admitted to myself. It’s also deeply personal. Reminders of your infertility are everywhere. I’m not just talking about all of the babies at the employee picnic or the pregnant women at the grocery store or the mailbox full of baby announcements and shower invitations. I’m talking about insidious little reminders like this ad that Aldi posted on Twitter.

Aldi Tweet

“Dear Aldi, you are opening a giant, fluorescently lit discount grocery store. You are not having a baby,” is what I was thinking when I read this tweet. (After clicking the link, it turns out that Aldi is starting to carry a line of baby products so I can see how the people in charge of marketing would think this advertisement is clever. Even so, it still feels a little like- “oh, even a grocery store can have a baby… but not me!”)

Infertility affects millions of women— over 6 million in the United States alone. It is so common that I’m sure you know at least one person affected by it. Yet as common as it is, people still say the strangest things when they find out you are struggling to conceive. So if you would like to be a more sensitive person to those you know (or may not even realize you know) that are dealing with fertility issues, here are some things not to say.

“You just need to relax and then it will happen.”

I cannot count how many well-meaning people have told me this. I also cannot count the ways I tried to “relax” in order to get pregnant. I got massages and acupuncture and did so many yoga classes I became a yoga teacher. I meditated. I feng shui-ed my house. I talked to my belly. I went on vacation. I thought about getting pregnant. I stopped thinking about getting pregnant. And guess what? None of those things make you pregnant. You cannot relax your way into pregnancy any more than you can relax your way into making it rain. If it’s not going to rain, it’s not going to rain.

Why this is unhelpful: You are essentially blaming me for my infertility when you say this. Infertile women (and most women for that matter) are already blaming ourselves for so many things that are really out of our control. Please stop blaming us for this, too. Also, studies show that moderate stress does not affect fertility.

What to say instead: Wow, that must be really hard. I’m here to listen if you ever want to talk about it.

“I know so many people who started the adoption process and then got pregnant.”

Good for you! Good for them! Do I really need to explain why this is so ridiculous? Okay, I will. Adoption is not a cure for pregnancy. I could see how this would be confusing to some people because it can be an alternate way to grow your family when you can’t grow them in your body. However, it is not a magic pill that tricks your body into getting pregnant. Most people who say this think that you are just too focused on getting pregnant and that starting the adoption process will distract you and therefore make you pregnant. This false logic is closely tied to the “relax and it will happen” (see above). It is akin to telling Michael Phelps that his body will swim faster if he just takes up knitting.

Why this is unhelpful: The only people that should start the adoption process are the people who are ready and excited to adopt. Adoption is not a placebo for pregnancy.

What to say instead: Wow, that must be really hard. I’m here to listen if you ever want to talk about it.

“Why don’t you just adopt a (twelve-year-old/ handicapped kid/ kid with cancer)? I would totally do that.”

The people who have said these things to me are invariably the people who had zero problems conceiving their 2-5 perfectly healthy children. Let me tell you something about coming to the decision to adopt a child. It is a very hard thing for many people. Especially when you have dreamed of having a child that looks like you and your partner. Especially when you have imagined what it must be like to feel your baby move inside you, a very part of you.

When you don’t actually have to make that decision, you can imagine you are the type of person that would adopt any and every desperate child in the world no matter the circumstance. Your heart is just that big. You can imagine that you would be the Mother Teresa of adoptive parents. And you can sit with your perfectly healthy, instantly conceived child in your lap while having fantasies about what kind of person you are. BUT when you actually start the adoption process, the fantasy stops. Because you literally have to write down what you are willing to deal with and what you would rather not deal with. Which means you have to say, “hey, you know what, I don’t really want to adopt a kid with cancer because going through the adoption process and becoming a parent is already hard enough.” Remember above where I said we infertile women are already blaming ourselves enough? Cue the crashing waves of guilt for wanting a healthy baby when there are so many other children that need homes. Does anyone ever blame a pregnant woman for wanting a healthy baby?

Why this is unhelpful: The adoption process is challenging, exhausting, and often extremely expensive. Judging anyone’s decision about when and how they proceed with this process (especially if you have no experience with adoption) isn’t just ridiculous. It’s cruel.

What to say instead: Wow, that must be really hard. I’m here to listen if you ever want to talk about it.

“I’m pregnant! April Fools!”

Since the United States treats pregnancy like a disability anyway, this could be a little like saying “I’m in a wheelchair! Just kidding!” Okay, maybe that’s a stretch, but it’s a weird thing to joke about. And it’s a thoughtless thing to joke about.

Also, according to the CDC, nearly half of all pregnancies are unintended. I would imagine an unintended pregnancy is very stressful, too.

Why this is unhelpful: Not only are you poking those of us who are infertile but you’re likely causing anxiety for half of your pregnant friends as well.

What to say instead: Nothing. Have you ever heard a good April fool’s joke?

“Happy Mother’s Day.”

I don’t think I am one to take things personally when it’s not warranted. Maybe I used to but as I mentioned above, I’m very relaxed now (lots of yoga classes… seriously, tons). However, this one stings. It just does. For the past couple of years, I’ve been lucky enough to spend Mother’s Day with two of the best mothers out there, my mom and my sister. During the course of the day, sales clerks, servers, and other people we encountered would say to each of us, “Happy Mother’s Day!” Sure, these lovely folks got it right for two out of three. Yet for me, each time felt sort of like a tiny little dagger into my infertile little heart.

Why this is unhelpful: It’s not really unhelpful. It’s well-meaning. But it still hurts those who aren’t mothers yet desperately want to be.

What to say instead: I don’t know. Keep being nice to people for sure. The world is too hard not to. Maybe try a genuine, “I hope you’re having a really nice day” rather than a robotic “Happy Mother’s Day!” to every woman that comes through your check-out line.

I did leave one thing off the list. Never, ever, ever comment when a woman is buying a pregnancy test. There is no right thing to say here. Not “oooh how exciting!” Not “uh-oh, good news or bad news?” Not “you must be celebrating tonight!” Remember when I said above how many people were dealing with fertility issues and also how half of all pregnancies are unplanned? More times than not, pregnancy tests are bringing tough news. Don’t comment on these at all.

I’m sure if you have dealt with fertility issues you could add others to this list. What have people said to you that made things harder? Was there anything anyone told you that was helpful?

We Need Your Help

More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, like it, please help support it. Contribute now.

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This article was published originally in June 2016.

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Prescription Medications While Pregnant

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A subject near and dear to my mom-scientist’s heart is the rapid increase and over-use of prescription medications during pregnancy. In the span of about 30 years, we’ve moved from a strong, and perhaps more medically prudent, tradition of no medication, no caffeine, no alcohol while pregnant, to 70–80% of women taking at least one prescription medication during pregnancy.

The Rise in Prescription Medications during Pregnancy

According a report by the CDC, between 1976-2008 prescription medication use during pregnancy grew at a staggering rate.

  • 60% increase in first trimester prescription medication use
  • The number of women taking >4 prescription medications while pregnant has tripled
  • The number of women taking anti-depressants while pregnant has increased significantly
  • 1 in 33 babies are born with birth defects

On average, American women are taking 2.3 medications during pregnancy and sometimes more. I cannot help but wondering when we became so unhealthy.

Prescription Opiates during Pregnancy

More recently, a study published in the Journal of the American Medical Association estimated that 13,500 babies are born every year with Neonatal Abstinence Syndrome or NAS. NAS is a polite way of describing children who are born addicted to the pain killers that were, at least originally, prescribed by physicians to their pregnant mothers. Infants who, in their first moments of life outside the womb, must endure the suffering of opiate withdrawal.

Anti-depressants during Pregnancy

A similar abstinence syndrome is observed in infants born to women taking prescribed selective serotonin uptake inhibitor (SSRI) anti-depressants. It’s called newborn behavioral syndrome, another overly benign name that describes the tremors, agitation, excessive crying, respiratory difficulties, and seizures that emerge post birth as an infant withdraws from SSRIs. This is addition to the increased risk of congenital heart malformations, Long QT syndrome and Persistent Pulmonary Hypertension, that are associated with SSRI infants.

Take Back Pregnancy

Much of this increase can be attributed to the brilliance of pharma’s mega-marketing machine, but the culpability for the consequences lay with us. Women make 80% of all family medical decisions.  We are the deciders for health. We have bought into the notion that a pill cures what ails us. Sometimes it is true. Often times is it not. It is incumbent upon us to know the difference, especially during pregnancy. Many women do not realize that:

Medications do not metabolize the same way in a pregnant versus non-pregnant woman

Most medications cross the placental barrier

Drug testing is not done on pregnant women

So we often have no idea what works, does not work and what the true risk and severity of the side effects will be until after the medication hits the market. Even then, the true risks are difficult to discern because of the glut of medical marketing that often discredits the early reports.

Marketing Prescription Medications to Physicians and Consumers

Just because a medication is prescribed by a physician or it can be purchased over-the-counter, does not make it safe. All medications have side-effects and most of those are not well-understood during pregnancy.  In the case of anti-depressants during pregnancy, study after study, after study, after study (here, here, here) has been published showing the adverse effects of these medications during pregnancy. Indeed, another two were published just recently, linking anti-depressants to pre-term birth and infant convulsions. And yet, the conventional wisdom has been, and is still, that treating depression during pregnancy pharmacologically will improve pregnancy outcome.

Depression treatment during pregnancy is essential. If you have untreated depression, you might not have the energy to take good care of yourself. You might not seek optimal prenatal care or eat the healthy foods your baby needs to thrive. You might turn to smoking or drinking alcohol. The result could be premature birth, low birth weight or other problems for the baby — and an increased risk of postpartum depression for you, as well as difficulty bonding with the baby.”

The data have not born that out. Even the FDA , though they acknowledge the serious adverse events associated with SSRIs during pregnancy,

FDA Drug Safety Communication: Selective serotonin reuptake inhibitor (SSRI) anti-depressant use during pregnancy and reports of a rare heart and lung condition in newborn babies.”

they recommend no changes in prescribing practices.

“At this time, FDA advises health care professionals not to alter their current clinical practice of treating depression during pregnancy. Healthcare professionals should report any adverse events involving SSRIs to the FDA MedWatch Program.”

What is a Girl to Do?

Learn a little chemistry, understand basic statistics, read and research every medication you take, even when you are not pregnant, but especially when you are, and most importantly, make educated choices about your health, your child’s health and the health of your family.

This article was published originally on Hormones Matter in September of 2012. I am sad to say, the problem has only become worse.

 

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