Stress is everywhere

Robert A. Hatcher MD, MPH     

September 11, 2009 

Stress is all about us.  It creeps into our lives like fog the day after a rainstorm.  Stress seems to taunt us with the refrain: “Stop me if you can.”  But sometimes it seems almost impossible to stop.  Sometimes it enters our lives from unexpected quarters. Sometimes we can see it a-coming and run from it! Sometimes we bring it on ourselves. Sometimes it happens in response to something completely beyond our control.

So where does all this leave us? Hopefully, it does not lead us to paralyzing uncertainty. Stress is undoubtedly a major cause of disease – a formidable foe for a person trying to be healthy! 

No one has written my destiny for me or your destiny for you. No one has written my plan for today for me or your plan for today for you. Each person’s response to the stress in her or his life is going to be an important determinant of his or her health.

What are the diseases linked to stress?

• Heart disease
• Hypertension
• Ulcers
• Cancer
• Accidents
• Depression
• Suicide
• Anxiety attacks
• Eating disorders (too much and too little)
• Some kinds of headaches
• Failure of women to ovulate (and therefore infertility – more on this in an upcoming column)
• Poor school and job performance

What are some ways to lower the stress level?

• Deep breathing is a part of virtually every stress reduction program for the past several thousand years
• Prayer and meditation
• Exercise is important for health and one of the healthiest aspects of regular exercise are the benefits in terms of stress reduction
• Carrying a book at all time so that frustration from delays while driving, waiting rooms, lines, broken appointments, and waiting for the completion of car repairs becomes a treat rather than an event that raises your blood pressure
• Carrying a charged up cell phone may also let you make a call you have been wanting to make diminishing your frustration from a delay
• Daily meditation
• Counting to ten when beginning to become angry

The serenity prayer outlines the two approaches you and I can take in the face of each stressful event, experience or relationship we face today. This short prayer helps many millions of people every day by encouraging us to accept things we cannot change and change things we can change.

But let us not give stress a 100% negative rating. It is certainly true that stress may have some beneficial motivating effects.  Stress can keep our nose to the grindstone if we are taking organic chemistry, a tough math course or a daunting creative writing course. Stress can heighten our awareness in some dangerous situations where awareness is essential. Stress may cause us to eliminate procrastination. Stress may help us to visualize the best course of action for a given situation.

Stress can help a woman who is being beaten and sexually abused to see the wisdom of leaving that man. In Rabun County she should call FAITH. And stress can help a person prepare for a difficult speech (in most surveys found to be the most stressful experience a person can be faced with). But for the most part stress is something I hope to minimize in my life today.

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ISSUE: Pfizer Inc. notified healthcare professionals and consumers that it recalled 14 lots of Lo/Ovral-28 (norgestrel and ethinyl estradiol) Tablets and 14 lots of Norgestrel and Ethinyl Estradiol Tablets (generic) for customers in the U.S. market. An investigation by Pfizer found that some blister packs may contain an inexact count of inert or active ingredient tablets and that the tablets may be out of sequence. As a result of this packaging error, the daily regimen for these oral contraceptives may be incorrect and could leave women without adequate contraception, and at risk for unintended pregnancy.

BACKGROUND: These products are oral contraceptives indicated for the prevention of pregnancy. These products are packaged in blister packs containing 21 tablets of active ingredients and seven tablets of inert ingredients. Correct dosing of this product is important in avoiding the associated risks of an unplanned pregnancy.

RECOMMENDATION: Patients who have the affected product should notify their physician and return the product to the pharmacy. See the Press Release for a list of affected lot numbers.

Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA’s MedWatch Safety Information and Adverse Event Reporting Program:

Complete and submit the report Online: www.fda.gov/MedWatch/report.htm1 Download form 2 or call 1-800-332-1088 to request a reporting form, then complete and return to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178

This recall is being conducted with the knowledge of the U.S. Food and Drug Administration.

Lot numbers of affected packs of Lo/OvralR-28 (norgestrel and ethinyl estradiol)Tablets and Norgestrel and Ethinyl Estradiol Tablets (generic) follow on the table below:

NDC Product Lot Expiration Configuration/Count 24090-801-84 LO/OVRALR 28 E15678 08/31/2013 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 E15679 08/31/2013 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 E15686 08/31/2013 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 E15687 01/31/2014 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 E15690 01/31/2014 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 E15698 01/31/2014 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 E15700 02/28/2014 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 E80434 07/31/2013 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 E80438 08/31/2013 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 F36908 02/28/2014 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 F36909 02/28/2014 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 F43915 03/31/2014 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 F43926 03/31/2014 6 PilpacksR of 28 tablets each
24090-801-84 LO/OVRALR 28 F43927 03/31/2014 6 PilpacksR of 28 tablets each
24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg E15677 08/31/2013 6
PilpacksR of 28 tablets each 24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg E15704 01/31/2014 6
PilpacksR of 28 tablets each 24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg E15706 01/31/2014 6 PilpacksR of 28 tablets each
24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg E80440 08/31/2013 6
PilpacksR of 28 tablets each

24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg F16388 01/31/2014 6
PilpacksR of 28 tablets each
24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg F16390 02/28/2014 6
PilpacksR of 28 tablets each
24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg F22132 02/28/2014 6
PilpacksR of 28 tablets each
24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg F31330 02/28/2014 6
PilpacksR of 28 tablets each
24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg F36911 03/31/2014 6
PilpacksR of 28 tablets each
24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg F36913 03/31/2014 6
PilpacksR of 28 tablets each
24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg F43924 03/31/2014 6
PilpacksR of 28 tablets each
24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg F43925 03/31/2014 6
PilpacksR of 28 tablets each
24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg F43934 03/31/2014 6
PilpacksR of 28 tablets each
24090-961-84 Norgestrel 0.3 mg/Ethinyl Estradiol 0.03 mg F53238 03/31/2014 6
PilpacksR of 28 tablets each

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Bob Hatcher

May 14, 2012

I never hear one of Steve Hall’s sermons at the St. James Episcopal Church but that I am inspired, uplifted or prodded to do something I had not been thinking of doing.  On Easter he said several phrases three or four times. He said: “Peggy, can you hear His words? Peggy, I love you.  You are one of the best.” 

Then he said “John, can you hear His words? John, I love you. You are one of the best.”

And then he said Mary, can you hear His words? Mary I love you.  You are one of the best.”

This message resonates with me because it is about the only spiritual message that resonates with me.  It is the only message that I am almost certain about.  I do believe that whatever this thing we call God or our higher power is, He or She does love all of us.  I believe I have a loving God and that there is forgiveness for my shortcomings.  But I am far more certain about the love than the forgiveness!

Moreover, I believe that I am personally called upon by God to love both my neighbor and myself.  This reminds me immediately of another of Steve Hall’s messages when he said that the problem with “love thy neighbor as thyself” is that that is exactly what we do and since we don’t love ourselves we don’t love our neighbor.

So, what I am just about as certain of as I can be is that love is the message of my God or higher power to me.  I am pretty certain of that in spite of these words that came to me today from my friend Gerald Kemper. These words were:

          Moral certainty is always a sign of cultural inferiority. The more uncivilized the man, the surer he is that he knows precisely what is right and what is wrong. All human progress, even in morals, has been the work of men who have doubted the current moral values, not of men who have whooped them up and tried to enforce them. The truly civilized man is always skeptical and tolerant, in this field as in all others. His culture is based on “I am not too sure.” -H.L. Mencken, writer, editor, and critic (1880-1956).

PS: A week after those thoughts appeared in the Clayton Tribune I came across another wise sentence

by H.L. Mencken: “It is the dull man who is always sure, and the sure man who is always dull.”

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A woman is said to be pregnant when the early embryo has successfully made its way through the lining of the uterus establishing contact with the maternal circulation.  This process is called implantation.

Here is an easily understood example.  A couple with infertility problems is trying to become pregnant via in vitro fertilization (IVF). Several eggs are harvested from her ovary, transferred onto a carefully prepared medium and then the man’s sperm are flooded over the woman’s eggs.  They get together in that dish and their development is followed using a microscope. 

Soon thereafter several fertilized eggs are transferred into the woman’s uterus. Shortly after that a test is done.  If implantation has not occurred the pregnancy test is negative.  Up to this point, has fertilization happened? YES, IT HAS?  Has implantation happened? NO, IT HAS NOT. And is she yet pregnant? NO, SHE IS NOT. To review: if implantation has NOT happened her pregnancy test is negative and the couple, so eager to be told “You are pregnant” is told “You are not pregnant yet.  Implantation has not happened.”

In other words, no implantation – no pregnancy. Several days later if implantation has happened her pregnancy test will become positive and THEN the couple will be told “You are pregnant!”

All of the hormonal contraceptives, combined birth control pills, progestin-only pills, contraceptive rings, contraceptive patches, Depo-Provera injections, the hormonal IUD called Mirena, and the Implanon implant  work primarily by stopping ovulation (no egg, then no pregnancy) OR by preventing the ascent of sperm up to the egg (no fertilization – no pregnancy). The copper IUD called ParaGard also works primarily by stopping fertilization but perhaps 3 % of the time works by blocking implantation. Every single one of these methods can alter the lining of the uterus (the endometrium) preventing implantation (no implantation – no pregnancy). And perhaps most important, none of these methods will interrupt the process after implantation (NO INTERRUPTION OF AN IMPLANTED BLASTOCYST, NO ABORTION)

It would appear that whether women will continue to be able to choose to use the very best of our modern contraceptives, the three Long Acting Reversible Contraceptives (LARC methods) and all the other hormonal contraceptives is going to depend in large part on the way PREGNANCY and PERSONHOOD are defined. If a woman is deemed to be pregnant as soon as fertilization occurs, then anything that stops the reproductive process after fertilization is defined as an abortion. This would mean that all the modern contraceptives developed since 1960 (and used by well over 90 percent of American women) would be unavailable for many women. Then these women would not be able to choose consciously whether they will or will not become pregnant.

Robert A. Hatcher MD, MPH
Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, Georgia

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Doctors Leon Speroff and Dan Mishell wrote the lead article in Contraception in August, 2008.  They suggest that “the 6-week postpartum visit is an anachronism.”  It simply does not make sense.  Many women resume sexual activity, they point out BEFORE 6 weeks and ovulation frequently occurs before 6 weeks. They suggest that “A 3-week visit would be more effective at preventing postpartum conception by initiating effective contraception at this time, instead of after the 6-week visit.”

This has been suggested for the past 2 decades by clinicians wanting to diagnose harmful bleeding due to a partially retained placenta.  Obviously it is desirable to detect this earlier than the 6-week visit. 

Speroff and Mishell point out that “total contraceptive protection is achieved by the exclusively breastfeeding woman for a duration of only 10 weeks”  [Visness, Kennedy, Gross et al 1997].  “Supplemental feeding increases the chance of ovulation (and pregnancy) even in amenorrheic women [Diaz S, Aravena R, Cardenas H. 1991 43-335-52]. Speroff and Mishell further point out that “Half of women who are not fully breastfeeding ovulate before the sixth week. Lactation, therefore, provides a contraceptive effect, but it is variable and not reliable for every woman.” 

RAH COMMENT:  When a physician, nurse midwife or nurse practitioner cares for a woman in the immediate postpartum period, neither the woman nor her clinician knows with certainty whether she will be exclusively breastfeeding for the entire 6 weeks suggesting that even for breastfeeding women the routine postpartum visit be scheduled for 3 weeks postpartum.

Handing an immediately postpartum woman her birth control pills in the hospital  and instructing her to take her first pill when her baby is 3 weeks old (if it is her plan to use combined pills), avoids some of the confusion and loss of effectiveness of delaying starting her pills until her 6-week postpartum visit.

Similarly, handing an immediately postpartum woman her progestin-only pills in the hospital  and instructing her to take her first pill on discharge from the hospital (if it is her plan to use POPs), avoids some of the confusion of delaying starting her pills until her 6-week postpartum visit.

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The following information is taken from the 20^th edition of Contraceptive Technology:

Intrauterine Contraceptives by Gillian Dean, MD, MPH and Eleanor Bimla Schwarz, MD, MS

Cancer Protection

Both IUCs are associated with a reduction in the risk of endometrial cancer.  Although the mechanism of action in the copper IUC is unknown, it may relate to alterations in the endometrium.  Similarly, progestin-releasing intrauterine contraception has also been shown to protect against endometrial cancer, as is true of contraceptives that deliver a progestin systemically.  Indeed, the LNg IUC has been used to prevent development of endometrial hyperplasia in women using estrogen therapy in the peri-and postmenopause.  While the TCu380A is generally preferred for women with recent breast cancer, the LNg IUC is used at times for women treated with tamoxifen to protect the endometrium.  Moreover, the LNg IUC has been used for the treatment of nonatypical endometrial hyperplasia.  It may also be effective for atypical hyperplasic and grade 1 endometrial cancer.                           

Non-contraceptive Health Benefits of the LNg IUC Topical delivery of progestin to the uterine cavity has exciting therapeutic uses aside from contraception. Some are well established and approved indications, while others are still being explored. The LNg IUC reduces dysmenorrhea and menstrual blood loss from a variety of causes. Overall blood loss drops about 90%, and at least 20% of women stop bleeding altogether. This translates into clinically important increases in hemoglobin and iron stores. The reduction in menstrual blood loss occurs both in women with normal coagulation parameters and in those with bleeding diatheses, including those using anticoagulant therapy. Some evidence supports a benefit in treating heavy bleeding associated with adenomyosis and leiomyomas with the LNg IUC. Trials have compared this approach to treatment with an oral progestin, a nonsteroidal anti-inflammatory drug, or mefenamic acid (which is not available in the United States) and found the LNg IUC superior to the other alternatives. In addition, the LNg IUC is an acceptable and cost effective alternative to endometrial ablation or hysterectomy. The LNg IUC may also decrease the risk of pelvic inflammatory disease (PID), similar to other progestin-containing contraceptives. By thickening cervical mucus, progestin may provide a barrier to ascending infection. 

IUDs May Protect Against Cervical Cancer

By NICHOLAS BAKALAR Published: September 19, 2011

Intrauterine devices may offer some protection against cervical cancer, a large review of studies has found.

Related

·         Health Guide: Cervical Cancer

·         More Vital Signs Columns

The studies were conducted from 1985 to 2007 in Europe, Asia and South America and involved nearly 20,000 women. After controlling for many health and behavioral factors, the researchers found that using an IUD reduced the risk of cervical cancer by 45 percent, compared with never using one. The review, published online last week in Lancet Oncology, said the protective effect was apparent in the first year of use and continued for as many as 10 years.

Women who choose to have IUDs inserted are more likely to have been screened for cervical cancer, but the researchers found that screening was not a factor in the reduced risk. And women with IUDs were no more or less likely than women without them to be infected with human papillomavirus, the main cause of cervical cancer. Rather, the researchers suggest, the insertion of an IUD might provoke an immune response to HPV.

The data underscore two important points, according to the lead author, Dr. Xavier Castellsagué, an epidemiologist at the Catalan Institute of Oncology in Barcelona, Spain. First, having an IUD does not change the risk for HPV infection. And second, IUD use is associated with a reduction of almost 50 percent in the risk for cervical cancer.

Robert A. Hatcher MD, MPH

Professor of Gynecology and Obstetrics

Emory University School of Medicine

Atlanta, GA 

Reference:

Dean G, Schwarz EB. Intrauterine contraceptives (IUCs) IN Hatcher RA, Trussell J, Nelson AL, Cates Jr. W, Kowal D, Policar MS. et al Contraceptive Technology 20^th edition, pages 152 and 153: Ardent Media Inc. 2011

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One day a good friend and colleague walked me out to the parking area next to the building where we both worked. It was across the street from Grady Memorial Hospital where I have worked since 1963 save for two years of active duty in the Public Health Service and one year at the University of California in Berkeley.

I was seated in the driver’s seat and had rolled down the window.  Our conversation went on for about five minutes. My friend was standing right next to the open window.

Then without raising her voice and in the exactly the same matter of fact tone in which she had been speaking, she said “Oh, Bob, I just ovulated in my right ovary.”

I roared! She told me that occasionally she could feel a slight twinge of pain as she ovulated.  This is what had happened that afternoon.  About 15% of women occasionally do feel something in the pelvic area as ovulation happens.  It can happen on the right or the left as ovulation can occur in either ovary.  When there is any discomfort from rupture of an egg out of the ovary it usually happens about 2 weeks after the first day of the previous menstrual period. This month my friend’s ovulation happened in the right ovary. 

Sometimes the pain of ovulation is quite severe (and must be distinguished from pain associated with pain from appendicitis and other causes). In the vast majority of women ovulation causes no symptoms at all.

Since my friend and I were working in the area of fertility control a recurrent symptom right at the time of ovulation, we realized, could have interesting implications for a woman both in terms of trying to become pregnant and trying to avoid pregnancy.

Well, those are probably more details about ovulation than you expected to hear about from reading today’s issue of the Clayton Tribune!

Next month when I am lecturing to 100 students at a women’s health course at the University of Michigan in Ann Arbor, I will have to tell them of this happening some 30 years ago and go into more details about the implications of that little moment of slight pain in the 15% of them who have experienced it.

So what does this moment of my life some 40 years ago possibly mean to the average reader of this paper? It reminds us that our bodies are speaking to us all the time and that if we are aware and attentive we can pick up signals that could be helpful to us.

Each of us is the captain of his or her own health team.  And it is my strong belief that each of us must be listening and looking for clues as to how our bodies are functioning.  This means looking closely at our habits as well as at the ways our bodies are responding to life and to our habits.

The challenge is to be interested and involved detectives without becoming paranoid or overly self-absorbed. 

Here a suggestion: take a few very, very deep breaths right now. It feels good, doesn’t it?  Now if you haven’t felt this good feeling recently take a number of deep breaths in the day ahead. Deep breathing is such a stress reducer and nothing is better for our health than stress reduction!

Robert A. Hatcher MD, MPH
Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, Georgia

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At 6:15 AM on the Wednesday 2 ½ weeks before Christmas last year a woman asked me if I was all set for Christmas. She was a complete stranger and we were walking along a corridor at the Emory Midtown Hospital. I said briefly how plans were progressing for Maggie and me and then turned her question around and asked her: “How about your plans?”

“I am having 82 people to our house in Hayesville this weekend” she said.  “Last year we had 84. Things are pretty well lined up, she said. Then she outlined a number of the details necessary to pull off the huge affair.  I am convinced that she actively wanted to tell me about the throng of people expected at her house. It was on her mind and in her heart and I feel quite sure that a number of others she would be with that Wednesday would hear about this gala affair!  I told her WOW! And wished her the very best. 

          If someone asks you as question, it may be telling you what he or she wants you to ask in return.  That initial question may be asked almost as an invitation to you to ask the same question of the person standing opposite you.

Often we ask about another person’s children and this tends to be genuinely appreciated.  In some cases we are hoping that this will lead to a question about our own children, and if this does not happen we may be disappointed.

          Another example: recently I heard a person ask another person: “Do you have any great grandchildren.”  The answer was “Yes, and it was just recently. This is my first.” He turned the question around and asked,  “And what about you?”

“Oh yes, I now I have three great grandchildren!” came back the enthusiastic reply.

The next time someone asks you a question, answer it and then consider coming right back to him or her with exactly the same query.

Robert A. Hatcher MD, MPH
Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, Georgia

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My question is in regards to the rule of “taking your pill at the same time every day”.

Due to a medical condition, I have to take my Ocella at bedtime.  I do take my pills RELIGIOUSLY every day, but my bedtime also varies everyday.  It is usually never more than a 4 hour window – meaning I take them between 10:30pm – 2:30am… everyday. 

Reading through your posts, I noticed that there is quite some leeway when it comes to pill-taking.  But, considering my pill-taking habit, am I still getting the full pregnancy protection from the pill or should I consider another method of birth control? 

As always, your advice and assistance is most highly appreciated!

Warm Regards & Happy Holidays

A:        Not a problem.

Her email reply on 12-6: “A million thanks again for all your help!  You and your team are truly a beacon of truth in the fog that is contraceptive management!    

Happy Holidays to you all!”

Happy New Year and thank you for such nice words.

Robert A. Hatcher MD, MPH

Professor of Gynecology and Obstetrics

Emory University School of Medicine

Atlanta, GA

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Good morning!

 Her email reply on 1-12: “Yes, I took my pill at 9:00 PM every night and not even 24 hours after my last pill, I received my first Depo shot.   

Thank you so much for the quick response!  I tried many other sites and this is the first reply I received.  This is definitely the place to get the right answers!” 

To learn more about the advantages and disadvantages of birth control pills and Depo-Provera injections, go to our website: www.managingcontraception.com and click on Choices.  You can also order this wonderful new educational book from our website or by calling 404-875-5001.  Do you have your copy yet?

Robert A. Hatcher MD, MPH

Professor of Gynecology and Obstetrics

Emory University School of Medicine

Atlanta, GA

January 11, 2012, January 12, 2012, January 18, 2012

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