We are excited to announce that Champlain OB/GYN has added Certified Nurse Midwifery to the practice. 

Our goal, as always, is to provide comprehensive services, and appropriate and effective care.  We are confident that the FAHC Midwives are the perfect addition to our practice because we are all committed to offering you the most advanced and complete care that is personalized to your needs.  The FAHC midwives are the longest standing midwifery group in Chittenden County with many years of experience and they are well known for their individualized family-oriented prenatal care.   The physician and midwifery collaborative care model at Champlain OB/GYN will give you a balance of natural and medical perspectives during your pre and postnatal care in a convenient, comfortable and relaxed practice.  You will have the same or similar testing and treatment options available to you and you will still deliver your baby in the hospital setting.  

This is how the transition will work for you during your pregnancy:

If you had your first obstetrical visit before 4/1/14, your care will be shared.  You will see both the midwives and the physicians of Champlain OB/GYN throughout your pregnancy.  The weekly on-call schedule for delivery will consist of 5 nights of Champlain OB/GYN physician call and 2 nights of Midwifery call. 

If your first obstetrical visit was on 4/1/14 or after, your care will be primarily with the Midwives.  They will see you for your monthly, bi-monthly, weekly, and bi-weekly visits.  Champlain OB/GYN physicians will see you for any ultrasounds, problem visits, or consults that the Midwives recommend.  The on-call schedule for delivery will consist only of Midwifery call and the FAHC physicians will offer assistance if needed.

For all patients the 6 week post-partum visit will be performed by a physician at Champlain OB/GYN.

We value the relationships that we have created with you and we understand that with any change there are many questions and concerns.  We would greatly appreciate you allowing us to answer your questions about this transition, please ask any questions or voice any concerns at your next visit, or call the office.

 Sincerely,

Champlain OB/GYN Physicians and Staff

Acne

ACNE

 

Question:  I’m not a teenager anymore, why do I still have acne?

 

Answer:  Acne is a skin problem that starts when dead skin cells and oil clog up pores, then get infected by bacteria, and cause pimples and cysts which can be unsightly, painful or permanently scar the skin.

 

Symptoms of acne include whiteheads, blackheads or pimples.  It can occur on the face, neck, shoulders, back or chest.

Acne can start in the pre-teenage years but continue throughout adult life, and actually get worse in our 30s-50s.

To control acne, look for products that say “noncomedogenic” on the label.  Wash your face with a gentle soap.  You can also use over the counter cream with benzoyl peroxide or salicylic acid.

For acne that does not respond to these treatments, stronger prescription medicines, both hormonal and non-hormonal, can be used.

**To discuss treatment of acne, call Champlain OB-GYN for an appointment.  Most medical insurances cover these visits.  In addition, Dr. Maria Carracino is now prescribing Isotretinoin (also known as Accutane), a strong vitamin-based medication that completely and permanently cures acne.  For more information, schedule an appointment today at 879-1802.

Flu shots for winter

Should I get the flu shot or not?  This is a question that MANY people ask themselves every year.  As the winter marches on in Vermont, you may find yourself asking this very question.  We are here to provide information to help you make a decision if the flu shot is right for you.

The flu is a highly-contagious respiratory illness that is caused by the flu virus.  The flu virus infects the respiratory track, and results in symptoms ranging from mild to severe.  The symptoms can include: fever, chills, cough, sore throat, nasal congestion, headaches, muscle or body aches, fatigue, extreme tiredness (rarely people have nausea, vomiting, and/or diarrhea). For most people, the flu is self-limiting (the body will fight it on it's own) and people will recover fully without significant complications.  However, there are special populations that may have severe illness with complications from the flu virus, including hospitalization and possible death.  These "at risk" populations typically include: older adults and elderly, infants and young children, pregnant women, and people with ongoing health issues such as diabetes, cancer, heart failure, or asthma.

The very best way to prevent the flu is by getting a flu shot in the fall.  The flu shot we offer at Champlain OB/GYN is an inactivated trivalent (three viruses) vaccine.  Medical researchers make a prediction (based on data from last year, the flu season in the southern hemisphere, and medical models) to determine which three virus strains to put in the flu vaccine, which will hopefully protect us the best.  The flu vaccine is recommended for all people over 6 months of age - it is the best way to protect yourself, your family and friends, and your community from the flu.  The more people get vaccinated, the better our community is protected.  There is something called "herd immunity" which is that if most people get vaccinated, the virus does not have enough hosts to survive in and rates of illness are reduced.

Hospitalization rates by age

- Pregnant women:
All pregnant women who will be pregnant during the flu season (October through April) will be offered the flu shot.  Pregnancy represents a very high-risk time - pregnant women are more likely to have a complication, including respiratory compromise that may result in difficulty breathing.  It is important to protect yourself when you are pregnant from the flu, and the best way to do so is by getting a flu shot.


There are a lot of misconceptions about the flu out there.  Just to clear up come common rumors...
- You can NOT get the flu from the flu vaccine.  The vaccine that is given is a DEAD virus, and you cannot get sick from a dead virus.
- You can get the vaccine even if you don't like eggs, or vomit when you eat eggs.  Only those people who have an anaphylactic reaction to eggs should not get the vaccine (if you've ever eaten a cookie, then you don't have an allergy to eggs).
- The flu-vaccine does not cause autism or any other developmental delays.  There have been many research studies done that show there is no correlation between vaccines and autism.

You can check the Vermont Surveillance website to see if there is any flu activity in the state, which it is updated continuously as the flu is diagnosed and reported. 

Calcium = bone health

We're going to be talking about specific nutrients, vitamins and minerals that are necessary in maintaining health (and specific to women's health) over the next few weeks, starting with calcium.

Calcium is the most abundant mineral found in the body.  Most of the calcium in your body (99%) is locked up in your bones and teeth, but some of the calcium (1%) is circulating around the body and is necessary for the body systems to function normally, including vascular function, muscle contraction, nerve transmission, and hormone secretion (to name a few).  Our bodies tightly regulate how much calcium is circulating by using the stores found in our bones - our bones are continuously being remodeled - calcium gets stored in the bones, and also gets taken out and used by the body.  It is strange to think of our bones as being metabolically active, but they are.

Adequate calcium intake is necessary to maintain strong bones and prevent osteoporosis.  Osteoporosis is a state in which bones have a low density and therefore are brittle and at risk of fracturing.  Approximately 10 million people in the U.S. have osteoporosis (80% of them are women), and another 30 million have osteopenia, which is a precursor to osteoporosis. 

Throughout childhood, adolescence, and early adulthood our bones are not only growing in length, but they are also getting stronger.  We reach peak bone density by around age 25-30 years.  After that, our bones slowly lose density over time.  Adequate calcium and vitamin D (which we will talk about in the next blog entry) intake is necessary throughout our life.  In childhood, healthy intake of calcium and vitamin D will ensure our bones to their highest peak density.  After age 25-30, continuing with healthy calcium and vitamin D intake will slow and prevent bone loss that naturally occurs over time.  The bottom line: get your bones as strong as you can, and keep them strong for as long as you can!

How much calcium do you need?  It depends on your age, as well as a couple other factors such as pregnancy and breastfeeding, as well as some medical issues (such as malabsorption disorders like Celiac, or certain medications like steroids).  Each person is a little bit different, but this is a great guide to most women.
Current recommended daily allowances for calcium:
 Age 4-8yrs: 1,000mg
Age 9-18yrs: 1,300mg
Age 19-50yrs: 1,000mg
Age 50 and older: 1,200mg
Pregnancy and lactation: 1,300mg

The BEST source for getting calcium is through your foods.  You should only take a calcium supplement if you cannot eat enough calcium in your diet.  Calcium is best absorbed and utilized by the body when eaten, not as a supplement.  Recent studies have shown an increased risk of cardiovascular disease (including heart attacks or strokes) in people who take excessive calcium through supplementation.

Different foods have different calcium amounts.  As you can see, there are many food sources of calcium, and not just dairy.  Try to space your calcium intake throughout the day (at each meal or as a snack), as your body can only absorb around 500mg at a time.

 

Maintaining healthy amounts of calcium in your diet, in conjunction with adequate vitamin D intake (see our next blog entry) is the best way to prevent osteoporosis in women.  The last piece of the puzzle is weight-bearing exercise!  You have to put small amounts of stress on your bones in order to keep them healthy and strong.  Some examples of weight-bearing exercises are brisk walking, running, hiking, yoga, weight lifting, Tai Chi, soccer, basketball, dancing, and others - anything that uses gravity and puts weight on your bones.  Your goal is to do at least 30 minutes, 5 days per week.

Some good resources include the NIH Office of Dietary Supplements, the NIH Osteoporosis and Bone Health Resource Center,  the National Osteoporosis Foundation, and the American Cancer Society.  Or call us and schedule an appointment to discuss your specific nutrition needs.

The China Study

Someone asked us about the China Study, so I wanted to address her question....

The China Study was a 20 year research study completed by Dr. Campbell from Cornell University in partnership with Oxford University and China.  The China Study was an epidemiologic survey of diet and health conducted in 65 villages throughout China.  It has been touted as “the most comprehensive study of nutrition ever conducted" by some.  The findings were published in a book, "The China Study", authored by Dr. Campbell, who asserts that we could prevent or cure most disease (heart disease, cancer, diabetes, autoimmune diseases, bone, kidney, eye and other diseases) by eating a whole foods plant-based diet, reducing our protein intake, and avoiding meat and dairy products entirely.  The book was then used as the basis for the documentary "Forks over Knives".

A quote from Dr. Campbell from an interview after the book was released:
"The idea is that we should be consuming whole foods... We should not be relying on the idea that nutrient supplementation is the way to get nutrition, because it’s not. I’m talking about whole, plant-based foods. The effect it produces is broad for treatment and prevention of a wide variety of ailments, from cancer to heart disease to diabetes"
 
I have to admit, I haven't read the book personally, so I don't know specifics regarding research methods, statistics, etc.  But in doing some research, it looks like his book as drawn a lot of applause, and also a lot of criticism. The main thing that people take issue with from his research was cutting out dairy and meat completely.  In my lack of awareness about the book and research, I did some digging...  I found the experts.

The American Institute for Cancer Research (AICR) and the World Cancer Research Fund (WCRF) publishes many recommendations regarding nutrition and cancer prevention.   If you haven't looked at AICR's website yet, you should!  They also have a website specifically addressing foods that fight cancer, which lists foods and how they impact your health.  However, it is important to remember that no single food or food component can protect you against cancer alone, however strong evidence does show that a diet consisting of a variety of plant foods such as vegetables, fruits, whole grains and beans helps lower risk for many cancers.

Their most recent report, published a few days ago, asserts that 3 out of 5 cases of endometrial cancer could be prevented through healthy nutrition, physical activity, and maintaining a healthy weight, avoiding sugar-sweetened foods and beverages.  “Many women are not aware of the strong link between obesity and cancer, which is particularly strong for endometrial cancer,” she said, “however, it is good news that many cases could be prevented every year by maintaining a healthy weight and being physically active" (Elisa Bandera, MD, PhD, AICR Panel member).

AICR's top 10 recommendations to prevent cancer are:

1. Be as lean as possible without becoming underweight.
2. Be physically active for at least 30 minutes every day.
3. Avoid sugary drinks (diet and regular sodas). Limit consumption of energy-dense foods.
4. Eat more of a variety of vegetables, fruits, whole grains and legumes such as beans.
5. Limit consumption of red meats (such as beef, pork and lamb) and avoid processed meats.
6. If consumed at all, limit alcoholic drinks to 1 per day for women (2 for men).
7. Limit consumption of salty foods and foods processed with salt.
8. Don't use supplements to protect against cancer.
9. * It is best for mothers to breastfeed exclusively for up to 6 months and then add other liquids and foods.
10. * After treatment, cancer survivors should follow the recommendations for cancer prevention. 

And of course, do not smoke or use tobacco products!  (They don't even include it in the list because it is just a given).

The AICR does address the China Study and Dr. Campbell's research directly, stating that diet is only a piece of the puzzle.  They agree with Dr. Campbell that the link between excess body fat and cancer is convincing, and that the obesity epidemic now raging through our society "will result in millions of cancers in the future unless something this changed".  

The AICR goes on to recommend getting 1/3 of your daily food intake from healthy protein sources.  Remember, protein does NOT necessary equal meat.  Protein can be found in beans, rice, grains, nuts, legumes, fish, poultry, eggs, and low-fat dairy.  They also recommend limiting red meats, processed meats (like some sandwich meats, hotdogs, and smoked/cured meats) to no more than 2 times per week. 

What's the bottom line?  We need protein to survive - to build muscle, regenerate tissues, to heal, to function.  But in the American culture we tend to be rather protein-obsessed (how many people have seen ads for protein shakes? or tried them?)  Get your protein from a wide variety of BOTH plant-based and animal-based sources.

Again, if you haven't checked out the American Institute on Cancer Research website yet, I would highly recommend it!

Nutrition overview - Food as Medicine

We spend a lot of our time thinking about what we are eating, what "should" we be eating, and how our nutrition is affecting our health.  The next few blog entries we will touch on some of the major topics in nutrition.  Notice I use the word nutrition to describe what food you put into your body to fuel your life - I don't like the word "diet" because it tends to imply something that you "go on to", or something you do for a short period of time.  Nutrition is foundational to our health. 

Americans are bombarded with information every single day about "healthy eating" - from our parents, spouses or significant others, coworkers, books, magazines, TV shows, commercials, and the list goes on and on...  However, as a nation, we have the highest rates of obesity, and obesity-related disease, of all the developed countries.  This summer of 2013, the American Medical Association (AMA) finally recognized obesity as a disease - hopefully to bring more attention to the health consequences of obesity, including type 2 diabetes and heart disease, and to get better insurance reimbursement for the providers who are working with their patients to help them get to a healthy weight.

The rates of obesity (defined as BMI above 30) have sky-rocketed in the last 20 years.

We have forgotten somewhere along the way that our food is our medicine.  Most of the pharmaceuticals and prescription medications that we have today can be traced back to a plant origin.  Just because something is made in nature, does not mean that it is not potent.  We evolved eating food that came from the land - foraging wild fruits, veggies, nuts, roots, fungi, and hunting wild meat.  This diet is not feasible for the vast majority of us in the current day.  However, what does remain is that our bodies evolved to function, grow, and be healthy entirely fueled by foods that we got from our environment (which did not include dietary supplements from our local drug store).

So what's the bottom line??
1) Food is our original medicine, and we should try to get most of our nutrition from foods that are found in their original state.  Try to eat or cook with WHOLE foods - things that you could find in a garden.  Using foods that are close to their original state allows your body to best utilize the food, without additional ingredients or processing.
2) Avoid foods that come pre-packaged and highly-processed.  Just because it says "Lean Cuisine" or "healthy" on the package doesn't mean it is good for you.

Try to eat at least one of each color every day!

3) Try to eat a wide variety of foods, as this will get a wide variety of nutrients and minerals. A good rule of thumb is to eat one of each color every day, i.e. something that is red (like strawberries or an apple), something orange (like yams or golden beets), something yellow (like squash or a bell pepper), something green (like kale, spinach, broccoli, or avocado), and something blue/purple (like blueberries or eggplant). 
4) Supplements should only be used when we are not getting adequate nutrition from our foods.
5) Exercise is necessary in order to maintain our health, prevent disease, and maintain a healthy weight.  Goal: at least 30 minutes, 5 days per week (at a minimum).  Figure out something that works for you and your life.
6) Avoid sweetened beverages, both diet and sugar-containing.  Drink water!
7) Maintaining a healthy weight is not just about "looking good" as our culture defines it, but rather is about preventing diseases that can be caused by excessive weight.

We will talk about many different aspects of nutrition and exercise in future blog posts, and discuss how to get all of the nutrients you need from a healthy, balanced diet.  If there is a specific question you have or want addressed regarding nutrition and exercise, let us know!

In the mean time, some good nutrition resources include the Harvard School of Public Heath, the American Heart Association, the U.S. Dept of Health and Human Services, or the CDC.

TDaP Vaccine

As you may have heard, Pertussis (also known as Whooping Cough) is back in our community here in Vermont, including Chittenden county.  Pertussis is an infectious disease, caused by the bacteria Bordetella pertussis.  It is a respiratory infection, that causes inflammation of the tissues in the lungs and airways, impaired ability to clear respiratory secretions, and severe cough with the characteristic "whoop" that can last up to 6-10 weeks, hence the name.  In the 1900's, Pertussis was a major cause of death especially for infants and young children.  However, with the invention of the vaccine and routine administration of vaccines during childhood, Pertussis declined considerably.  Pertussis is particularly dangerous for young children and infants.

The Vermont Health Department tracks Pertussis cases in the state, and they have reported a considerable increase in the number of confirmed cases.

Pertussis is on the rise. Vermont had over a 3-fold increase in the number of Pertussis cases from 2011 to 2012.

Pertussis can be prevented with a vaccine - the TDaP vaccine, which stands for Tetanus, Diphtheria, and Pertussis.  It is recommended that everyone make sure they are up to date on their TDaP vaccine.

Current guidelines for vaccination:
- Infants and Children:  The vaccine DTaP (the formulation for children) series of five shots given at 2, 4, and 6 months of age, 15-18 months, and the fifth shot is given when a child enters school, at 4-6 years of age.

- Preteens and Teens: Vaccine protection for pertussis, tetanus, and diphtheria can decrease with time. Preteens should get a TDaP booster at 11-12 years. Teens and young adults who didn't get a booster of TDaP as a preteen should get one dose when they visit their health care provider.

- For Pregnant Women: Expectant mothers should get one dose of TDaP during each pregnancy, preferably at 27-36 weeks. By getting TDaP during pregnancy, maternal antibodies transfer to the newborn, likely providing protection against pertussis in early life, before the baby starts getting DTaP vaccines. The TDaP vaccine will also protect the mother at time of delivery, making her less likely to transmit pertussis to her infant.  Fathers, childcare providers, or anyone that will be in close contact with the baby should make sure they are up to date on their vaccine, as well.

- For Adults: Adults 19 years and older who didn't get TDaP as a teen should get one dose of TDaP. Adults get TDaP in place of one of their regular tetanus boosters, Td, which is recommended for adults every 10 years.  However, the dose of TDaP should be given no matter when the last Td shot was received. It's a good idea for adults to talk to a health care provider about what's best for their specific situation.  Adults who are in close contact with infants and young children should make sure they are up to date with their vaccine to prevent exposure/risk to the infant.

We carry the TDaP vaccine in our office and administer it routinely!  Please call us if you need to update your vaccine, or if you are unsure.  When in doubt, it is always better to re-vaccinate.  There is no risk to receiving the vaccine twice if you are unsure if you have received the vaccine or not.  As recommended, we provide the vaccine to all pregnant women at 27-36 weeks.  Check out the CDC Pertussis website for more information.

Contraceptive options

Contraception, more commonly known as birth control, is something all women think about and many women utilize at some point in their life.  Birth control allows women and families to prevent pregnancy, plan and time when they want to become pregnant, or space out when they have their children.  There are many options available.  Women often will change their birth control method depending on her preference, health, age, or other factors.  Many of these contraceptive options are also used for medical reasons not related to pregnancy-prevention.  It is important for women to understand what options are available, in order to make an informed decision with her provider about which method would be best.

Currently, the following contraception methods are available, with their relative effectiveness:

1) Permanent contraception (99.2-100% effective): male vasectomy, female sterilization (via Essure or tubal ligation) - non-reversible forms of contraception, require surgical or in-office procedure.  Generally, permanent procedures are done after women and families have completed their child-bearing and are sure they do not desire any more children.  A follow up visit is usually required to ensure the procedure was successfully completed.

Essure sterilization coils

Tubal ligation

 2) Extended implants (99.1-99.9% effective): Mirena IUD containing progesterone, Skyla IUD containing progesterone, Nexplanon arm implant containing progesterone, Paragard copper IUD.  Reversible methods that require a short in-office procedure, but then do not require the woman to do anything to ensure the birth control method is effective.  Each of these methods can be used for an extended period of time, but are reversible, meaning fertility returns once the method is removed from the body.  It is not required that a woman use the device for the entire time and can be removed early if she desires pregnancy or wants to change methods.

Mirena IUD

Life-span of one device:
- Mirena IUD: 5 years
- Skyla IUD: 3 years
- Nexplanon implant: 3 years
- Paragard copper IUD: 10 years
If a woman is happy with her method and wants to continue with the same method, it is possible to remove the device at the end of its effective time period, and insert a new one, or "piggy back" them.

Paragard Copper IUD

Nexplanon arm implant

Birth control pills

3) Hormonal methods (92-99% effective, depending on adherence and proper use): Depo-Provera progesterone injection every 12-13 weeks, daily birth control pills, NuvaRing vaginal ring used once a month, OrthoEvra patch applied to skin weekly.  Each of these methods require the patient to use the method correctly as directed (for example, taking the birth control pill every day at the same time).  If not taken or used effectively, the efficacy of the birth control goes down.

NuvaRing

OrthoEvra

4) Barrier methods (76-90% effective depending on proper use with every intercourse): male condom, diaphragm, female condom, cervical cap, sponge.  The barrier methods need to be used with every act of intercourse, and need to be used as directed for maximum efficacy. 

Diaphragm

Male condoms

5) Other methods (50-70% effective depending on proper use): Natural family planning, breast feeding, spermicide alone, withdrawal method. 

If you are interested in discussion any of the above methods, please let us know, and we are happy to sit down with you at an appointment and review all of the available options for you, including how they work, efficacy, risks and benefits associated with use, and answer any questions you may have.

Gardasil vaccine

As a follow up to the last blog post on the PAP test, it is appropriate to talk about cervical cancer prevention.  The most recent data tells us that the vast majority of cervical cancers are caused by HPV (Human Papilloma Virus).  There are many different strains of HPV that can infect the body; some are benign (albeit annoying) and can cause benign warts on your fingers or toes.  Some are high-risk, cancer-causing (also known as oncogenic) and can infect the cervix and cause pre-cancerous lesions, which if left undiagnosed or untreated may lead to cervical cancer.  The PAP smear screens for cervical pre-cancerous changes.

Approximately 20 million Americans are infected with HPV, making it the most common sexually transmitted infection, with 6 million new cases per year.  A healthy body is often able to attack the virus and successfully eradicate it.  However, we also have a way to prevent HPV infection - the Gardasil vaccine.  This vaccine is quadravalent, meaning it confers protection from 4 different strains of HPV.  Two "low-risk" types - HPV 6 and 11 (responsible for most cases of genital warts), and two "high-risk" types - HPV 16 and 18 (responsible for ~70% of pre-cancer changes).

Gardasil is a series of 3 vaccines administered over a period of 6 months.  The first vaccine can be given at any time from age 9 to 26 years.  The second vaccine is given 2 months after the first.  And the third vaccine is given 4 months after the second.  Despite much wide-spread media attention regarding Gardasil, there have been large trials demonstrating the safety of the vaccine.  Gardasil has now been licensed for use in boys aged 9 to 26 years as well, to help prevent the spread of HPV, to prevent anal, throat, and mouth cancers.  For more information, check out the CDC website or the FDA website on Gardasil.

Call us to schedule your first Gardasil vaccine! 

PAP Guidelines

There has been a lot of media attention about the newest guidelines for Pap testing, which in turn brings up a lot of questions.  Pap tests (named after Dr. Papanicolaou) are part of routine well-women care, used to screen for pre-cancerous and cancerous cervical lesions.  Guidelines are published by medical organizations to be used by medical practitioners to help inform their clinical practice, using the most up-to-date evidence and research available.  However, guidelines are just that - they are a guide - and it is important for all women to to have a discussion with their practitioner, and create an individualized plan of care that is right for you.

The current guidelines for Pap Testing in women of average-risk:
- Initiate Pap Test at age 21 years, regardless of sexual history.
- Pap Test every 3 years from 21 through 29.
- Pap Test with HPV test (co-testing) every 5 years from 30 through 65, or Pap Test alone every 3 years.
 - Stop screening after age 65, or after total hysterectomy with cervical removal (for non-cancerous reason).

The following table shows the guidelines from different medical organizations, which are in agreement regarding screening for average-risk women.  It is important to discuss your Pap history with your provider, and determine your best screening schedule.

The annual well-women exam is often where Pap Testing is done; however, just because you don't need an annual every year does not mean you should skip your annual.  Having an annual exam is part of routine health maintenance and disease prevention - making sure you are up to date with other screening recommendations, a clinical breast exam, immunizations, lab work, discussing healthy behaviors, and of course answering any questions you have about your health.

With the new Affordable Care Act, as of 2010 preventative services, including an annual exam and recommended screenings, are all covered 100% by your insurance!