Tuesday, February 8, 2011

the Doctor's Note

The powerful doctor's note.

 Some people think we will write anything on their behalf.

Two recent requests for doctor's notes come to mind. One from a woman who was pulled over for not wearing a seatbelt. She wanted to take a Doctor's Note to court excusing her from wearing a seatbelt because she is claustrophobic. As far as I know, not wearing your seat belt makes you a flying object in a car, and a menace on the road. I don't think doctors have the right to waive that requirement. Perhaps she should consider a public conveyance that does not require restraint like a bus.

The second one is from a woman who wants a Doctor's Note to take to Weight Watchers. She doesn't want to lose weight. It's her husband, you see, she does his cooking and feels that she deserves to be a lifetime member of weight watchers. This one I don't understand at all. That's what cookbooks are for, and all the literature WW gives its members. I don't think they allow you to audit this course.

Of course there are the "too numerous to count" disability requests due to pregnancy. Women  have had the audacity to ask for permanent disability at two months of pregnancy when they had a 9-5 desk job while I was "out to here pregnant" on my feet all day and most nights. The letters of medical necessity for an at home gym because we recommend exercise, the letters to extend sick leave when the patient has recovered "because I have another two weeks".

Then there are the drug fraud scams that patients will request you to approve. You prescribe a medication for two weeks for an acute illness. The patient requests you make it out for 90 days, because the copay is the same. Are they selling this stuff on the black market?

Not to mention the "get me out of jury duty" letters. The excuses for that one are legendary. "I am going to be on my period that week." " I have to go to the bathroom every two hours." " I had surgery" ( last week, last month, last year, ten years ago) you get the picture. I take medication.What does that mean? What happened to a jury of peers or civic duty?

Then there are the endless requests for controlled substances: sleeping pills, narcotics, tranquilizers that I have no diagnosis for and have never prescribed. The famous, I lost my prescription is popular especially at night, on the weekends and on Friday at 3pm.

Remember who selection committees pick for medical school. Doctors tend to be straight shooters who don't want to lose  medical licensure due to fraud.

So when you are denied prescription requests, doctor's notes, or letters for court, remember we are liable for the veracity of our statements, and generally believe in accountability.

Until next time......

Friday, February 4, 2011

Abnormal Uterine Bleeding and Modern Gynecology

I thought I would write a bit about abnormal uterine bleeding. There are a number of causes, but things basically boil down to two groups:

 Hormonal and Anatomical.

Most hormonal problem bleeding is irregular. Some women will tell me they have never had a regular period in their menstrual life. Some women will develop this in their 30's and 40's after having had normal spontaeous periods. Oh, let's differentiate between spontaneous periods and those on hormones. I am talking about spontaneous periods. Usually irregular bleeding with birth control pills/ Depo Provera/ Mirena IUD and progestin only birth control pills is due to taking the medication. No periods when you are not pregnant also fall into this category.Most irregular bleeding with spontaneous periods is due to hormonal issues. There are four levels where things can go wrong. The uterus, the ovaries, the pituitary gland and the hypothamus. Your gyn will check these depending upon the clinical scenario.

Anatomical abnormal bleeding is generally in the form of heavy bleeding or abnormally light bleeding. This is generally due to problems with the uterus itself. Most of which is benign, but could be premalignant ( precancer ) or malignant (cancer). This includes fibroids, polyps, hyperplasia, cerivcal problems, infections, you get the idea.

Methods of understanding what is going on depends upon the clinical picture, but blind D&;C has pretty much been abandoned as a diagnostic tool. Hysterectomy has been reserved for cancer and large tumors.Ultrasound, saline infusion hysterogram ( "water test"), hysteroscopy and endometrial biopsy help the gyn to diagnose the exact issue, and then target therapy. Some bloodwork may also be done.

Many therapies exist for heavy periods that did not just a few years ago. The use of  agents to induce clotting now has been approved by the FDA and is finding a place to treat those one to two days of heavy bleeding some women experience. The use of a progesterone bearing IUD is another great way to manage heavy bleeding without surgery.Hysteroscopic removal of fibroids and polyps helps eliminate these frequent and specific problems.Uterine Artery Emobolization is a nonsurgical way of treating the heavy bleeding due to fibroids. Some practitoners perform these in the office Endometrial ablation is  a permanent outpatient surgical procedure that has been around in a number of forms for twenty years.. I have never found that to be too comfortable, but recent studies show that most women find the discomfort associated with this as an office procedure acceptable.

The bottom line is that irregular, absent, or heavy bleeding as a problem should not be ignored, and that many specific diagnostic studies are available to target specific therapies.

Until next time....

Friday, January 7, 2011

Bioidentical Hormones, the Confusion and Balance

Good day dear Readers

The issue of Bioidentical Hormone Replacement had come up again and again. Here in South Florida it is touted as a feel good, safe option and antiaging, youth enhancing, and general good for you regimen.

There is a webinar called "The Buzz on Bioidenticals" that is a good but somewhat biased resource. It presents the facts regarding bioidentical hormone replacement, and why practitoners like transdermal preparations. It was developed by a group called "the Red Hot Mamas" and Dr.Elizabeth Lee Vliet.
I found the discussion informative but biased against compounding pharamacies. 

The truth is of course, always somewhere in the middle.

Both FDA approved and compounding pharmacies dispense bioidentical hormone replacement. Until I arrived in South Florida, the need to prescribe compounded products was almost negligible. It seems to be local custom to get creams and gels from the compounder instead of the pharmacy. Not a problem for me, but buyer beware. The compounding pharmacist uses the same precursor ingredients as the phamaceutical industry, and is regulated by your individual State Board of Pharmacy. They are not compounding roots and berries. These products are essentially all from plant source originally.Any preparation that is compounded does not get you the FDA required information regarding side effects, risks and benefits. Many women interpret this as it must be "natural and safe". No, it is a drug and has the same risks and benefits as FDA monitored medication.

Depending upon your global location, you will have estradiol( E2), and progesterone available to you. Estrone (E1)is a weak estrogen that is not usually secreted until after menopause, it is biologically mostly inactive. Estriol ( E3)  is another estrogen made by the placenta during pregnancy. Neither of these is necessary as a postmenopausal hormone. They are often combined with estradiol in compounds, but are unnecessary.
Estradiol is the predominant estrogen prior to menopause.It is secreted by the ovarian follicles (eggs) every day.

Progesterone is secreted by the ovary after ovulation and during pregnancy. It stabalizes the uterine lining.It stops being secreted if you are not pregnant and a period ensues.Progesterone is not necessary after hysterectomy. It only serves to increase side effects and risk.

Testosterone is used rarely for short intervals for those women who need more control of hot flashes or increase in sexual thought. It has lots of side effects including hair growth, acne, adverse effects on lipids and cardiac risk. Like most anabolic steriods, it give people a feel good effect, but underneath is treacherous.

Methods and forms of administration vary from oral to topical cream, gel, lotion, patch and transvaginal gel and rings. In some localities there are subdermal pellets and implants. I try to stick with the cheap and easy to administer transdermals. Research shows these pose the least risk and are easy to manage.Remember that the sooner you start the most benefit and least risk is derived from HRT.

Good resources are:www.menopause.org,www.acog.org; http://www.thebuzzonbios.com/

I believe in evidence based medicine. We know what works, what the issues are with the problem/solutions and what to expect. Unfortunately that doesn't occur with each and every problem, issue or solution. I try to stick as close to that as possible to protect my patients. Sometimes I need to draw outside the lines and go to compounding, but rarely. If you are wondering about what to do, stick with the tried and true first. Most people respond just fine and the costs tend to be much lower. If you are having difficulties with your HRT talk to your provider and work them her/him to get to your happy place. I have worked with thousands of women in menopause and have yet to find one that didn't find her happy place. Sometimes it just takes a bit of doing.