The Well-Rounded Mama

More Evidence That Vertical Incisions Have Increased Complications

2012-01-29T21:00:00.000-08:00

We have blogged about this before, but here's yet another study that vertical (up-down) cesarean incisions in "obese" women have more complications than low transverse (side-to-side) incisions.

As we've noted before, sometimes there can be legitimate justification for using a vertical incision. However, most of the time, its use in fat women springs from outdated and non evidence-based teachings that an incision under the belly (pannus) predisposes the wound to infection, and that a vertical incision will supposedly lower the risk for infection and improve outcomes.

Yet when researchers finally got around to actually studying the question, they found that vertical incisions either did not improve outcome OR significantly worsened it, as in this study, where incision type was associated both with infectious complications and with wound separation.

Notice that in this study, ~46%% of "morbidly obese" women with vertical incisions experienced a wound complication of some sort. Nearly half!

In comparison, only ~12% of morbidly obese women with low transverse incisions experienced a wound complication.

Yet still, despite more complications with vertical incisions, about 7% of obese women in this study (11% in others) are being subjected to vertical incisions instead of low transverse incisions during cesareans. That's around 1 out of every 10 to 14 obese women having a cesarean. That's far too high a rate, considering the poorer medical and cosmetic outcomes with vertical incisions.

More and more data is accumulating to show that the most optimal incision is usually the low transverse incision, even in very fat women. When will doctors heed their own research?

J Matern Fetal Neonatal Med. 2012 Jan 10. Risk factors for wound complications in morbidly obese women undergoing primarycesarean delivery. Thornburg LL, et al. PMID: 22233403

Source: Department of Obstetrics & Gynecology, Maternal Fetal Medicine, University of Rochester Medical Center, Rochester, NY, USA.

Objective: To determine factors influencing separation and infectious-type wound complications (WC) in morbidly obese women undergoing primary cesarean delivery (CD).

Methods: Retrospective cohort study evaluating infectious and separation WC in morbidly obese (Body mass index (BMI) greater than 35) women undergoing primary CD between 1/1994 and 12/2008. Chi-square, Fisher's exact, and Student's t-test used to assess associated factors; backwards logistic regression to determine unadjusted and adjusted odds ratios.

Results: Of 623 women, low transverse skin incisions were performed in 588 (94.4%), vertical in 35 (7%). Overall WC rate was 13.5%, which varied by incision type (vertical 45.7% vs. 11.6% transverse; p less than 0.01), but not BMI class. Incision type and unscheduled CD were associated with infection risk, while incision type, BMI, race, and drain use were associated with wound separation.

Conclusion: In morbidly obese women both infectious and separation-type WC are more common in vertical than low transverse incisions; therefore transverse should be preferred.

News Flash: Labor Managed Differently in High-BMI Women!

2012-01-23T02:30:00.000-08:00

For a long time, doctors have observed a higher cesarean rate in high-BMI women, but always blamed this solely on obesity.

But how would obesity impede labor and result in more cesareans, you ask?

The usual reasons given (based on assumptions or poor research) were soft tissue dystocia (i.e., the fat vagina theory), or inefficient uterine contractility due to high leptin or cholesterol levels (seriously, that's a current theory still floating around, despite evidence that contradicts it).

Yet no one was asking whether the way labor was managed in "obese" women contributed to this high cesarean rate.

Now, for the first time, FINALLY someone is starting to ask these questions! A Canadian study out earlier this year examined labor management of obese women compared with other women.

And guess what?! As I've been saying for years, they found that the labors of women of size are indeed managed differently, with more interventions and a much lower threshold for surgery.

Furthermore, when the study controlled for the use of interventions, the relationship between obesity and cesareans was "markedly attenuated."

Details from the Study

There are a couple of interesting items in the study worth a closer look.

Induction Rates

First, induction rates went up strongly as BMI increased. Here's a summary of induction rates by BMI category (delivery BMI):

"Normal" BMI (20-24.9) 23.7% induced
"Overweight" BMI (25-29.9) 29.3% induced
"Obese" BMI (30-39.9) 37.2% induced
"Morbidly Obese" BMI (40+) 50.0% induced

Now, some of that increased rate is to be expected, given that fatter women have higher rates of pre-eclampsia and other complications, and induction is more common in women with these complications. But even so, a 50% induction rate? Do 50% of all "morbidly obese" women really need to be induced? Come on!

A great deal of research has shown that induction of labor is linked to higher cesarean rates. This is particularly true for first-time mothers or women who have never had a vaginal birth before, or whose cervix was not ripe before the induction.

So why don't any researchers (including this one) connect the dots between such an extremely high induction rate in women of size and a resulting high cesarean rate?

The authors don't really comment on the induction rates or question them at all; most research never does. Most authors assume that all these inductions are truly indicated, especially in women of size. But frankly, they need to question such a high rate of induction more closely.

How many of these inductions were for real medical indications, and how many were for dubious indications like suspected macrosomia or provider fear?

We know from research that inducing early for a suspected big baby does not improve outcomes, and actually strongly increases the cesarean rate in many studies. Yet it is common practice still among clinicians to induce labor early if a big baby is suspected, especially in women of size.

So when you see the 50% induction rate in "morbidly obese" women, how many were for "soft" indications like suspected macrosomia? And what was the cesarean rate among those induced for "soft" indications? I would love for researchers to look more carefully at induction indications and how that influences cesarean rates in women of size.

We know from another recently published study that high induction rates definitely do have a strong influence on cesarean rates in obese women. According to the authors of that study:

We conclude that morbid obesity is associated with a significantly higher risk of pre-existing medical conditions, developing antenatal complications, induction of labour, caesarean section and greater birth weight. However, there was no significant difference in caesarean section rates when adjusted for induction of labour.

More research is needed to further clarify the impact of high induction rates on cesarean rates in obese women, and researchers need to finally start questioning the validity of many of these inductions.

Cervical Status Upon Admission

Another interesting finding that deserves further investigation is a major difference in cervical status upon admission and what might be influencing this.

Women whose cervix is more dilated upon admission tend to have shorter labors and a lower cesarean rate; those whose cervix is less dilated at admission usually have longer labors and more cesareans because their bodies aren't ready to labor yet.

In this study, 37.9% of women of average BMI had minimal cervical dilation (2 cm or less) upon admission to the hospital. In comparison, 55.7% of "morbidly obese" women had minimal cervical dilation upon admission.

Yes, this is surely partly due to a higher rate of inductions and therefore less spontaneous labors in the high-BMI group, but it also suggests that perhaps this group is far less ready for labor when being induced. Again, many authors have noted this and have blamed it on "inefficient uterine contractility" or hormonal deficits, but what if there are other factors they are not considering?

Studies have shown that high-BMI women have longer menstrual cycles and longer gestations; perhaps what is happening is that their due dates are not being sufficiently adjusted for their longer cycle length and as a result, their bodies are less ready for labor when the doctors think they "should" be going into labor. And, as a result, they have more inductions, less cervical ripeness when induced, and more cesareans when the induction doesn't work.

More Interventions

The study found that there was more use of oxytocin augmentation and epidurals as BMI increased. The pit augmentation increase may reflect the lower level of cervical ripeness before labor, but it may also reflect the common perception among some clinicians that obese women won't labor sufficiently on their own. So they automatically just start pitocin augmentation, without ever looking at whether it's needed or not.

The increased epidural rate may simply reflect the higher rate of inductions and pitocin augmentations; it's hard to go through such induced and augmented labors with little mobility and not need some pain relief. However, it may also reflect the common practice of strongly encouraging early epidural placement in obese women to avoid a difficult placement later if a cesarean is needed.

(And of course, once that epidural is placed, oxytocin augmentation is often needed to compensate for the way that epidurals tend to slow labor. It can be an vicious circle.)

Lower Surgical Threshold

The study also shows that doctors were quicker to terminate labor early and move to a cesarean in "obese" women. In the study, the labors of "morbidly obese" women were terminated about an hour earlier than women of average BMI.

Some of this is understandable; surgery in a very heavy woman is more difficult and takes quite a bit longer than in a woman of average size. Doctors want to avoid an emergency situation where every second counts to save a baby, and especially so in a woman whose extensive adipose layers may require more time to get to the baby in the first place. Therefore, doctors may be more prone to intervene early in women of size, before things get to an emergency situation.

Yet most cesareans are not done under truly emergent conditions, and research shows that many women whose progress is slow are able to give birth vaginally if just given a little more time, and their babies generally do just as well.

So doctors have to walk a fine line between not waiting too late and not intervening too early. From this study, it looks like too many doctors are erring on the side of intervening far too early. And because cesareans are extra risky for women of size, this is a cause for concern ─ and a potentially modifiable variable for reducing the tremendously high cesarean rate in women of size.

Final Thoughts

As I've been saying for years, the high cesarean rate in obese women is not only about obesity itself, but also about the way that obese women are managed during pregnancy.

Sky-high induction rates, increased utilization of interventions during labor, and a very low threshold for surgical intervention all combine to ratchet up the cesarean rate in women of size.

The important thing to note is that these are all potentially modifiable factors for reducing the cesarean rate in this group.

Up till now, the only options most doctors saw for lowering the cesarean rate in women of size involved encouraging weight loss before pregnancy or restricting weight gain during pregnancy. Yet this research suggests that if doctors simply change their management practices and fear levels around women of size, it's likely that the cesarean rate can be lowered in this group without draconian weight restrictions.

In the Canadian study, the authors concluded:

Because of the potential morbidities associated with Caesarean section, we must modify our management approaches to allow equal opportunity for a vaginal birth for all women.

Those are strong words for an obstetrical community that's usually pretty mealy-mouthed about these things, and frankly, it's nice to finally hear them from someone other than me. Bravo to these authors for being willing to advocate for vaginal birth for women of size at a time when some doctors are advocating pre-emptive cesareans across the board for this group.

But if doctors really want to get serious about allowing equal opportunity for a vaginal birth for fat women, first and foremost they need to crack down on the insanely high induction rates, as well as re-examining the use of interventions and threshold for surgery in this group.

References

J Obstet Gynaecol Can. 2011 May;33(5):443-8. Higher caesarean section rates in women with higher body mass index: are we managing labour differently? Abenhaim HA, Benjamin A. PMID: 21639963

Background: Higher body mass index has been associated with an increased risk of Caesarean section. The effect of differences in labour management on this association has not yet been evaluated.

Methods: We conducted a cohort study using data from the McGill Obstetrics and Neonatal Database for deliveries taking place during a 10-year period. Women's BMI at delivery was categorized as normal (20 to 24.9), overweight (25 to 29.9), obese (30 to 39.9), or morbidly obese (≥ 40). We evaluated the effect of the management of labour on the need for Caesarean section using unconditional logistic regression models.

Results: Data were available for 11 922 women, of whom 2289 women had normal weight, 5663 were overweight, 3730 were obese, and 240 were morbidly obese. After adjustment for known confounding variables, increased BMI category was associated with an overall increase in the use of oxytocin and in the use of epidural analgesia, and with a decrease in use of forceps and vacuum extraction among second stage deliveries.

Higher BMI was also found to be associated with earlier decisions to perform a Caesarean section in the second stage of labour.

When adjusted for these differences in the management of labour, the increasing rate of Caesarean section observed with increasing BMI category was markedly attenuated (P less than 0.001).

Conclusion: Women with an increased BMI are managed differently in labour than women of normal weight. This difference in management in part explains the increased rate of Caesarean section observed with higher BMI.

Aust N Z J Obstet Gynaecol. 2011 Apr;51(2):172-4. Impact of morbid obesity on the mode of delivery and obstetric outcome in nulliparous singleton pregnancy and the implications for rural maternity services. Green C, Shaker D. PMID: 21466521

Obesity represents a rapidly emerging epidemic amongst pregnant women. Our study looks at the impact of morbid obesity on pregnant singleton nulliparous women in comparison with normal body mass index women. We conclude that morbid obesity is associated with a significantly higher risk of pre-existing medical conditions, developing antenatal complications, induction of labour, caesarean section and greater birth weight. However, there was no significant difference in caesarean section rates when adjusted for induction of labour. We also found no significant difference in length of hospital stay, postnatal complications and neonatal morbidity.

Increased Morbidity After Just One Cesarean

2012-01-16T12:00:00.000-08:00

This study is about adverse outcomes in the next pregnancy after just one cesarean. Women with only one prior cesarean were already at increased risk for anemia, placental abruption (where the placenta pulls away from the uterus before birth, cutting off nutrients and oxygen), uterine rupture, and hysterectomy.

Of course, the actual numerical risk of these complications is generally small, but it does represent an increased risk over women who first birth was vaginal, and that's an important point.

If 1 out of 3 women in the USA is having a baby via cesarean (and in some hospitals, the rate is more like 1 in 2 or more), that's an awful lot of potential risk being put onto women. And that's after only one cesarean. Most women who have one cesarean will go on to have more with future children because VBAC is not an option in far too many hospitals.

When cesareans save lives, these risks are absolutely worth the trade-off. When cesareans are used casually or for dubious indications, these trade-offs are much more ominous.

The authors' conclusion is that women who have cesareans need to be counseled about the possible increased risks in future pregnancies. This is true, but the importance of reducing these risks by avoiding that first cesarean whenever possible should also have been mentioned.

Recognizing that cesareans carry risks is an important part of the discussion of the public health implications of a high c-section rate.

Am J Obstet Gynecol. 2011 Sep 24. [Epub ahead of print] Morbidity following primary cesarean delivery in the Danish National Birth Cohort. Jackson S, et al. PMID: 22051815

Source: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA.

OBJECTIVE: Cesarean delivery rates are on the rise in many countries, including the United States. There is mounting evidence that cesarean delivery is associated with adverse reproductive outcomes in subsequent pregnancies. The purpose of this article is to review those outcomes in a well-defined cohort of pregnant women.
STUDY DESIGN: In a cohort of primigravid women from the Danish National Birth Cohort with known baseline exposure characteristics, we stratified women by method of first delivery, vaginal or cesarean, and evaluated for appearance of adverse reproductive events in subsequent pregnancies.
RESULTS: After adjusting for age, body mass index, alcohol, smoking, and socioeconomic status, women who underwent cesarean delivery at first birth were at increased risk in their subsequent pregnancy for anemia (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.3-3.4), placental abruption (OR, 2.3; 95% CI, 1.5-3.6), uterine rupture (OR, 268; 95% CI, 65.6-999), and hysterectomy (OR, 28.8; 95% CI, 3.1-263.8).
CONCLUSION: Women who deliver their first baby with a cesarean are at increased risk of adverse reproductive outcomes in subsequent pregnancies and should be counseled accordingly.

Need an Extra Layer for Warmth?

2012-01-09T18:30:00.000-08:00

If you are a person of size and a "cold" person ─ that is, strongly affected by cold weather and in need of lots of extra layers during the wintertime ─ then you know how hard it can be to find those extra layers in our sizes. So let's talk about that for a minute.

As frequent readers know, I have hypothyroidism. It's well-treated with meds, my TSH is in my ideal range, and I'm much less symptomatic than I used to be, but that doesn't mean I am totally symptom-free.

One of the most striking symptoms that remains is how poorly I regulate my temperature. Within a certain range of temps, I'm fine, but even slightly outside that narrow range and I'm really uncomfortable. In particular, I am strongly affected by cold. It really makes me absolutely miserable, I kid you not.

So I'm always looking for extra layers to help keep me warmer in the winter...but I am a bit claustrophobic and hate feeling suffocated by really thick or poufy layers. And I don't tolerate itchy fabrics like wool very well either. In addition, even when there's good-quality stuff available, it's usually not available in my size. Most plus-sized stuff in the athletic brands goes up to 2x or maybe 3x, but I typically prefer a 4x because I like things quite roomy and comfortable. So it's not easy to find something that suits my needs very well.

Junonia makes exercise and outdoorwear in extended sizes (4x, 5x, sometimes 6x). I've bought from them for years but their quality is spotty. Sometimes I get something really great from them (so they are definitely worth checking out), but sometimes I've gotten some very mediocre stuff too. Generally speaking, they don't seem to have the kind of quality and choice of really good outdoor stuff that I could get at REI if I were of average size, like the really high-tech insulation-against-cold fabrics or the ultra-light packable gear, etc. And I really want the good stuff.

I am not overly outdoorsy because of my cold-weather intolerance but I do have times when I do outdoorsy stuff. I like to take walks in my area, and we have been known to camp or hike. I also volunteer at my kids' school, which regularly has "farm days" (for environmental education), no matter what the weather is...raining, windy, snowing, sleeting, you name it. That can be pretty brutal. So I definitely need some layers and good outerwear for these activities.

Even around the house at night, it gets a lot colder than I am comfortable with, but I'm not willing to crank up the heat for the whole house that far when I'm the only one really affected. So, given how cold I tend to be, I need some good-quality layers for lounging around or working at home. I'm looking for lightweight but very warm layers ─ in my size ─ that I can add and subtract as needed.

Last year, I discovered that Columbia Sportswear carries good-quality sports and cold-weather clothing/gear in plus sizes. They have women's sizes up to 3x, but their men's sizes go up to 4x and sometimes 5x. This gives more choices to those of us who need/prefer extended sizes. (The men's sizes also have an option for "tall" sizes if you need that. I, alas, am very far from needing that.)

It frustrates me to have to shop in the men's department in order to get really good-quality sports and outdoor clothing in my size, but hey, at least we have some choices, even if it's in menswear. So last year I invested in a whole bunch of winter gear from Junonia and Columbia, and have been testing it this year to see what's best.

I've fallen in love with the following item and wanted to let you know about it before it's all gone:

http://www.columbia.com/Men%E2%80%99s-Mountain-Tech%E2%84%A2-1/2-Zip-%E2%80%94-Big/AX6565,default,pd.html#

It's a lightweight polyester half-zip sports shirt for wicking away moisture while running or biking. However, I've found that it does an amazing job of keeping me warmer, much better than a wool sweater or a cardigan. I just wear normal clothes underneath, and put this on top whenever I start feeling chilly.

That's usually enough for hanging around the house, doing chores, driving in the car or for short jaunts outside if the weather's not too bad. For longer outside jaunts in nasty weather, I wear them for layering under my winter coat (the soft shell coat or the Bugaboo parka from Columbia) as needed.

Sometimes if I'm really cold I will put on two of these zip-up sports shirts. They are so lightweight that I don't feel like the Stay-Puft Marshmallow Man, and they really do add a nice layer of extra warmth. I haven't found this combination of warmth and thinness of fabric with any other product, so I wanted to be sure to let you know about these before they are all gone.

These little zip-up sport shirts have made a MAJOR difference for me in staying warmer in and out of the house. I still have cold moments, but these have really helped. They come in several different colors and pack really well, so they'd be ideal for trips too.

I'm buying some more to have on-hand. I was hoping they'd be on sale after the holidays, but no such luck. So they're not cheap....about $40.....but well worth it in my book!

If you need some more stay-warm options, you might want to check them out.

Fourth Annual Turkey Awards: Leaps of Logic, the Dead Baby Card, and Scorched Earth Tactics

2011-12-29T22:00:00.000-08:00

Well, it's that time of year again...time for my Fourth Annual Turkey Awards.

The Turkey Awards are my opportunity to highlight a biased or ignorant remark or media coverage of "obesity and pregnancy," a particularly insensitive treatment by a care provider towards a woman of size, or a trend in the care of women of size that is troubling and frustrating.

As always, I have plenty of candidates to choose from. The hard part is limiting myself to just one.

Here's this year's nominee, another gem from My OB Said What. I picked this one because it fails on several different levels:

“I am sure you have gestational diabetes because you are overweight, you need to be on Glucophage. If you are not comfortable taking that medication you will end up with a stillborn.” – OB to mother, as found here

Sigh. This doctor may have meant well, but his statement has several things that demonstrate some of the troubling trends and perceptions around obesity and pregnancy, including:

Jumping To Conclusions About Risks
Scorched-Earth Tactics To Deal With Inflated Perception of Risk
Pulling the Dead Baby Card To Ensure Compliance with Intervention.

Jumping To Conclusions About Risk

Okay, let's start with the obvious ─ the exaggeration of risk around obesity and pregnancy. We've discussed this before, but it always bears repeating because it's such a common issue.

The problem with the coverage of risk around obesity and pregnancy is that providers often start doing "mental inflation" of the actual numerical risk, and then they start making unfounded leaps of logic from there.

A statement with some truth to it, such as "Obese women are at increased risk for gestational diabetes," gets hyped in the press and in the research until it becomes transformed in some caregivers' minds into "Most obese women get gestational diabetes." Then it's just a short jump to "Nearly all obese women get gestational diabetes" to "This obese woman no doubt ALREADY HAS gestational diabetes right now."

But the fact of the matter is that while the risk for gestational diabetes is definitely increased in women of size, most women of size still don't get GD. You can cherrypick whatever study you want, but no study shows a 100% GD rate in obese women, even the most obese women.

Many studies show around a 15% risk for GD in "morbidly obese" women. This is definitely higher than the 2-4% range found in a "normal BMI" population, but hardly universal. What most providers fail to do is the opposite math.....that is, if 15% of morbidly obese women get GD, then that means that 85% do NOT.

Yes, that's right.....the majority of even very fat women will not get GD.

Are fat women at increased risk for getting GD? Yes, absolutely. Do all of them get it? No, not even remotely close. In fact, most do not get it.

And remember, just because a particular group is at increased risk for a complication does not mean that everyone in that group will get that complication, nor does it mean that you can predict the outcome for any individual within that group.

Of course, you can make a case for this being a rogue doctor, jumping to conclusions. Hopefully, most providers who care for women of size understand that GD is by no means a foregone conclusion in this group. But I'm hearing stories like these more and more often.

There are a lot of care providers out there who have a distorted sense of risk around obese women and GD, from the ones who force their obese clients to undergo really frequent GD testing to those that push weight loss during pregnancy as a way to avoid GD (despite evidence that weight loss in pregnancy is risky).

So this comment is a candidate for this year's Turkey Award because of this individual doctor's mental inflation of risk ─ turning a mere potential of risk into an inevitable outcome in his mind.

But this comment also gets nominated because it's not just about this doctor's individual bias; it demonstrates an overall troubling trend of a distorted sense of risk about pregnancy in women of size.

Scorched Earth Tactics for Inflated Perception of Risk

Another issue I see in the comment is the kind of Scorched Earth, over-the-top tactics that some providers take in order to try to reduce the risks associated with obesity and pregnancy. There is little research on these tactics, mind, but because care providers have such an exaggerated sense of risk around obese pregnancies, they feel justified in taking the Napalm Option...just in case.

For example, in the past, some care providers have advocated extremely restrictive diets for obese women in pregnancy. Obese pregnant women have been put on 1200 calorie or even 1000 calorie diets during pregnancy, or told to drink Slim-Fast in order to limit their weight gain. Some are told that they have to lose weight during pregnancy....10, 20, even 50 pounds, during pregnancy. It doesn't matter how this is achieved, the main goal is for them to lose weight in pregnancy, even if it sacrifices nutritional adequacy, since many care providers erroneously believe that fat women have extra nutritional stores to draw from instead.

This is the Napalm Option; resorting to extreme measures because you don't know what else to do or you are convinced that the risk is SOO high that only extreme measures will improve outcomes.

A new Scorched-Earth Tactic being considered is a move among some care providers to prophylactically prescribe metformin to all obese women during pregnancy in order to prevent big babies and other complications.

The use of Glucophage (metformin) in pregnancy is already somewhat controversial, even in women with strong indications for it (PCOS, severe insulin resistance, gestational diabetes). Its use prophylactically in all obese women, even those without other risk factors, should be even more controversial...yet many care providers are not questioning it at all.

Metformin is probably relatively safe during pregnancy for those with strong indications for it but some docs are very conservative about its use because the trials on it so far are small and some have found an increase in pre-eclampsia in women on metformin (while others have not). More data is needed.

Therefore, many docs err on the side of taking women off metformin during pregnancy, but there are a number of practices where the protocol is to continue metformin (with informed consent) because it lowers the risk for GD and possibly miscarriage and big babies as well.

I'm not opposed to the use of metformin in pregnancy in those for whom it is indicated and in those who have been given full informed consent. They get to evaluate the research and decide for themselves whether they think it's a worthwhile intervention. However, I think across-the-board use of metformin on all obese women is highly questionable.

One early trial of metformin in pregnancy found an increase in both pre-eclampsia and stillbirth in the metformin group, so caution is clearly indicated. [However, it has to be noted that there are two major confounding factors here. The women on metformin were mostly type 2 diabetics with pre-existing diabetes and poorer control; they also put these same women on 1200 calories a day, which might also be a factor.] Later trials have found no increase in stillbirth with metformin.

Another study of metformin vs. insulin for treatment of GD found a slightly higher rate of spontaneous-labor prematurity in the metformin group, although the confidence intervals were wide and crossed 1.0, so the trend could be attributable simply to chance.

Bottom line, we need more long-term data from larger groups on the safety of metformin during pregnancy in women with PCOS or GD, as well as the benefits and risks of metformin used in a wider population of women. Right now, the best data shows it lowers the risk for GD and miscarriage in women with PCOS, and probably does not increase the risk for birth defects. Other results vary from study to study. It’s probably a reasonably safe med for women with PCOS or GD, but we need more data to be sure.

Despite this, there is a trend to put ALL women of size on metformin prophylactically (there is a trial of this in the UK right now) and THAT I have problems with. It’s one thing to put a woman with severe PCOS or GD on this med, it’s entirely another to put all healthy high-BMI woman with no known glucose issues on it prophylactically. Ugh.

So this comment gets an individual nod for the Turkey Award because not only does the doctor assume the woman is automatically going to get gestational diabetes, he also wants to put her on metformin prophylactically, just on the basis of her being "overweight" (without proof of GD).

But it also gets a Disturbing Trend nod because it represents a new willingness among some care providers to prescribe extreme measures ─ like prescribing weight loss during pregnancy or putting all fat women on metformin ─ because of their inflated sense of risk around pregnancy in women of size.

Remember, the Napalm Option often harms more than it helps. We must be cautious about being overly-interventive without proof that such interventions actually improve outcomes.

Pulling the Dead Baby Card to Ensure Compliance

Yet another problem highlighted by this quote is the issue of what we cynical activists call "The Dead Baby Card."

The Dead Baby Card is telling women in an emotionally manipulative way, your baby will die if you don't do exactly what I tell you.

(Its corollary is, And If You Question Me, You're A Bad Mother and Must Not Love Your Child.)

It's not merely informing a woman of the possibility of a poor outcome, it's medical bullying trying to force a woman (via scaring or shame or guilt etc.) to go along with a particular kind of highly interventive care the physician wants.

It's not a reasonable or sensible precaution in the face of an extremely high-risk situation, it's using the mother's fears to manipulate her into some dubious intervention the doctor wants, usually for his own convenience or fear of litigation. And it's implying that the woman is a Bad Mother if she even thinks about questioning these interventions.

It's statements like, "We think your baby is going to be 9 lbs., so you have to have a planned cesarean or your baby will get stuck and die," even though research shows that elective cesareans for macrosomia do not improve outcome and may actually worsen it.

Or telling a woman that if she chooses Vaginal Birth After Cesarean, her baby will almost certainly die. And if the woman dares to question the provider, it's using scare tactics or implying that she's selfish to even consider such another choice. It's using emotionally manipulative language to bully a mother into following a questionable course of treatment the doctor wants.

In the Metformin example above, telling the mother that if she does not go along with the doctor's preferred treatment plan (i.e. use of metformin), her baby will probably die is medical bullying, a.k.a. Pulling The Dead Baby Card. The doctor is trying to scare her into complying with his questionable intervention by using the biggest scare tactic he knows.

Instead, the mother should be counseled about the possibility of gestational diabetes, the pros and cons of GD testing, the small but real possibility for stillbirth if there was uncontrolled pre-existing diabetes, and offered GD testing. She should be informed that some care providers are using Glucophage to prevent/treat GD, she should be informed of the pros and cons of metformin, and offered the choice to consider it.

She should not be ordered to take metformin, or told that if she doesn't take it her baby will undoubtedly die. That's classic Dead Baby Card territory, and that's unethical and unconscionable medical bullying.

So this comment is a "winner" a third time because of this doctor trying to scare this mother into an extreme intervention by using emotional manipulation, and because it sadly represents a tactic that's being used against women of size far too often these days.

Medical bullying is being used far too often these days, and particularly against women of size. This kind of over-the-top manipulation has to stop.

Final Thoughts

This comment is nominated for my Fourth Annual Turkey Award because it demonstrates an Epic Fail on several different levels.

It presumes an "overweight" woman will automatically get gestational diabetes (when most will not), it orders her to take metformin prophylactically just on the basis of her weight alone (without proof of GD), and tries to scare her into compliance by suggesting that her baby will die if she doesn't agree to this intervention. It's a classic case of medical bullying.

Of course, we need to make it clear that most providers don't treat women of size like this. And hopefully most would never result to medical bullying like this.

But this comment does represent several troubling trends in the care of women of size, including the tendency to Jump to Conclusions about Risks, the increasing use of Scorched-Earth Tactics, and the use of the Dead Baby Card to scare women of size into whatever extremist intervention the doctor wants to use on them.

And that's why this little comment gets this year's nomination for a Turkey of the Year Award.

*By the way, My OB Said What is looking for submissions on the idiotic things caregivers sometimes say to women. If you have more doozies on things they say to fat pregnant women, I hope you will submit them so we can document this kind of treatment.

Do note, they also accept submissions for positive, helpful things caregivers say to women─it doesn't always have to be bad. If you have had a really supportive caregiver as a woman of size, be sure to nominate those stories too. It's so important to highlight the positive stuff too!

Either way, email your story to submissions@myobsaidwhat.com

Dear Santa: Research on My Wish List

2011-12-22T13:00:00.000-08:00

Dear Santa:

As I review the research on "obesity" and pregnancy, it always strikes me what's missing from this research.

Santa, since you are Patron of the Plus-Sized, I'd like to request some improvements as my Christmas gift this year. Could you whisper in some researchers' ears and plant the following suggestions?

Do More Meaningful Research

First, I'd like to request that researchers stop going for the easy publishing hits and start making their research more meaningful. For example, most research on obesity and pregnancy now is just a litany of risks....fat women have more risk for "x" or "y" ─ but without any insight as to why they are more at risk for these things. Study after study reiterating a litany of risks is not very meaningful anymore, but it does tend to ratchet up doctors' perceptions of risk around obesity, especially when they only use odds ratios instead of actual numerical risk.

I think it's well-established that women of size are more at risk for certain things....the question is what can we do about it. That's where our focus needs to be in obesity and pregnancy research right now; not just documenting increased risk but what to do about it. And that leads us directly to the next item on my Dear Santa List.....

Research Improving Outcomes Without Weight Loss

Without fail, nearly every study pushes weight loss as the answer to Life, the Universe, and Everything. Yet they stubbornly fail to connect the dots from other research that clearly shows that long-term weight loss is extremely unlikely, and that weight loss attempts often actually lead instead to further weight gain.

If the only tool in our toolkit for improving outcome is one that is extremely unlikely to succeed, then it's time to develop some new tools in the toolkit. We must start looking beyond weight loss as the only answer to improving outcomes.

Distinguish Between Correlation and Causation

I would love to see more obesity research differentiate between correlation and causation when it comes to obesity. Just because a certain outcome is associated with obesity does not mean obesity causes it (or that weight loss cures it). In fact, a third factor common to both may actually be the cause...or some factor we don't understand yet.

I'd love to see researchers consider the possibility the obesity is a symptom of an underlying difference (in genetics, in metabolism, in hormonal issues, in ability to process insulin, etc.), rather than the automatic cause of problems. If obesity is just another symptom, then focusing on weight loss is just a band-aid approach (and would explain why weight loss is often unsuccessful). Focusing on the exact cause would lead to more improvement in outcomes long-term, which is what we really want, isn't it?

We have to move beyond our "blame the victim" mentality around obesity (i.e., obesity is a voluntary state caused mostly by bad behaviors), and start considering the possibility that obesity may often be simply another symptom of an underlying physical or metabolic difference.

Examine Interventions to See If They Improve Outcome

Many interventions to improve outcome have been proposed for women of size, especially "morbidly obese" women. RCOG, the British version of ACOG, recommends that morbidly obese women be put on a low-dose aspirin regimen prophylactically to try and lower the rate of pre-eclampsia in this group. The SOGC (Canadian version of ACOG) now recommends that morbidly obese women be put on regimens of ultra-high dose folic acid to try and lower the rate of birth defects in this group. Yet both of these recommendations were undertaken without research to show that they improve outcome, nor am I aware of any current studies looking to see if such regimens improve outcome.

Doctors often recommend care regimens in fat women in hopes that they will reduce poor outcomes, but without follow-up testing to see if these interventions improve outcome. For example, as we recently discussed, doctors were taught for years that a vertical incision would lower the wound complication rate in very obese women, but when someone finally actually did a study of this question, they found that vertical incisions actually performed more poorly.

There's nothing wrong with proposing a potential intervention to see if it improves outcome in women of size (and prophylactic aspirin or high-dose folic acid may actually be a reasonable precaution for at least some very heavy women), but researchers have to then follow up and examine whether the proposed intervention actually improves outcomes or not.

Ideas for Specific Studies I'd Love To See

Antibiotic Dosing - In size acceptance circles, we've been saying for years that weight-based dosing may be needed to improve outcomes in people of size after surgery (depends on the type of antibiotic and its mechanism of action; some need weight-based dosing and some do not). But we've consistently had difficulty in getting care providers to actually do this.

A recent study showed that 2 g of cefazolin given shortly before a planned cesarean did not reach minimal inhibitory concentration to knock out gram-negative bacteria in nearly half of morbidly obese women. Since cefazolin is the antibiotic of choice in many surgical procedures (especially cesareans), it's time for a randomized controlled trial to find out what the optimal dosage for morbidly obese women actually is.

This shouldn't be that hard or that difficult a study to do; it's beyond me why it hasn't been done already. And it's vital that this be done, since chronically underdosing obese people may be adding to the increasing societal problem of antibiotic-resistant bugs, not to mention worsening outcomes among women of size.

Midwifery Model of Care - I'd love to see a study that specifically compared outcomes for obese women who experienced a low-intervention, "midwifery" model of care, vs. obese women who experienced a high-intervention, high-risk "bariatric obstetrics" model of care. Research clearly shows that cesarean rates are lower for most women who experience a midwifery model of care, but there is no study that directly compares the two models of care specifically for obese women.

Given the strong move in many places to deny women of size the right to access low-intervention midwifery care ─ or even just regular obstetric care ─ and "alternative" options like waterbirth, birth centers, and homebirth, it behooves us to examine the which model of care actually improves outcomes better in this population. What data we have and anecdotal stories suggest that the midwifery model will be advantageous for women of size who do not experience severe complications ─ but we need direct studies of the issue to confirm or deny that.

Fetal Malpositions - I'd love to see another modern study examine whether women of size have more malpositioned babies. Many very old studies mention a common perception that obese women have higher rates of malposition, and there is one modern study that confirms nearly twice the rate of posterior babies in obese women ─ but we really need more than that. From the stories women have submitted to me (and from my own experiences), it seems like more women of size have malpositions, and this may be a prime reason behind our higher rates of labor dystocia and slower labors, but it'd be really useful to be able to show that conclusively.

If we can document more malpositions in women of size, then we could raise awareness of the possibility among care providers and then use chiropractic care (to prevent malpositions) and manual rotation techniques (to lower the c-section rate associated with OP babies during labor) to improve outcomes. And perhaps we could keep care providers from just assuming that inefficient uterine contractions and/or soft tissue dystocia is always to blame, as they usually do now.

Bottom line, if we can elucidate whether or not there are increased rates of malpositions in women of size, we can incorporate the interventions that improve outcome when malpositions are encountered (chiropractic care, maternal repositioning, more patience during labor, manual rotation) and probably lower the cesarean rate in women of size.

Iatrogenic Factors in Cesarean Rates - A couple of recent studies have found that the labors of obese women were managed differently, with far more interventions, more inductions, and a lower threshold for surgical delivery. When these factors are controlled for, the higher cesarean rate in obese women was either markedly attenuated or it completely disappeared. I'd love to see more follow-up on these studies in a similar vein.

The high cesarean rate in women of size is not only about direct iatrogenic factors, but they do likely play a strong role in it. Until care providers are willing to objectively look at their own role in poorer outcomes, care will not improve markedly in this group.

Compare Those with Good Outcomes to Those with Poorer Outcomes - Researchers need to start acknowledging that many women of size have good outcomes and start studying these women. They need to compare women who had good outcomes vs. those who had poorer outcomes and see if they can gain more clues about underlying causes of problems.

For example, if obese women who experience pre-eclampsia have higher hyperinsulinemia rates than obese women who do not experience pre-eclampsia, then perhaps treating women with metformin or fixing insulin receptor/signaling issues will help lower the rates of pre-eclampsia. Or if obese women who experience a birth defect have lower pre-existing folate stores, then pre-conception blood testing and treating those with low folate stores will help prevent more birth defects in this group. Or if they find that obese women who do not develop GD have consistently higher exercise rates than those who do develop it, then increasing exercise rates is an easy intervention to promote.

The point is that at this point, everyone is so busy blaming and shaming the fat mother for complications that virtually no one is exploring why some fat women have great outcomes and some do not. Examining the differences between the two groups might help elucidate the real causes of complications in women of size, and might give some really concrete directions for improving outcome.

PCOS and Breastfeeding - There is some preliminary research that shows that PCOS can impact milk supply and lower breastfeeding rates, but we have very little data on how many women with PCOS are affected, and why some with PCOS are affected and others are not.

Research on the impact of PCOS on milk supply has been out for more than 10 years, yet little follow-up research has been done, and rarely is this confounding factor even mentioned in studies on why breastfeeding rates are lower in women of size. Nor has anyone studied possible interventions (metformin, goat's rue, progesterone supplements, etc.) to see if these could improve milk supply in affected PCOS women. Considering how important breastfeeding is to a mother and baby's long-term health, it's long past time for far more attention to be paid to this issue.

Health at Every Size® and Pregnancy Outcome - Again, if weight loss before pregnancy is the only tool in our toolkit for improving outcome, we are greatly limiting our choices. A Health At Every Size approach has been shown to improve outcomes in non-pregnant women; might it improve outcomes in pregnancy too?

We need to uncouple weight loss from exercise and promotion of healthy habits in the research. When "lifestyle interventions" are shown to improve outcome, was it really from the minimal weight loss associated with these interventions, or from the increased levels of exercise and improved habits instead? If we focus on exercise and improved habits, will we improve outcomes without risking the long-term weight gain so commonly associated with weight cycling? We need research targeted to this question, and we need it now.

Final Thoughts

Thanks for listening, Santa. I will be waiting with bated breath for studies on these topics and a general improvement in the direction of research around obesity and pregnancy.

Researchers and care providers, are you listening too? Wouldn't you like to be a Santa's Helper and help improve outcomes among women of size? A more thoughtful and targeted approach to research on obesity and pregnancy would go a long way towards achieving that goal.

Friday Fluff: Yoga Cat Silliness

2011-12-16T03:30:00.000-08:00

Here's a cute little Friday Fluff entry for the holidays.

This is a video of a woman doing yoga, and her cat "helping."

I did prenatal yoga and loved it. I tried to carry it over outside of pregnancy but between the babies and the cats climbing all over me, I could never make it work very well.

This woman makes it work impressively, even with feline "help." I'm impressed!

Misleading Wording: Vertical vs. Low Transverse Incisions

2011-12-13T11:00:00.000-08:00

Recently, we discussed cesarean incisions in "obese" women, and specifically the pros and cons of a low transverse (side-to-side) incision vs. a vertical (up-down) incision.

As we noted before, for many years doctors were taught that doing an incision under an obese woman's belly fat ("pannus" in medical jargon) made it prone to infection because of the "bacteriologic cesspool" (yes, actual quote) found in the warm, moist conditions in that area. Many were therefore taught to do a vertical incision in very fat women to lower the risk for wound complications.

However, some studies show a greatly increased risk for wound complications/blood loss with vertical incisions in obese women. Yet to this day, many still cling to this teaching, despite a lack of support in the medical literature for it.

Just after my post on the topic was published, a new study on the subject came out. Here's what the abstract says (my emphasis):

After controlling for confounding factors, no difference in wound complication based on type of skin incision was apparent. The type of skin incision does not appear to be associated with wound complications in the obese parturient; however, larger studies would be needed to confirm this finding.

Sure makes it sound like a vertical incision is just as good as a low transverse one, right? But look more closely at the full text of the study and the picture begins to change.

What The Study Really Shows

In the study, the number of vertical incisions was n=25, whereas the number of low transverse incisions was much higher, n=213. The authors note that this was not enough to conclusively decide which incision was better, and that bigger trials were needed. Very true.

Although the abstract gives lip service to this, the phrasing in the abstract makes it sound like vertical incisions did not result in worse outcomes, but that they needed larger studies to confirm that.

But the thing is, the study did find worse outcomes with vertical incisions. 5 of the 25 vertical incisions (or 20%) experienced a problem with wound separation, as opposed to 22 out of 213 (or 10%) of the low transverse incisions.

So in the study, vertical incisions had twice the rate of wound separation, but because of the small number of vertical incisions, this difference did not rise to statistical significance.

The authors were quite forward with this information in their conclusion:

We found that vertical skin incisions are associated with increased odds of postoperative wound separation, although this difference did not reach statistical significance. Although many variables factor into a surgeon’s decision on what type of skin incision to perform, the results of our study do not support the use of vertical skin incisions to reduce wound complications among obese women at the time of cesarean delivery.

That doesn't sound like what the abstract was implying, does it? Too bad the editors of the journal did not see fit to word the abstract more clearly. They should have acknolwedged that there was no statistical significance, yes, but that there was a strong trend towards worse outcomes with vertical incisions, and that the study was underpowered to detect a statistically significant difference.

They did acknowledge the need for larger studies, but in the context of this abstract's wording it sounded like they needed larger studies to confirm that vertical was just as safe ─ when that's not at all what the authors said in the study.

Final Thoughts

OBs are very busy people and they often do not have time to read the full text of every journal article they run across. Many just go by the conclusion of the abstracts. Unfortunately, this abstract gives the mistaken impression that vertical incisions have outcomes just as good as low transverse incisions, when what data we have does not support this.

A more definitive study is needed, one with a large enough sample to confirm or deny whether vertical incisions are associated with poorer outcomes. All our research so far suggests that they are, but what we need is access to a really large database that records maternal BMI, types of incision used, and tracks post-op complications thoroughly. Perhaps the MFMU database? Researchers, are you listening?

In the meantime, I suppose it's some comfort that apparently, most women of size who have cesareans are getting low transverse incisions. YAY. We need to do less cesareans in women of size, period, but at least most of the cesareans in this group are being done with low transverse incisions. Small comfort, but I'll take it.

But the stories I hear from women of size suggest that even so, too many obese women are STILL being subjected to the greater risks and ugliness of vertical incisions. In fact, in this study, 11% of obese women were still being subjected to vertical incisions. That's too many. Sometimes, vertical incisions can be needed, but not one out of every ten sections.

Vertical incisions don't "prevent" infection or improve outcome in any way; research suggests it actually increases blood loss, operative time, and wound complications; it increases the likelihood of a classical uterine incision underneath (which is associated with more morbidity short- and long-term); and it creates an ugly scar that negatively impacts a fat woman's sense of self.

Considering the number of cesareans done every year on women of size, it's time someone accessed a large database and debunked this outdated teaching once and for all. Until that is done, however, doctors need to acknowledge the clear trend in the research and not use vertical incisions routinely in women of size.

Am J Perinatol. 2011 Nov 21. Type of Skin Incision and Wound Complications in the Obese Parturient. McLean M, et al. PMID: 22105439

We examined the relationship between type of skin incision at time of cesarean delivery and postoperative wound complications in the obese parturient. Women with a body mass index (BMI) of greater than 29 who had undergone cesarean delivery at The University of North Carolina were identified from the Pregnancy, Infection and Nutrition study. Inpatient and outpatient medical records were reviewed for maternal demographics as well as intrapartum and intraoperative characteristics. The exposure of interest was type of incision, classified as vertical or transverse. The primary outcome was wound complication, defined as partial or complete wound separation. Logistic regression analysis was used to create a final model of risk factors for wound complications while controlling for potentially confounding variables. From 1998 to 2005, 238 women with a BMI greater than 29 who underwent cesarean delivery were identified. Of these 238 women, a vertical skin incision was performed in 25 (11%) and a transverse skin incision in 213 (89%). The overall incidence of wound complications in this group was 13%. BMI was associated with wound complications (p less than 0.01). After controlling for confounding factors, no difference in wound complication based on type of skin incision was apparent. The type of skin incision does not appear to be associated with wound complications in the obese parturient; however, larger studies would be needed to confirm this finding. Increased BMI is associated with a higher rate of wound complications.

Open Thread: What Do You Want To Tell Caregivers?

2011-12-02T15:00:00.000-08:00

I'm speaking next week to a group of midwives (and possibly some doctors) about caring for women of size.

I'll be presenting lots of facts and figures and discussing research studies, but I'm also there to represent the voice of consumers, specifically of women of size.

So what in particular do you think is most important for these caregivers to know about caring for women of size? How do you want to be treated? How do you not want to be treated?

How should caregivers responsibly discuss risk with women of size? How can they improve outcomes in women of size? What do you most wish you could say to your own caregivers about the care you received during your pregnancies (or if you were to have one)? About your gynecological care? What constitutes good care in women of size?

This is an open thread; please feel free to add your comments. However, remember that caregivers will be reading this thread in the future and we want to promote constructive dialogue about improving care in women of size. Please keep comments constructive and helpful, even as you make the points you feel need to be made.

I hope this will generate some interesting dialogue and give some thought-provoking feedback to caregivers.

*P.S. Logistical note: For those who asked.....by no means am I done with the PCOS series. It just went on hiatus for a bit while I worked on some major deadlines on other projects. It will be a periodic series. Stay tuned!

Cesarean Incision Choice in Women of Size: Up-Down or Side-to-Side

2011-11-30T11:00:00.000-08:00

One major problem with the medical care of "obese" patients is that it's often based on what doctors think they know about obesity, rather than being truly evidence-based.

Certain maxims get taught about obesity, it influences medical procedures and protocols, and no one ever questions whether these beliefs are true or whether resulting protocols actually improve outcome.

Often, no one has even researched the question; they just assume outcomes are improved because everyone "knows" this way is best when dealing with fat patients.

More and more we are finding that these assumptions and protocols do not improve outcome, and in fact, sometimes actually worsen outcome.

Cesarean incision type in "obese" women is one of these issues.

Vertical Versus Transverse Incisions: What's Been Taught

Doctors were taught for many years that a vertical (up-and-down) incision was better than a transverse (side-to-side) incision in "morbidly obese" and especially in "super-obese" patients.

They were told that a vertical incision was superior because the area under a fat woman's "apron" or "pannus" (the droopy belly flap overlap that some women have) was hot, moist, and prone to infection. Therefore, to lower the risk for infection, a vertical incision was made to avoid the area under the pannus.

I've seen this maxim repeated over and over in the medical literature throughout the years. And certainly, on my website I have the stories of a number of big moms who were given a vertical cesarean (low vertical or "classical"--i.e. stem to stern) and told it was "necessary" because of their obesity.

Yet to my surprise, until recently, few studies had actually EXAMINED whether a vertical incision actually improved outcomes or not in "obese" women.

Certainly it seems intuitive that avoiding the area under the belly might lower the risk for infection. But interestingly, several studies show the opposite ─ that vertical "up-down" incisions don't improve outcome at all ─ or actually worsen them. And they are certainly far more scarring and unsightly for the women involved.

The Studies That Examine Incisions in Women of Size

Interestingly, there were very few studies on this topic for a very long time; doctors were just taught without question that vertical incisions would reduce the risk of infection and speed up operating time.

Over time, many doctors began using low transverse incisions on women with moderate obesity, and eventually some began expanding their use into women with more "severe" obesity as well. As a result, many women of size did have low transverse incisions, while other doctors kept using vertical incisions on "supersized" women. Yet few people studied which was superior until about 10 years ago.

In 2001, D'Heureux-Jones et al. presented a paper on a small study that compared different combinations of incisions in obese patients. They found that the low transverse (skin and uterine) incision was the best incision for obese women because it was faster and had less morbidity associated with it. Vertical abdominal incisions had the highest blood loss rate. They concluded that a low transverse incision was advantageous "because it improves speed of operation, blood loss, and rate of complications" in obese patients.

In 2003, Wall et al. did a larger study examining this question. They examined the records of 239 women with a BMI of 35 or more. The wound complication rate was 12.1%, or nearly 1 in 8 women of this size. They found that vertical incisions were associated with twelve times the risk for wound complications.

Alanis 2010 found that vertical incisions had greater blood loss in super-obese women (BMI 50+), and they did not improve outcome. Contrary to expectations, they also found that vertical incisions also had increased operative time. To improve outcome in this group, they suggested forgoing surgical drains and promoting low transverse incisions.

Bell et al. (2011) studied 424 women with BMI greater than 35 who had a cesarean between 2004 and 2006, including 41 who had a vertical incision. After adjusting for confounders, the study found that vertical skin incisions were not associated with higher rates of wound complications or blood loss.

However, if the full text of the study is examined, there actually were quite a bit more wound complications (14.6% in the vertical incision group vs. 7.6% in the low transverse group) and blood transfusions (9.8% in the vertical group vs. 1.6% in the low transverse group). These simply did not rise to statistical significance after controlling for confounders. The adjusted odds ratios were 1.91 for wound complication and 2.78 for blood transfusion with vertical incisions, but the confidence intervals were very wide and crossed 1.0, so the results could not be said to be statistically significant. However, the trend towards more complications with a vertical skin incision was very clear. With more subjects in the vertical incision arm, these differences might have risen to statistical significance.

Other Problems with Vertical Incisions

In addition to these concerns, research also indicates that vertical incisions tend to be less strong than transverse incisions, and more prone to dehiscence (coming apart) during recovery.

Women with classical incisions also tend to experience more complications, including post-operative pulmonary issues, more pain, blood transfusions, infections, and more admissions to intensive care units afterwards.

Most importantly, vertical skin incisions often meant vertical incisions in the uterus below. For example, both Bell et al. (2011) and Alanis 2010 found increased rates of vertical/classical incisions in the uterus when vertical skin incisions were used. Bell found that when doctors used a vertical skin incision on obese women, 66% (two-thirds!) went on to use a classical vertical uterine incision too.

A classical vertical uterine incision places these women at strong risk for future complications, particularly uterine rupture, should any more pregnancies occur.

Bakhshi 2010 found that women with a prior classical cesarean had longer hospitalizations, longer operative times, and more admissions to intensive care units in a subsequent pregnancy. Most importantly, they had a greatly increased incidence of scar separations in their pregnancies compared to women with a prior low transverse uterine incision (2.46% vs. 0.27%).

As the authors of Alanis 2010 say in their study:

Our results also support the use of Pfannenstiel incisions in obese patients with a large panniculus and contradict classic teaching by veteran surgeons and obstetrical texts. It has been written that transverse abdominal incisions made under the pannicular fold exist in “a warm, moist, anaerobic environment associated with impaired bacteriostasis . . .[that] promotes the proliferation of numerous microorganisms, producing a veritable bacteriologic cesspool.” However, we are unable to locate any evidence to support this popular conclusion...

Transverse abdominal incisions are less painful and allow for earlier mobilization and decreased pulmonary complications. Furthermore, vertical abdominal incisions were associated with vertical hysterotomy in our study, usually a result of inadequate access to the lower uterine segment. When the incision extends into the contractile portion of the uterus, a vertical hysterotomy has a profound impact on future pregnancy. Therefore, it is important to incorporate practices, like transverse abdominal incisions, that facilitate low uterine incisions.

It is notable that the authors could not find any evidence in the research to support the common teaching about use of vertical incisions to prevent infections in obese women. Again, this shows that many maxims that are taught about obesity and pregnancy are not necessarily supported by evidence.

Although some studies have found that outcomes were statistically similar between vertical incisions and low transverse incisions (usually because of too few partcipants), none have shown better outcome with vertical incisions.

Given the lack of data showing vertical incisions to be superior, not to mention the associated post-operative and future risks with them, the question is why these vertical incisions continue to be used in women of size.

Cosmetic Considerations

Furthermore, it must be pointed out that vertical incisions can be very scarring emotionally and physically.

Long-term Results from Low Transverse Incision in a woman of size
photo from website reader

A low transverse incision is not usually terribly visible long after it's healed. Although all scars are annoying to deal with and can have long-term emotional impact, a transverse incision tends to have less long-term psychological impact because it's further down on the abdomen and not nearly as obviously visible.

Although still traumatic to many women, a transverse scar is less mutilating to a woman's general sense of self.

On the other hand, a vertical incision often leaves a line of separated-looking tissue underneath, as demonstrated in the following pictures.

Recent Vertical Incision on a Woman of Size
From pregnancy.about.com

Long-Term Results of a Vertical Incision on a Woman of Size
photo from blog reader

Long-Term Results of Vertical Incision
photo from website reader

Some doctors have the attitude that it "doesn't matter" if an incision is vertical in a fat woman. Some have even told fat women that they gave them a vertical incision because "it's not like you're going to be wearing a bikini."

This is an unjust, callous, and unreasonable reason for imposing a vertical incision. Whether or not they ever wear a bikini is irrelevant to the discussion. It matters to the woman and her partner.

Botched Vertical CS Incision
from makemeheal.com

Women with vertical incisions often complain that their incision "looks like a giant butt" on their frontside, and find it unsexy and humiliating for partners to see. It also can create problems under clothes and limit what fabrics and styles people choose to wear.

Although it's "just" cosmetic, a vertical skin incision can have profound impact on a woman's body esteem. Unless there is a better outcome associated with it, it simply should not be used routinely in women of size.

Conclusion

Although the practice of doing a vertical or classical incision on "very obese" women has declined somewhat over the years, it is still done at times. Some doctors do it because they still believe that it's "safer" and less prone to infection in women of size; some do it because it can be technically and physically difficult to do low transverse incisions on women with a larger belly.

While it is important to acknowledge that it is harder to do cesareans on very fat women, and there can be occasions where alternate incisions become necessary, most of the time low transverse incisions are very do-able in fat women, even "morbidly obese" and "super obese" women.

As the authors of Alanis 2010 say in their study:

Our results also support the use of Pfannenstiel incisions in obese patients with a large panniculus and contradict classic teaching by veteran surgeons and obstetrical texts...
Although a Pfannenstiel incision can be challenging in obese patients with an overhanging panniculus, it is usually feasible in all but the most obese women.

Doctors must start questioning the conventional wisdom that they are taught about what's best for "obese" people. They need to find out if this teaching is actually based on real research, and if so, whether the research has adequately controlled for confounding factors.

Once doctors actually started looking into the question, research showed that it is NOT necessary to do vertical incisions in fat women, even "massively obese" women. Outcomes are no better or are actually poorer when vertical incisions are used, despite what many doctors have been taught for so long.

The tendency towards greater blood loss, more wound complications, poorer cosmetic outcomes, more classical uterine incisions (and associated negative impact on future pregnancies) all suggest that vertical incisions should be avoided in most obese women.

Low transverse incisions have been used successfully even in extremely obese women (BMI of 88) in case reports found in the medical literature. Unless there are other complicating factors to consider, a vertical skin incision should NOT be used routinely in fat women.

References

Vertical Incisions vs. Low Transverse Incisions in Women of Size

Obstet Gynecol. 2003 Nov;102(5 Pt 1):952-6. Vertical skin incisions and wound complications in the obese parturient. Wall PD, Deucy EE, Glantz JC, Pressman EK. PMID: 14672469

OBJECTIVE: To examine the relationship between the type of skin incision and postoperative wound complications in an obese population.
METHODS: A hospital-based perinatal database was used to identify women with a body mass index (BMI) of greater than 35 undergoing their first cesarean delivery. Hospital and outpatient medical records were reviewed for the following variables: age, insurance status, BMI, gestational age at delivery, birth weight, smoking history, prior abdominal surgery, existing comorbidities, preoperative hematocrit, chorioamnionitis, duration of labor and membrane rupture, dilation at time of cesarean delivery, type of skinand uterine incision, estimated blood loss, operative time, antibiotic prophylaxis, use of subcutaneous drains or sutures, endometritis, and length of stay. The primary outcome variable was any wound complication requiring opening the incision. Multiple logistic regression analysis was completed to determine which of these factors contributed to the incidence of wound complications.
RESULTS: From 1994 to 2000, 239 women with a BMI greater than 35 undergoing a primary cesarean delivery were identified. The overall incidence of wound complications in this group of severely obese patients was 12.1%. Factors associated with wound complications included vertical skin incisions (odds ratio [OR] 12.4, P less than .001) and endometritis (OR 3.4, P = .03). A high preoperative hematocrit was protective (OR .87, P = .03). No other factors were found to impact wound complications.
CONCLUSION: Primary cesarean delivery in the severely obese parturient has a high incidence of wound complications. Our data indicate that a vertical skin incision is associated with a higher rate of wound complications than a transverse incision.

D’Heureux-Jones AM. Incision choice for cesarean celivery in obese patients: experience in a university hospital. Obstetrics & Gynecology. 2001 Apr;97(4 Suppl 1):S62-S63. http://www.sciencedirect.com/science/article/pii/S0029784401012959

Objective: Cesarean deliveries in obese patients are surgically difficult and associated with a higher incidence of complications. The choices of skin or uterine incision are subjective. Our aim was to determine the impact of different incisions on the speed of the operation and the intraoperative and postoperative morbidity in obese patients.
Methods: We conducted a 14-month retrospective review of all primary singleton cesarean deliveries performed at our institution. The abdominal (vertical: V, or Pfannenstiel: P) and uterine incision (low transverse: L, or classical: C) were evaluated by one-way and two-way ANOVA for their impact on the time of delivery (skin–baby) based on maternal weight in obese (>200 lb) versus nonobese women. Measures of intraoperative and postoperative morbidity included EBL, wound infections, and metritis.
Results: Seventy-one patients were subjects of this study. Forty-five patients (63%) met criteria for obesity (265.1 ± 8.4 lbs), significantly different from nonobese patients (156.5 ± 4.1 lbs). PL was the most frequent association both in the obese (64%, n = 29) and nonobese (88%, n = 23), with an average skin–baby time of 9.4 ± 0.8 minutes and 9.9 ± 1.1minutes, respectively (P < 0.05). In both obese and nonobese patients, a C was associated with a higher rate of prematurity and NICU admission. When a C was performed, the time was longer if the patient was obese (16.4 ± 2.8 min) versus nonobese (9.07 + 1.2 min), P = 0.03). Skin incisions did not affect the speed of delivery. In obese patients, VL had the highest EBL (1,167 ± 3.57 cc) and PL the lowest (1,075 ± 5.1cc, P = 0.02), both increased compared with nonobese patients with similar incisions. Metritis, but not wound infection, was more frequent in obese patients (20%) versus nonobese patients (3%), irrespective of the incision type. Length of stay was not affected either by obesity or by incision type.
Conclusions: The combination of P and L is preferred for cesarean delivery in both obese and nonobese patients. For obese patients, PL is further advantageous because it improves speed of operation, blood loss, and rate of complications.

Complications of cesarean delivery in the massively obese parturient. Alanis MC, Villers MS, Law TL, Steadman EM, Robinson CJ. Am J Obstet Gynecol. 2010 Sep;203(3):271.31-7. PMID: 20678746

OBJECTIVE: The objective of the study was to determine predictors of cesarean delivery morbidity associated with massive obesity.
STUDY DESIGN: This was an institutional review board-approved retrospective study of massively obese women (body mass index, greater than/=50 kg/m(2)) undergoing cesarean delivery. Bivariable and multivariable analyses were used to assess the strength of association between wound complication and various predictors.
RESULTS: Fifty-eight of 194 patients (30%) had a wound complication. Most (90%) were wound disruptions, and 86% were diagnosed after hospital discharge (median postoperative day, 8.5; interquartile range, 6-12). Subcutaneous drains and smoking, but not labor or ruptured membranes, were independently associated with wound complication after controlling for various confounders. Vertical abdominal incisions were associated with increased operative time, blood loss, and vertical hysterotomy.
CONCLUSION: Women with a BMI 50 kg/m(2) or greater have a much greater risk for cesarean wound complications than previously reported. Avoidance of subcutaneous drains and increased use of transverse abdominal wall incisions should be considered in massively obese parturients to reduce operative morbidity.

Eur J Obstet Gynecol Reprod Biol. 2011 Jan;154(1):16-9. Epub 2010 Sep 15. Abdominal surgical incisions and perioperative morbidity among morbidly obese women undergoing cesarean delivery. Bell J, Bell S, Vahratian A, Awonuga AO. PMID: 20832161

OBJECTIVE: To test the hypothesis that there is no difference in perioperative morbidity and the type of uterine incisions between vertical skin incisions (VSI) and low transverse skin incisions (LTSI) at the time of cesarean delivery in morbidly obese women.
STUDY DESIGN: Retrospective cohort study of morbidly obese women (BMI greater than 35 kg/m(2)) who underwent cesarean delivery between June 2004 and December 2006.
RESULTS: During the study, 424 morbidly obese women underwent cesarean section. Patients with VSI were older (31.0 ± 6.2 years vs. 26.7 ± 5.8 years), heavier (48.2 ± 9.1 kg/m(2) vs. 41.7 ± 6.7 kg/m(2)), and more likely to have a classical than a low transverse uterine incision (65.9% vs. 7.3%), p less than 0.001. After controlling for confounders, women with VSI did not have an increase in perioperative morbidity, but underwent more vertical uterine incisions (adjusted odds ratio = 18.49, 95% CI: 6.44, 53.07).
CONCLUSION: VSI and LTSI are safe in morbidly obese patients undergoing cesarean section, but there is a tendency for increased vertical uterine incisions in those who underwent VSI.

Risks of Classical Cesareans

Obstet Gynecol. 2002 Oct;100(4):633-7. Maternal and perinatal morbidity associated with classic and inverted T cesarean incisions. Patterson LS, O'Connell CM, Baskett TF. PMID: 12383525

OBJECTIVE: To estimate the maternal and perinatal morbidity associated with cesarean delivery involving the upper uterine segment compared with that of low transverse cesarean delivery. METHODS: A 19-year review of a perinatal database and the relevant charts was used to determine the maternal and perinatal morbidity associated with low transverse cesarean, classic cesarean, and inverted "T" cesarean deliveries. RESULTS:Over the 19 years, 1980-1998, there were 19,726 cesarean deliveries: low transverse cesarean, 19,422 (98.5%); classiccesarean, 221 (1.1%); and inverted T cesarean, 83 (0.4%). As a proportion of all cesarean deliveries, the rates of low transverse cesarean and classic cesarean have remained stable, whereas the rate of inverted T cesarean has risen from 0.2% to 0.9%. Maternal morbidity (puerperal infection, blood transfusion, hysterectomy, intensive care unit admission, death) and perinatal morbidity (stillborn fetus, neonatal death, 5 minute Apgar less than 7, intensive care) were significantly higher in classic cesarean compared to low transverse cesarean. Some maternal morbidity (puerperal infection, blood transfusion) and perinatal morbidity (5 minute Apgar less than 7, intensive care) were also significantly higher for inverted T cesarean compared to low transverse cesarean. CONCLUSION: Classic cesarean section has a higher maternal and perinatal morbidity than inverted T cesarean and much higher than low transverse cesarean. There is no increased maternal or perinatal morbidity if an attempted low transverse incision has to be converted to an inverted "T" incision compared to performing a classic cesarean section.

Am J Perinatol. 2010 Nov;27(10):791-6. Epub 2010 May 10. Maternal and neonatal outcomes of repeat cesarean delivery in women with a prior classical versus low transverse uterine incision. Bakhshi T, et al. PMID: 20458666

We compared maternal and neonatal outcomes following repeat cesarean delivery (CD) of women with a prior classical CD with those with a prior low transverse CD. The Maternal Fetal Medicine Units Network Cesarean Delivery Registry was used to identify women with one previous CD who underwent an elective repeat CD prior to the onset of labor at ≥36 weeks. Outcomes were compared between women with a previous classical CD and those with a prior low transverse CD. Of the 7936 women who met study criteria, 122 had a prior classical CD. Women with a prior classical CD had a higher rate of classical uterine incision at repeat CD (12.73% versus 0.59%; P less than 0.001), had longer total operative time and hospital stay, and had higher intensive care unit admission. Uterine dehiscence was more frequent in women with a prior classical CD (2.46% versus 0.27%, odds ratio 9.35, 95% confidence interval 1.76 to 31.93). After adjusting for confounding factors, there were no statistical differences in major maternal or neonatal morbidities between groups. Uterine dehiscence was present at repeat CD in 2.46% of women with a prior classical CD. However, major maternal morbidities were similar to those with a prior low transverse CD.

The Role of the Fatosphere in Responding to Obesity Stigma

2011-11-19T14:17:00.001-08:00

Qual Health Res. 2011 Aug 2. The Role of the Fatosphere in Fat Adults' Responses to Obesity Stigma: A Model of Empowerment Without a Focus on Weight Loss. Dickins M, Thomas SL, King B, Lewis S, Holland K. PMID: 21810992

Source: Monash University, Melbourne, Victoria, Australia.

Abstract

Obese adults face pervasive and repeated weight-based stigma. Few researchers have explored how obese individuals proactively respond to stigma outside of a dominant weight-loss framework.

Using a grounded theory approach, we explored the experiences of 44 bloggers within the Fatosphere-an online fat-acceptance community. We investigated participants' pathways into the Fatosphere, how they responded to and interacted with stigma, and how they described the impact of fat acceptance on their health and well-being.

The concepts and support associated with the fat-acceptance movement helped participants shift from reactive strategies in responding to stigma (conforming to dominant discourses through weight loss) to proactive responses to resist stigma (reframing "fat" and self-acceptance).

Participants perceived that blogging within the Fatosphere led them to feel more empowered. Participants also described the benefits of belonging to a supportive community, and improvements in their health and well-being. The Fatosphere provides an alternative pathway for obese individuals to counter and cope with weight-based stigma.

Honey for Wound Healing?

2011-11-06T20:10:00.000-08:00

One of the most interesting bits of folk medicine to enjoy a resurgence has been the use of honey for wound healing.

Honey was often used by the ancient Egyptians and Greeks for wound healing. It was used at times in the modern era as well ─ until the mid 20th century. After antibiotics were invented, it went out of common use in Western countries, but was still used to some degree in third-world countries as a folk remedy.

In the last 20 years or so, honey has experienced a resurgence of use, and a number of studies have investigated its utility in wound care. However, at this time, research on honey for wound-care is lagging inside the United States, despite the fact that medical honey dressings were approved by the FDA a few years ago.

It's time that honey for wound care be investigated more thoroughly, both here in the United States and abroad, in various low- and high-resource settings. We need much more data on when and how it is best utilized because it looks like a promising weapon in the fight against antibiotic-resistant bacteria.

How Does Honey Help Healing?

One review of the topic discussed why honey has come back into use:

Dressing wounds with honey, a standard practice in past times, went out of fashion when antibiotics came into use. Because antibiotic-resistant bacteria have become a widespread clinical problem, a renaissance in honey use has occurred. Laboratory studies and clinical trials have shown that honey is an effective broad-spectrum antibacterial agent that has no adverse effects on wound tissues. As well as having an antibacterial action, honey also provides rapid autolytic debridement, deodorizes wounds, and stimulates the growth of wound tissues to hasten healing and start the healing process in dormant wounds. Its anti-inflammatory activity rapidly reduces pain, edema, and exudate and minimizes hypertrophic scarring. It also provides a moist healing environment for wound tissues with no risk of maceration of surrounding skin and completely prevents adherence of dressings to the wound bed so no pain or tissue damage is associated with dressing changes. Using appropriate dressing practice overcomes potential messiness and handling problems.

Honey works on several fronts. First, the sugar in it draws out moisture from bacteria in the wound through osmotic action, and this plus the acidity of honey inhibits the growth of bacteria. Second, it draws more lymph fluid into the wound, which speeds healing. Third, the honey forms a barrier to protect the wound from outside infections, and provides a moist environment that helps promote tissue regrowth and minimize scarring. Fourth, it has an enzyme which produces hydrogen peroxide in a dilute form, which helps disinfect the area without damaging the skin the way the commercially-available hydrogen peroxide does. Finally, it keeps bandages from sticking to wounds as they heal, making dressing changes easier and less damaging to skin as it works to heal.

It's likely that there are other ways in which honey helps healing, but these seem to be the main modes of healing that we have figured out so far.

The biggest advantage of honey is that it does not promote antibiotic resistance, and that it's often effective against antibiotic-resistant "superbugs" like MRSA. Honey's most important use currently may be in treating wounds infected with antibiotic-resistant bugs. However, it may be that honey could have an important preventative role before antibiotic-resistant infections ever take hold. Only further research will tell.

Since bees make honey from varying plant sources, different kinds of honey can have different levels of antibacterial effects. In other words, some honeys may be more effective than others.

Research has mostly been done on Manuka Honey (marketed as Medihoney) from New Zealand, which supposedly has greatly increased antibacterial properties compared to many other honeys. However, this company's aggressive marketing has led some to question whether its claim of superiority is more marketing than substance. Tualang honey from Malaysia is also being researched, as well as RS honey (Revamil honey) from The Netherlands; many other honeys from other countries are sure to follow. New Zealand, Germany, and the Netherlands are the countries currently leading the research surge on medical-grade honey.

It's important to note that honey used in research is different from ordinary honey you might get from the supermarket. It's not clear whether research honey is more effective than supermarket honey, but it seems likely. In addition, impurities within honey (and botulism spores) lead some companies to irradiate their honey before marketing it. Therefore, at this time, most authorities do not promote the use of ordinary over-the-counter honey for wound healing. Medical-grade honey is what has been studied.

A Brief Summary of the Research

Research suggests that medical-grade honey is quite effective for improving healing in burn patients. A 2009 meta-analysis of studies found that patients treated with honey had better healing. The authors concluded:

Available evidence indicates markedly greater efficacy of honey compared with alternative dressing treatments for superficial or partial thickness burns, although the limitations of the studies included in the meta-analysis restrict the clinical application of these findings. Further studies are urgently required to determine the role of honey in the management of superficial or partial thickness burns.

However, the use of honey in patients with leg ulcers has been less convincing. Jull 2008 did a randomized clinical trial and found that treatment with honey did not improve healing. On the other hand, Gethin and Cowman (2009) found that honey did have some beneficial effect on desloughing ulcers and minimizing infection.

One problem is that many medical honey trials have been less than rigorous. They often come from only one or two main centers, and frequently are run or funded by companies who produce medical-grade honey. Furthermore, difficulties with study design (use of medical-grade honey vs. ordinary honey, inconsistent antibacterial properties of honey between batches of the same honey, use of honey only after very serious infections are already present) have also limited the clinical application of the findings of existing studies.

The 2008 Cochrane review of honey in wound care concludes:

Honey may improve healing times in mild to moderate superficial and partial thickness burns compared with some conventional dressings. Honey dressings as an adjuvant to compression do not significantly increase leg ulcer healing at 12 weeks. There is insufficient evidence to guide clinical practice in other areas.

In other words, although many results are encouraging, not all are, and many studies weren't well-designed. Larger, more rigorous and more independent trials are needed to determine how and when honey is most effective.

Honey in Childbearing Women

What about the use of honey for healing in childbearing women?

One 1992 study found that honey helped heal infected cesarean wounds within 2 weeks and avoided the need for re-suturing the wound under general anesthesia.

A 1999 study found that in infections after either a cesarean or a hysterectomy, women treated with honey did better than women treated with traditional topical antiseptics (both groups received systemic antibiotics). The healing time in the honey-treated patients was cut in half, women needed far less time on antibiotics, 84% of the honey-treated group experienced complete healing (vs. 50% in the topical antiseptic group), and none of the honey-treated group needed re-suturing (vs. one-fourth of the topical antiseptic group).

The problem with the research on honey for post-cesarean healing is that the studies are extremely small, not very recent, and were done only in third-world countries with more outdated wound-care practices. However, the two studies that exist are encouraging and indicate that the possibility should definitely be tested more rigorously.

Some midwives also use honey for minor perineal tears after birth. Demetria Clark, herbalist, quoting from various sources, explains why honey can be helpful:

Raw honey is a great remedy for first-degree [perineal] tears. Honey's thick consistency forms a barrier defending the wound from outside infections. The moistness allows skin cells to grow without creating a scar, even if a scab has already formed. Meanwhile, the sugars extract dirt and moisture from the wound, which helps prevent bacteria from growing, while the acidity of honey also slows or prevents the growth of many bacteria. An enzyme that bees add to honey reacts with the wound's fluids and breaks down into hydrogen peroxide, a disinfectant. Honey also acts as an anti-inflammatory and pain killer and prevents bandages from sticking to wounds. Laboratory studies have shown that honey has significant antibacterial qualities. Significant clinical observations have demonstrated the effectiveness of honey as a wound healing agent. Glucose converted into hyaluronic acid at the wound surface forms an extracellular matrix that encourages wound healing. Honey is also considered antimicrobial.

From Volume 11, Issue 1, January 7, 2009 edition of Midwifery Today enews
Excerpted from "Herbs for Postpartum Perineum Care: Part I," The Birthkit, Issue 46
http://www.midwiferytoday.com/products/bk46.htm

Obesity, Diabetes, and Medical Grade Honey

In particular, it would be helpful to know if medical-grade honey could help lessen the incidence of wound infection in women of size, who have a higher rate of infection after cesareans or other operations. Or if it could lessen infection in diabetics, who are also quite prone to surgical site infections and poorly-healing skin ulcers.

Yet I have seen some experts recommend against using honey in these groups, on the assumption that it would raise the blood sugar of the patient, and thereby inhibit healing. However, this seems to be just that, an assumption rather than a proven fact, and needs to be tested before such groups are routinely excluded from such potentially promising treatment.

Some authors have also speculated that the high rates of methylglyoxal (MG) in Manuka honey (MediHoney) will impair healing in diabetic ulcers. But again, this theory has not yet been tested.

At this point, I have not seen definitive studies done to test the hypothesis that honey is unsuited for use in either of these groups. Diabetics were routinely excluded from many of the venous leg ulcer studies that were done, and I don't know of any studies done specifically on "obese" people.

However, we do have small studies and case reports of MediHoney being used successfully on diabetics, indigent diabetics with chronic wounds, and in people of size─with promising results─but we need systematic study before we jump to conclusions.

It is unfair to exclude fat people and diabetics from the potentially healing properties of medical-grade honey based on unproven assumptions.

Instead of excluding these populations, studies specifically examining outcomes in these populations should be done, utilizing various brands of medical-grade honey and wound-care protocols. Only then will we know whether exclusions from topical honey dressings is justified or not.

Conclusion

The FDA approved the use of honey for wound dressings in 2007, but U.S.-based research on honey dressings has been slow to catch on, and has been centered mostly on burns and leg ulcers.

Perhaps it's time that its use in other types of wounds, in childbearing women, in diabetics, and in people of size is investigated more thoroughly.

Clearly, we need more information and better studies before we can know just how helpful (or not) medical-grade honey might be.

But given its cost-effectiveness, its potential for lowering antibiotic resistance issues, and the possibility of improving outcome in those with difficult-to-heal wounds, it's a subject that deserves larger and better trials.

*Caution: Honey should not be used for very young children (especially newborns) because it can harbor botulism spores. Therefore many healthcare providers feel medical honey should not be used on anything that might come in contact with newborns either internally or externally (i.e. not for sore nipples or for cord healing after birth).

Honey dressings are well-tolerated by most people who use them, but occasionally a few people report a stinging sensation with their use at first. Those who are allergic to bee stings might also need to use extra caution with medical honey.

References

Honey for Wound Healing

http://www.worldwidewounds.com/2001/november/Molan/honey-as-topical-agent.html - review of honey for wound healing, including many references and practical advice for its use
http://cid.oxfordjournals.org/content/46/11/1677.full - review of RS honey and its use on antibiotic-resistant bacteria in vitro
http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/107/4/187.pdf - full text of a good easy-to-understand summary about honey for wound healing, with many references

Am J Clin Dermatol. 2011 Jun 1;12(3):181-90. Honey and wound healing: an overview. Lee DS, Sinno S, Khachemoune A. PMID: 21469763

Honey has been used to treat wounds throughout the ages. This practice was rooted primarily in tradition and folklore until the late 19th century, when investigators began to characterize its biologic and clinical effects. This overview explores both historic and current insights into honey in its role in wound care. We describe the proposed antimicrobial, immunomodulatory, and physiologic mechanisms of action, and review the clinical evidence of the efficacy of honey in a variety of acute and chronic wound types. We also address additional considerations of safety, quality, and the cost effectiveness of medical-grade honeys. In summary, there is biologic evidence to support the use of honey in modern wound care, and the clinical evidence to date also suggests a benefit. However, further large, well designed, clinical trials are needed to confirm its therapeutic effects.

Cochrane Database Syst Rev. 2008 Oct 8;(4):CD005083. Honey as a topical treatment for wounds. Jull AB, Rodgers A, Walker N. PMID: 18843679

19 trials (n=2554) were identified that met the inclusion criteria. In acute wounds, three trials evaluated the effect of honey in acute lacerations, abrasions or minor surgical wounds and nine trials evaluated the effect the honey in burns. In chronic wounds two trials evaluated the effect of honey in venous leg ulcers and one trial in pressure ulcers, infected post-operative wounds, and Fournier's gangrene respectively. Two trials recruited people with mixed groups of chronic or acute wounds. The poor quality of most of the trial reports means the results should be interpreted with caution, except in venous leg ulcers. In acute wounds, honey may reduce time to healing compared with some conventional dressings in partial thickness burns (WMD -4.68 days, 95% CI -4.28 to -5.09 days). All the included burns trials have originated from a single centre, which may have impact on replicability. In chronic wounds, honey in addition to compression bandaging does not significantly increase healing in venous leg ulcers (RR 1.15, 95% CI 0.96 to 1.38). There is insufficient evidence to determine the effect of honey compared with other treatments for burns or in other acute or chronic wound types. AUTHORS' CONCLUSIONS: Honey may improve healing times in mild to moderate superficial and partial thickness burns compared with some conventional dressings. Honey dressings as an adjuvant to compression do not significantly increase leg ulcer healing at 12 weeks. There is insufficient evidence to guide clinical practice in other areas.

Adv Skin Wound Care. 2011 Jan;24(1):40-4. Use of honey in wound care: an update. Song JJ, Salcido R. PMID: 21150765

The therapeutic use of honey in wound care has been used since ancient times. Honey has been shown to have antibacterial properties in vitro and animal studies have demonstrated accelerated wound healing with the use of honey. In human trials, there is currently not enough strong evidence to fully support the use of honey in wound care; however, use in minor burns and prevention of radiation mucositis appear to be 2 areas where honey shows therapeutic promise.

Br J Surg. 2008 Feb;95(2):175-82. Randomized clinical trial of honey-impregnated dressings for venous leg ulcers. Jull A, et al; Honey as Adjuvant Leg Ulcer Therapy trial collaborators. PMID: 18161896

This community-based open-label randomized trial allocated people with a venous ulcer to calcium alginate dressings impregnated with manuka honey or usual care. All participants received compression bandaging. The primary outcome was the proportion of ulcers healed after 12 weeks. Secondary outcomes were: time to healing, change in ulcer area, incidence of infection, costs per healed ulcer, adverse events and quality of life. Analysis was by intention to treat. RESULTS: Of 368 participants, 187 were randomized to honey and 181 to usual care. At 12 weeks, 104 ulcers (55.6 per cent) in the honey-treated group and 90 (49.7 per cent) in the usual care group had healed (absolute increase 5.9 (95 per cent confidence interval (c.i.) -4.3 to 15.7) per cent; P = 0.258). Treatment with honey was probably more expensive and associated with more adverse events (relative risk 1.3 (95 per cent c.i. 1.1 to 1.6); P = 0.013). There were no significant differences between the groups for other outcomes.CONCLUSION: Honey-impregnated dressings did not significantly improve venous ulcer healing at 12 weeks compared with usual care.

J Clin Nurs. 2009 Feb;18(3):466-74. Epub 2008 Aug 23. Manuka honey vs. hydrogel--a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. Gethin G, Cowman S. PMID: 18752540

Comparison of desloughing efficacy after four weeks and healing outcomes after 12 weeks in sloughy venous leg ulcers treated with Manuka honey (Woundcare 18+) vs. standard hydrogel therapy (IntraSite Gel). BACKGROUND: Expert opinion suggests that Manuka honey is effective as a desloughing agent but clinical evidence in the form of a randomised controlled trial is not available. There is a paucity of research which uses Manuka honey in venous ulcers. DESIGN: Prospective, multicentre, open label randomised controlled trial. METHOD: Randomisation was via remote telephone. One hundred and eight patients with venous leg ulcers having greater than or =50% wound area covered in slough, not taking antibiotics or immunosuppressant therapy were recruited from vascular centres, acute and community care hospitals and leg ulcer clinics. The efficacy of WoundCare 18+ to deslough the wounds after four weeks and its impact on healing after 12 weeks when compared with IntraSite Gel control was determined. Treatment was applied weekly for four weeks and follow-up was made at week 12. RESULTS: At week 4, mean % reduction in slough was 67% WoundCare 18+ vs. 52.9% IntraSite Gel (p = 0.054). Mean wound area covered in slough reduced to 29% and 43%, respectively (p = 0.065). Median reduction in wound size was 34% vs. 13% (p = 0.001). At 12 weeks, 44% vs. 33% healed (p = 0.037). Wounds having greater than 50% reduction in slough had greater probability of healing at week 12 (95% confidence interval 1.12, 9.7; risk ratio 3.3; p = 0.029). Infection developed in 6 of the WoundCare 18+ group vs. 12 in the IntraSite Gel group. CONCLUSION: The WoundCare 18+ group had increased incidence of healing, effective desloughing and a lower incidence of infection than the control. Manuka honey has therapeutic value and further research is required to examine its use in other wound aetiologies. RELEVANCE TO CLINICAL PRACTICE: This study confirms that Manuka honey may be considered by clinicians for use in sloughy venous ulcers. Additionally, effective desloughing significantly improves healing outcomes.

Biotechnol Res Int. 2011;2011:917505. Epub 2010 Dec 29. Antibacterial efficacy of raw and processed honey. Mohapatra DP, Thakur V, Brar SK. PMID: 21350671

In vitro antibacterial activity of methanol, ethanol, and ethyl acetate extracts of raw and processed honey was tested against Gram-positive bacteria (Staphylococcus aureus, Bacillus subtilis, Bacillus cereus, Enterococcus faecalis, and Micrococcus luteus) and Gram-negative bacteria (Escherichia coli, Pseudomonas aeruginosa, and Salmonella typhi). Both types of honey showed antibacterial activity against tested organisms with the zone of inhibition (ZOI) ranging from 6.94 to 37.94 mm, while E. coli, S. typhi, and P. aeruginosa showed that sensibility towards all the extracts with ZOI ranges between 13.09 to 37.94 mm. The methanol extract showed more potent activity than other organic extracts. Gram-negative bacteria were found to be more susceptible as compared to Gram-positive bacteria except E. faecalis. The broth microdilution assay gave minimum inhibitory concentrations (MIC) value of 625 μg/mL, while the minimum bactericidal concentration (MBC) ranges between 625 μg/mL 2500 μg/mL. The study showed that honey has antibacterial activity (bacteriostatic and bactericidal effect), similar to antibiotics, against test organisms and provides alternative therapy against certain bacteria.

N Z Med J. 2009 May 22;122(1295):47-60. Honey in the treatment of burns: a systematic review and meta-analysis of its efficacy. Wijesinghe M, et al. PMID: 19648986

Eight studies with 624 subjects were included in the meta-analysis. The quality of the studies was poor with each study having a Jadad score of 1. Six studies were undertaken by the same investigator. In most studies unprocessed honey covered by sterile gauze was compared with silver sulphadiazine-impregnated gauze. The fixed effects odds ratio for healing at 15 days was 6.1 (95% CI 3.7 to 9.9) in favour of honey having a superior effect. The random effects pooled odds ratio was 6.7 (95% CI 2.8 to 15.8) in favour of honey treatment. The secondary outcome variables all showed significantly greater efficacy for honey treatment. CONCLUSION: Available evidence indicates markedly greater efficacy of honey compared with alternative dressing treatments for superficial or partial thickness burns, although the limitations of the studies included in the meta-analysis restrict the clinical application of these findings. Further studies are urgently required to determine the role of honey in the management of superficial or partial thickness burns.

Ostomy Wound Manage. 2002 Nov;48(11):28-40. Re-introducing honey in the management of wounds and ulcers - theory and practice. Molan PC. PMID: 12426450

Dressing wounds with honey, a standard practice in past times, went out of fashion when antibiotics came into use. Because antibiotic-resistant bacteria have become a widespread clinical problem, a renaissance in honey use has occurred. Laboratory studies and clinical trials have shown that honey is an effective broad-spectrum antibacterial agent that has no adverse effects on wound tissues. As well as having an antibacterial action, honey also provides rapid autolytic debridement, deodorizes wounds, and stimulates the growth of wound tissues to hasten healing and start the healing process in dormant wounds. Its anti-inflammatory activity rapidly reduces pain, edema, and exudate and minimizes hypertrophic scarring. It also provides a moist healing environment for wound tissues with no risk of maceration of surrounding skin and completely prevents adherence of dressings to the wound bed so no pain or tissue damage is associated with dressing changes. Using appropriate dressing practice overcomes potential messiness and handling problems.

PLoS One. 2011 Mar 4;6(3):e17709. Two major medicinal honeys have different mechanisms of bactericidal activity. Kwakman PH, et al. PMID: 21394213

Honey is increasingly valued for its antibacterial activity, but knowledge regarding the mechanism of action is still incomplete. We assessed the bactericidal activity and mechanism of action of Revamil® source (RS) honey and manuka honey, the sources of two major medical-grade honeys. RS honey killed Bacillus subtilis, Escherichia coli and Pseudomonas aeruginosa within 2 hours, whereas manuka honey had such rapid activity only against B. subtilis. After 24 hours of incubation, both honeys killed all tested bacteria, including methicillin-resistant Staphylococcus aureus, but manuka honey retained activity up to higher dilutions than RShoney. Bee defensin-1 and H₂O₂ were the major factors involved in rapid bactericidal activity of RS honey. These factors were absent in manuka honey, but this honey contained 44-fold higher concentrations of methylglyoxal than RS honey. Methylglyoxal was a major bactericidal factor in manuka honey, but after neutralization of this compound manuka honey retained bactericidal activity due to several unknown factors. RS and manuka honey have highly distinct compositions of bactericidal factors, resulting in large differences in bactericidal activity.

Honey and Cesarean Healing

Eur J Med Res. 1999 Mar 26;4(3):126-30. Effects of topical honey on post-operative wound infections due to gram positive and gram negative bacteria following caesarean sections and hysterectomies. Al-Waili NS, Saloom KY. PMID: 10085281

The possible therapeutic effect of topical crude undiluted honey in the treatment of severe acute postoperative wound infections was studied. Fifty patients having postoperative wound infections following caesarean sections or total abdominal hysterectomies with gram positive or gram negative bacterial infections were allocated in two groups. Twenty-six patients (group A) were treated with 12 hourly application of crude honey and 24 patients (group B) were treated with local antiseptics: spirit (70% Ethanol) and povidone-iodine. Both groups received systemic antibiotics according to culture and sensitivity. Results showed that eradication of bacterial infections was obtained after 6 +/- 1.9 days (mean +/- SD) in group A and after 14.8 +/- 4.2 days in group B (p less than 0.05). Period for antibiotics use was 6.88 +/- 1.7 days in-group A and 15.45 +/- 4. 37 in-group B (p less than 0.05). Complete wound healing was evident after 10. 73 +/- 2.5 days in group A and after 22.04 +/- 7.33 in group B (p less than 0. 05). Size of postoperative scar was 3.62 +/- 1.4 mm after using topical honey and was 8.62 +/- 3.8 mm after local antiseptics (p less than 0. 05). The mean hospital stay was 9.36 +/- 1.8 days in group A and 19. 91 +/- 7.35 days in group B (p less than 0.05). After using honey, 22/26 patients (84.4%) showed complete wound healing without wound disruption or need for re-suturing and only 4 patients showed mild dehiscence. In group B, 12/24 patients (50%) showed complete wound healing and 12 patients showed wound dehiscence, six of them needed re-suturing under general anesthesia. We concluded that topical application of crude undiluted honey could (1) faster eradication of bacterial infections, (2) reduce period of antibiotic use and hospital stay, (3) accelerate wound healing, (4) prevent wound dehiscence and need for re-suturing and (5) result in minimal scar formation.

Aust N Z J Obstet Gynaecol. 1992 Nov;32(4):381-4. Topical application of honey in treatment of abdominal wound disruption. Phuapradit W, Saropala N. PMID: 1290445

The usefulness of honey application as an alternative method of managing abdominal wound disruption was assessed. Fifteen patients whose wound disrupted after Caesarean section were treated with honey application and wound approximation by micropore tape instead of the traditional method of wound dressing with subsequent resuturing. We achieved excellent results in all the cases with complete healing within 2 weeks. Honey application is inexpensive, effective and avoids the need to resuture which also requires general anaesthesia.

Happy Pumpkin Day Again

2011-10-31T12:00:00.000-07:00

Happy Halloween, y'all. Just a brief post to wish you joy of the day if you celebrate it. We love this holiday at our house.

What are your children dressing up as for Halloween?

Now that my kids are getting older, traditions are changing a bit at our house. Two of my kids are teens (my "bigs"), and two are younger (my "littles", or more precisely, one "little" and one "tween"). And having two teens in the house is changing things.

When my bigs were young, our Halloween costumes followed the usual themes....kitty cat, pumpkin, astronaut, pirate, teddy bear, princess, baseball player, fairy, firefighter, knight, lion, witch, etc. Oh, and at one point, my oldest son went as "Everyone's Worst Nightmare....an IRS Agent."

Although we encouraged non-commercial, non-media costumes for the most part, we did give in sometimes and had Madeline, Harry Potter, Tigger, Thomas the Tank Engine, various superheros, and Star Trek visit our home a few times. (Yes, we keep a list so we can remember who wore what which year! This is really fun to look back at.)

We also had a couple of cool themed years. A couple of times everyone (including littles) went as someone from Peter Pan (Peter, Wendy, Captain Hook, Tinkerbell, the Crocodile). That was precious, especially the Crocodile. That cute little reptile is now a hulking teen with a deep bass voice and a bottomless appetite, but I'll always remember him as the Croc with a Clock.

My personal favorite was the year they all dressed as a Star Wars character, along with some good friends (we had Princess Leia, the Emperor, Darth Vader, Luke Skywalker, and a Clone Trooper. I tried to get the toddler to be an Ewok but she wasn't having it). That's a picture I treasure now.

They were so adorable. Oh, how I miss those days!

This year, one teen, the "tween" and I are going to participate behind the scenes in a Haunted House. The other teen is going trick-or-treating for the local food bank with a club from his school, and DH and the youngest will tag along to help supervise. After that, we'll take them all for a brief round of trick-or-treating in our old neighborhood, just enough for the littles to show off their costumes and get a little candy.

Sadly, Halloween costumes have changed now that my bigs are teenagers. I find that their teen "hipness" vibe has changed the costume choices of my littles, even though the bigs are no longer dressing up. Know what my littles are going to be for Halloween?

The "tween" is going to be a Barrel of Toxic Waste. Yes, toxic waste. Sigh.

The "littlest" is going with a non-princess theme for the first time since she was a baby. For years it was All Princesses All The Time, although the last two years the princesses had combined with other themes and became a Cowboy Princess and then a Ninja Fairy Princess. But not this year.

Nope, this year she's going to be.......get this.......a Zombie Bride.

Yes, both of those were completely THEIR ideas. No teens tried to "hip up" their ideas or anything. Yet just having 2 worldly, hip teens in the house changed their expectations and visions.

Sigh. Although these are pretty funny and precious in their own way, I have to say I miss the old days! I may never see a sweet, "unhip," plain-vanilla costume again till I have grandkids. Wah!

Although it's wonderful to see my kids growing up and becoming such fine big people, every so often I get all misty and nostalgic for those "little one" innocent-joy moments. The bittersweet nature of being a parent, I guess. Sniff.

Well, Happy Pumpkin Day to you all. If you still have littles, enjoy the sweetness and innocence of these days. It will pass all too soon into zombies and toxic waste.

Restricting Prenatal Weight Gain in Women of Size: Adverse Side Effects

2011-10-28T14:15:00.000-07:00

Here's another study questioning whether rigid weight-gain restrictions in "obese" women are wise.

We've talked about this extensively before. But given how often care providers tout this as a way to improve outcomes in women of size, it bears frequent repetition.

In this study, the lower Cedergren weight gain criteria for obese women (less than 13 lbs.) resulted in slightly lower cesarean rates and definitely less macrosomia than the IOM guidelines.

However, it also resulted in an increase in preterm births, low birth weight babies, and NICU admissions.

Many providers mean well when they advise women of size to gain less weight in pregnancy. The question is, are we harming more than we are helping?

When restrictions are too draconian, I think the balance definitely falls to harm.

Discuss good nutrition and reasonable intake? Absolutely. Have rigid weight gain goals that require significant restriction? Not a good idea.

How about we emphasize excellent nutrition and trust the woman's body to gain what it needs?

Am J Perinatol. 2010 May;27(5):415-20. Obstetric outcomes in normal weight and obese women in relation to gestational weight gain: comparison between Institute of Medicine guidelines and Cedergren criteria. Potti S, Sliwinski CS, Jain NJ, Dandolu V. PMID: 20013574

We compared obstetric outcomes based on gestational weight gain in normal-weight and obese women using traditional Institute of Medicine (IOM) guidelines and newly recommended Cedergren criteria. Using the New Jersey Pregnancy Risk Assessment Monitoring System (PRAMS) database and electronic birth records, perinatal outcomes were analyzed to estimate the independent effects of prepregnancy body mass index (BMI) and gestational weight gain by IOM versus Cedergren criteria. Of 9125 subjects in PRAMS database from 2002 to 2006, 53.7% had normal BMI, 12.3% were overweight, 18.2% were obese, and the rest were underweight.

Among normal-weight mothers, when compared with the IOM guidelines, macrosomia (6.45% versus 4.27%) and cesarean delivery rates (30.42% versus 29.83%) were lower using Cedergren criteria but the rates of preterm delivery (5.06% versus 9.44%), low birth weight (0.38% versus 2.42%), and neonatal intensive care unit (NICU) admissions (7.02% versus 10.86%) were higher with the Cedergren criteria.

Similarly, among obese patients, when compared with IOM guidelines, macrosomia (10.79% versus 5.47%) and cesarean delivery rates (43.95% versus 40.71%) were lower using Cedergren criteria but the rates of preterm delivery (6.83% versus 8.32%), low birth weight (0.87% versus 1.88%), and NICU admissions (8.92% versus 13.78%) were higher with the Cedergren criteria.

Based on our results, ideal gestational weight gain is presumably somewhere between the IOM and Cedergren's guidelines.

BMI and Blood Pressure Measurement in Pregnancy

2011-10-22T13:41:00.000-07:00

BP Cuff Size Chart
(exact cutoffs may vary by brand)

We've written before about the importance of using a large cuff for blood pressure measurement in women of size.

Yet sometimes using a large BP cuff for women of size is not done routinely, especially in obstetrics.

Here's yet another study documenting the importance of the correct cuff size in "obese" women in pregnancy.

Note that Class One obesity is usually BMI 30-35, Class Two is usually BMI 35-40, and Class Three is BMI over 40.

In this study, nearly half of Class One obese women needed a large cuff, and with Class Two and above, 100% needed a large cuff.

My BMI is about 48 and has been for all four of my pregnancies, which occurred in the mid-90s through the mid 2000s. Research on the importance of blood pressure cuff size in "obese" people had been around for years before that, yet getting the correct cuff size was a problem in three of my four pregnancies.

And I still hear stories about use of the wrong cuff size from other high-BMI women, inside and outside of pregnancy, even today.

In theory, care providers know about the importance of the correct cuff size, but in practice, many don't follow the guidelines, don't think cuff size really makes that much difference, don't really check what size cuff was used (even when encountering a high BP in a large person), and don't emphasize the importance of cuff size adequately to the nurses and techs who do the actual BP measurements most of the time.

Yes, BP taken at the wrist with a regular cuff can be done for a ballpark figure in high-BMI people, but is not accurate enough for decision-making purposes. It tends to overestimate blood pressure in many cases.

A large or thigh cuff (depending on arm circumference) used on the arm is the only really accurate method of BP measurement in "obese" people.

You need accurate data on which to base care decisions. Ensuring the correct cuff size is a very simple but extremely important way that care providers can improve care for women of size.

Hypertens Pregnancy. 2011;30(4):396-400. Body Mass Index and Blood Pressure Measurement during Pregnancy. Hogan JL, et al. PMID: 20726743

Objective. The accurate measurement of blood pressure requires the use of a large cuff in subjects with a high mid-arm circumference (MAC). This prospective study examined the need for a large cuff during pregnancy and its correlation with maternal obesity.

Methods. Maternal body mass index (BMI), fat mass, and MAC were measured.

Results. Of 179 women studied, 15.6% were obese. With a BMI of level 1 obesity, 44% needed a large cuff and with a BMI of level 2 obesity 100% needed a large cuff.

Conclusion. All women booking for antenatal care should have their MAC measured to avoid the overdiagnosis of pregnancy hypertension.

PCOS: Possible Causes

2011-10-11T04:12:00.000-07:00

We've been talking about PCOS (Polycystic Ovarian Syndrome), its definition and symptoms, how it presents, and its testing and diagnosis.

Today let's talk about the controversy over possible causes of PCOS.

Caveats

Determining the causes of things like PCOS can be incredibly complex. Furthermore, as research develops, a better understanding of cause develops over time. Therefore, insert many caveats to this information and remember that our understanding may change as further research is done.

What Causes PCOS?

Unfortunately, no one really understands why PCOS happens or what causes it.

Because of this, PCOS is a controversial diagnosis. Some doctors don't really believe it exists, some think it's merely a marker for Syndrome X ("metabolic syndrome") in females, some think it's all about hormones only, some think it's all about insulin resistance, some think it's caused by obesity, some think it causes obesity.

Part of the problem is that PCOS is a syndrome and not a formal disease. One website clarifies the difference:

A syndrome refers to a group of symptoms, while a disease refers to an established condition. A disease a condition that is marked by 3 basic factors.

1. An established biological cause behind the condition
2. A defined group of symptoms
3. Consistent change in anatomy due to the condition

A syndrome does not have any of these features. Even the symptoms that are present are usually not consistent, and definitely not traceable to a single cause.

The reason behind most syndromes has still not been identified. For this reason, they are a type of medical mystery. In contrast, the reason or cause behind a disease can be identified very easily.

In other words, no one really knows why it happens or what causes it, and it presents with a wide variety of symptoms that make it difficult to classify.

Here's what we do know: In PCOS, an excess of androgens (male hormones) and insulin resistance seem to be key parts of the syndrome. However, what causes this, which comes first, and which is more important is not clear.

Some researchers consider PCOS to be primarily a hormone imbalance disorder, and view insulin resistance as a side effect of the hormonal issues.

Other researchers consider insulin resistance (problems processing insulin) to be the real root of the issue, which then causes hormonal disturbances.

At this point, it's a bit of a chicken-or-the-egg question and no one has any definitive answers as to what causes PCOS. All we have are educated guesses.

Hormones and Obesity and Insulin, Oh My

The most common suspects for a root cause of PCOS are hormones, obesity, and insulin resistance. Each has arguments for and against it.

Hormonal Imbalance

The prevailing view of PCOS suggests that it is primarily a hormonal disorder, and that an imbalance of hormones is the root cause of problems. Here is one common explanation, as given by one website:

A main underlying problem with PCOS is a hormonal imbalance. In women with PCOS, the ovaries make more androgens than normal. Androgens are male hormones that females also make. High levels of these hormones affect the development and release of eggs during ovulation...

The ovaries, where a woman’s eggs are produced, have tiny fluid-filled sacs called follicles or cysts. As the egg grows, the follicle builds up fluid. When the egg matures, the follicle breaks open, the egg is released, and the egg travels through the fallopian tube to the uterus (womb) for fertilization. This is called ovulation.

In women with PCOS, the ovary doesn't make all of the hormones it needs for an egg to fully mature. The follicles may start to grow and build up fluid but ovulation does not occur. Instead, some follicles may remain as cysts. For these reasons, ovulation does not occur and the hormone progesterone is not made. Without progesterone, a woman's menstrual cycle is irregular or absent. Plus, the ovaries make male hormones, which also prevent ovulation.

In this model, the immature follicles form cysts on the ovaries, and these cysts give off androgens ("male" hormones), and do not produce the progesterone that would normally be created if ovulation had occurred. The woman skips periods because she has not ovulated, and the endometrial lining builds up because it has not been shed and has been exposed to unopposed estrogen.

So the focus in this theory is on the ovaries, and the hormonal imbalances that cause ovarian cysts. However, the problem with this theory is that not all women with PCOS have cystic ovaries, yet clearly have symptoms of androgen excess. And some have cystic ovaries but no real signs of androgen excess.

Another model proposes that the basic problem is that the body does not produce or process androgens normally.

Women with polycystic ovarian syndrome (PCOS) have abnormalities in the metabolism of androgens and estrogen and in the control of androgen production...

...some evidence suggests that patients have a functional abnormality of cytochrome P450c17, the 17-hydroxylase, which is the rate-limiting enzyme in androgen biosynthesis.

Cytochrome P450c17 is active in the adrenals and ovaries, and excess activity of this enzyme could explain the increased androgen production from both sources in PCOS.

Whatever the reason, the end result is that women with PCOS have too many androgens floating around, and that creates side effects in the body.

Women with PCOS also tend to be estrogen-dominant, meaning too much estrogen and not enough progesterone. This can make it difficult to sustain a pregnancy, even when one is achieved. For some women with PCOS, the key to maintaining a pregnancy seems to be treatment with supplemental progesterone before and during in the first trimester, although this treatment remains controversial to some.

The question is where the hormonal imbalance originates. Some researchers theorize that PCOS originates with problems in the HPO (hypothalamic-pituitary-ovarian) axis. This in turn affects many other glands (like the thyroid or the gonadotropic glands) and sets up a cascade of imbalances and negative effects.

If this is true, it means that many of the treatments we have today are simply "band-aid" approaches, addressing only the symptoms and not the real cause of issues. But if a way to identify and treat HPO axis issues were to be found, perhaps PCOS could be prevented altogether.

Obesity

Some doctors will tell you that "obesity" may cause PCOS, because fat stores produce extra estrogen and this in turn can alter other hormones.

However, it is more logical that perhaps the metabolic changes of PCOS cause the obesity instead.

In my opinion, this seems a much more likely explanation, especially since many women with PCOS report bouts of sudden, severe, unexplainable weight gains at various points in life, despite no changes in habits or intake. And several studies report that the overall caloric intake of women with PCOS is similar to those without PCOS. So there may be more to the story than the usual "eating too much" theory.

Because our society is so biased about "obesity" and weight issues, and because PCOS and obesity go hand in hand so often, it's very difficult to get researchers (and consumers) to view it objectively. Many cannot disentangle their biases that obesity = gluttony long enough to consider the question of root causes of PCOS more objectively.

I certainly have heard from PCOS advocates who staunchly believe that their obesity is to blame for their PCOS status, and I've read materials from doctors theorizing that PCOS starts mostly in overweight teens because of their obesity which then triggers hyperandrogenism (in other words, there was a genetic predisposition there but it was the teens' overweight status that caused those genes to express, not the other way around).

However, this ignores the fact that average-sized women get PCOS too, and can have just as much androgen excess and insulin resistance as "obese" women with PCOS. And not every fat woman has PCOS.

This view of obesity "causing" PCOS seems to be falling out of favor now, and most resources acknowledge that obesity does not cause PCOS, although it can exacerbate the symptoms.

The question is, does significant obesity amplify and worsen PCOS, or is significant obesity simply a symptom of a more severe manifestation of the syndrome? Or do the two work synergistically in a negative feedback loop?

Insulin Resistance

It is clear that many women with PCOS have very strong insulin resistance (IR) issues, so it's been theorized that insulin resistance (and resulting hyperinsulinemia) causes both the tendency towards obesity, the hyperandrogenism, and the resulting PCOS symptoms. In other words, a problem with the insulin may be the root cause of everything else.

From http://www.fertilitycommunity.com/fertility/hyperinsulinemia-not-ovaries-at-core-of-pcos.html:

Polycystic ovary syndrome is in sore need of a new name, Dr. Barbara S. Apgar said at the annual meeting of the American Academy of Family Physicians.

Put aside the traditional notion that the primary defect in polycystic ovary syndrome (PCOS) involves the ovaries. Focus instead on hyperinsulinemia, which lies at the core of this common endocrinopathy, advised Dr. Apgar, a family physician at the University of Michigan, Ann Arbor.

Indeed, the finding of enlarged ovaries on palpation or polycystic ovaries on ultrasound in merely a sign of PCOS. Insulin abnormalities precede the elevated androgen levels that characterize PCOS. And switching off the ovaries via a GnRH agonist doesn't affect the hyperinsulinemia and insulin resistance, she noted...

In PCOS, hyperinsulinemia leads to hyperandrogenism, resulting in chronically elevated LH levels. The hair follicles are genetically sensitive to androgen stimulation, so acne and hirsutism are commonly part of the PCOS picture. Glucose intolerance, type 2 diabetes, and lipid abnormalities also are common. And 40%-60% of patients with PCOS are obese.

Treatment is not directed at the ovary. It's directed at the hair follicle level and also at the pancreatic level, where we see the insulin resistance, she explained.

Some doctors have hypothesized that perhaps women with PCOS have defective insulin receptors, so the body must overproduce insulin in order to get them to work properly. Another theory is that, while insulin receptors are normal, there is a "post-binding defect in insulin signaling," as suggested here:

Insulin resistance in PCOS can be secondary to a postbinding defect in insulin receptor signaling pathways, and elevated insulin levels may have gonadotropin-augmenting effects on ovarian function.

Another theory put forth in the past was that perhaps women with PCOS produce insulin that is slightly defective in some way, so again the body would need to work harder and overproduce in order to help the insulin "unlock" the doors to the cells and get blood sugar into them.

Whatever the reason, it is thought that women with PCOS overproduce insulin, and all that excess insulin floating around the body then causes hormonal disturbances and imbalances, including the production of excess androgens. These excess androgens then interfere with ovulation, reproduction, and can cause hirsutism, acne, and other issues.

One argument against insulin resistance as a root cause in PCOS is that not all women with PCOS are documented as having IR. Sources generally estimate that about 50-70% of women with PCOS have IR. However, perhaps PCOS women without overt IR may simply have a more subtle presentation of it, one that is on the IR spectrum but does not quite reach "official" diagnostic levels.

Other Possible Causes

Some have suggested that PCOS may be an autoimmune condition. However, it may simply be that autoimmune issues (like Hashimoto's hypothyroidism) are a side effect or coincidental co-morbidity of PCOS. This is an area that deserves further research.

Research suggests that whatever the base cause, genetics plays a strong role in PCOS.

Because the symptoms of PCOS tend to run in families, the syndrome is probably caused, at least in part, by a change (or mutation) in one or more genes. However, because of the complex pattern of how PCOS symptoms change from one generation to the next, gene mutations are probably not the only cause of PCOS.

It is likely that PCOS results from a combination of factors, including genes and environmental features. Recent research conducted in animal models also suggests that, in some cases, the origins of PCOS may occur in the womb.

This idea that both genetic and environmental influences are needed for full expression of the syndrome is growing in acceptance, despite not knowing exactly which genes are involved:

Familial clustering of PCOS has been consistently reported suggesting that genetic factors play a role in the development of the syndrome although PCOS cases do not exhibit a clear pattern of Mendelian inheritance. It is now well established that PCOS represents a complex trait similar to type-2 diabetes and obesity, and that both inherited and environmental factors contribute to the PCOS pathogenesis.

Some researchers combine all the theories together, proposing that both genetics and environment play a role, and that the most severe cases of PCOS have both an insulin resistance source and an androgen production or metabolism problem. From http://emedicine.medscape.com/article/256806-overview:

PCOS is, in some cases, a familial disorder, but the genetic basis of the syndrome remains unclear. Studies of family members with PCOS indicate that an autosomal dominant mode of inheritance, with premature male pattern baldness as the male phenotype, may occur. Full expression of the syndrome may require an insulin abnormality and a defect in androgen biosynthesis, but no gene (or genes) has been identified.

Conclusion

What causes PCOS is a chicken-and-egg question at this point. No one is sure what the underlying first cause is, and untangling that is a long and difficult process.

The two most likely candidates are a disturbance in androgen production/metabolism, or insulin resistance due to problems with insulin production, receptors, or signaling.

Another interesting possibility is an underlying disturbance in the HPO axis, which then creates the other disturbances commonly found with PCOS.

Familial clustering suggests a strong genetic component to PCOS, but some researchers believe that both genetic and environmental influences must combine for the full syndrome to express. Other possibilities include autoimmune issues.

At this point, most of our treatments for PCOS are aimed at lessening the symptoms and hopefully mitigating future risk for complications. In other words, they are "band-aid" approaches.

What we really need is to understand is the root cause of PCOS; only then can we begin to develop truly effective treatments.

References

*As always, trigger warning for many of these links and references. Most contain lots of weight loss promotion or assumptions about the habits of people of size.

General Information on PCOS and Possible Causes

http://emedicine.medscape.com/article/256806-overview - overview of PCOS, info on HPO axis issues, discussion of possible causes and treatments
http://medical-dictionary.thefreedictionary.com/insulin+resistance - general information on insulin resistance
http://www.nichd.nih.gov/publications/pubs/upload/PCOS_booklet.pdf - guide from the government with general information on PCOS, and some info on genetic links. Has a good explanation of the HPO axis and the hormonal cascade that results in ovulation
http://humupd.oxfordjournals.org/content/11/4/357.full - a study, based on animal models, theorizing that excessive androgen exposure while in utero may pre-program the body to PCOS-like symptoms
http://www.endocrine-abstracts.org/ea/0026/ea0026s28.1.htm - possible environmental influences on the development of PCOS
http://jcem.endojournals.org/content/91/6/2100.full.pdf - Dutch twin study that found a strong genetic component in PCOS; "a polygenic multifactorial model involving multiple genes is most likely"

Articles on Insulin Resistance and PCOS

Am J Physiol Endocrinol Metab. 2001 Aug;281(2):E392-9. Defects in insulin receptor signaling in vivo in the polycystic ovary syndrome (PCOS). Dunaif A, Wu X, Lee A, Diamanti-Kandarakis E. PMID: 11440917

Women with polycystic ovary syndrome (PCOS) are insulin resistant secondary to a postbinding defect in insulin signaling. Sequential euglycemic glucose clamp studies at 40 and 400 mU. m(-2). min(-1) insulin doses with serial skeletal muscle biopsies were performed in PCOS and age-, weight-, and ethnicity-matched control women...We conclude that there is a physiologically relevant defect in insulin receptor signaling in PCOS that is independent of obesity and type 2 diabetes mellitus.

Am J Physiol Endocrinol Metab. 2005 May;288(5):E1047-54. Insulin resistance in the skeletal muscle of women with PCOS involves intrinsic and acquired defects in insulin signaling. Corbould A, Kim YB, Youngren JF, Pender C, Kahn BB, Lee A, Dunaif A. PMID: 15613682

Insulin resistance in polycystic ovary syndrome (PCOS) is due to a postbinding defect in signaling that persists in cultured skin fibroblasts and is associated with constitutive serine phosphorylation of the insulin receptor (IR). Cultured skeletal muscle from obese women with PCOS and age- and body mass index-matched control women (n = 10/group) was studied to determine whether signaling defects observed in this tissue in vivo were intrinsic or acquired...In summary, decreased insulin-stimulated glucose uptake in PCOS skeletal muscle in vivo is an acquired defect. Nevertheless, there are intrinsic abnormalities in glucose transport and insulin signaling in myotubes from affected women, including increased phosphorylation of IRS-1 Ser312, that may confer increased susceptibility to insulin resistance-inducing factors in the in vivo environment. These abnormalities differ from those reported in other insulin resistant states consistent with the hypothesis that PCOS is a genetically unique disorder conferring an increased risk for type 2 diabetes.

Diabet Med. 2011 Sep 26. doi: 10.1111/j.1464-5491.2011.03460.x. Current perspectives of insulin resistance and polycystic ovary syndrome. Pauli JM, Raja-Khan N, Wu X, Legro RS. PMID: 21950959

"Insulin resistance likely plays a central pathogenic role in polycystic ovary syndrome and may explain the pleiotropic presentation and involvement of multiple organ systems. Insulin resistance in the skeletal muscle of women with polycystic ovary syndrome involves both intrinsic and acquired defects in insulin signalling. The cellular insulin resistance in polycystic ovary syndrome has been further shown to involve a novel post-binding defect in insulin signal transduction...Insulin resistance is linked to polycystic ovary syndrome. Further study of lifestyle and pharmacologic interventions that reduce insulin resistance, such as metformin, are needed to demonstrate that they are effective in reducing the risk of diabetes, endometrial abnormalities and cardiovascular disease events in women with polycystic ovary syndrome."

PCOS: Testing and Diagnosis

2011-10-04T10:38:00.000-07:00

We have begun a new series on the blog about PCOS, or Polycystic Ovarian Syndrome. This is an abnormal hormonal and metabolic condition that is common in women of size.

Today let's talk about the testing and diagnosis of it.

Previously we discussed the definition and symptoms of PCOS, and how it often presents in women.

In the future, we'll discuss its treatment, how it affects fertility, pregnancy, and breastfeeding, and its effects on menopause and aging.

But for now, let's talk about how to find out whether or not you have it, including what type of care providers to see, what type of tests are usually ordered and why, what they mean, and diagnostic debates.

Diagnostic Criteria for PCOS

PCOS is a somewhat controversial diagnosis. Unfortunately, this means that not everyone agrees on the best way to diagnose it. For example, 3 different organizations have come up with 3 slightly different criteria for diagnosis over the past 20+ years.

In 1990, the NIH came up with the following criteria to diagnose PCOS:

Clinical and/or biochemical hyperandrogenism
Chronic anovulation
Exclusion of related disorders

In 2003, the Rotterdam criteria were developed. To be diagnosed via the Rotterdam criteria, a woman must have two of the following three manifestations:

Irregular or absent ovulation
Elevated levels of androgenic hormones
Enlarged ovaries containing at least 12 follicles each.

To make things even more confusing, the Androgen Excess Society recently came up with its own criteria too:

presence of hyperandrogenism (clinical and/or biochemical)
ovarian dysfunction (oligo-anovulation and/or polycystic ovaries)
exclusion of related disorders

Fortunately, all of these different criteria have some similarities. They are all basically looking for:

evidence of disturbed menstrual cycles/ovulation, and
evidence of elevated androgens (male hormones)

These seem to be the key items in deciding whether someone has PCOS or not. However, since these all occur on a wide spectrum of severity, the milder presentations of these symptoms can still make the diagnosis ambiguous at times.

Variations in Interpreting the Criteria

Some doctors are more strict in their interpretation of these criteria than others. For example, some doctors consider women to have PCOS only if they have few, if any, menstrual periods. Others consider any menstrual cycle longer than about 35-40 days to be abnormal and indicative of PCOS. Still others require 8 or fewer menstrual cycles per year (which translates to cycles of about 45+ days each).

Some doctors require that you demonstrate impaired fertility, and believe that any woman who has had children without fertility treatment could not have PCOS. Others believe that some women can have spontaneous pregnancies yet still demonstrate other symptoms strongly enough that PCOS is likely.

Some doctors require lab work confirming that a woman has elevated androgen levels, while others will take physical symptoms of androgen excess (facial hair, thinning scalp hair, cystic acne) as enough proof of elevated androgens.

Ovarian follicles/cysts are now considered a particularly "soft" diagnostic requirement, since some women have cystic ovaries but no other symptoms of PCOS, while others clearly are symptomatic of PCOS yet do not have cystic ovaries. However, polycystic ovaries are a possible marker, so many providers still look for them, just not as "the" defining symptom of the syndrome.

The Rotterdam criteria is controversial because only 2 of the 3 criteria are needed for diagnosis, and "irregular" as well as "chronic" anovulation is considered. This opens up official diagnostic recognition to more borderline cases, such as:

...women with hyperandrogenism and polycystic ovaries but normal ovulatory function, and women with ovulatory dysfunction and polycystic ovaries but no clinical or biochemical evidence of hyperandrogenism (Azziz 2004, see references below).

In other words, it significantly widens the scope of who could be considered to have PCOS, while other criteria defines it more narrowly.

At this point, authorities are still debating the "best" criteria and who should and should not be considered to have PCOS. Diagnostic criteria are still evolving.

Testing for PCOS: An Overview

There is no simple test to measure conclusively whether or not someone has PCOS. Therefore, in order to try and diagnose PCOS, care providers usually:

do a medical history to elicit menstual and fertility history
do a physical exam to check for clinical evidence of symptoms
do blood work to check various hormone levels
do an ultrasound of the ovaries (not always done by every care provider)

PCOS tends to be a diagnosis of exclusion, meaning that other conditions that might cause similar symptoms must be ruled out before one can conclude that PCOS is present. Among others, these conditions might include:

hypothyroidism (may exist independently or concurrently with PCOS)
non-classical (late onset) congenital adrenal hyperplasia
hyperprolactinemia (some women with PCOS have mild hyperprolactinemia)
adrenal or pituitary tumor
Cushing's Syndrome

Blood work in particular is helpful in ruling out these other conditions, since many present with similar symptoms to PCOS (hirsutism, mentrual irregularities, weight gain, etc.).

Getting Diagnosed: What Type of Care Provider?

A difficult question for many women is what type of provider to see when trying to decide whether or not they have PCOS. Unfortunately, there is no definitive answer to this question.

Women with PCOS have been diagnosed and treated by Family Doctors, GPs (General Practitioners), Internists, Midwives, OBs, Endocrinologists, and Reproductive Endocrinologists. Occasionally PCOS is caught by a Dermatologist or other specialist, but the patient is usually referred back to another specialty for further testing and treatment of non-skin symptoms.

Many women see their family doctor or GP (General Practitioner) for testing. The advantage of this is that the family doctor or GP tends to be less fat-phobic on average than specialists, and tend to listen better at appointments. However, not every family doctor or GP has very deep or thorough knowledge about PCOS and its proper testing and treatment.

Midwives and OBs are often the main source of diagnosis because PCOS problems usually reach critical levels around menstrual, fertility, gynecologic, or obstetric issues. Therefore, many midwives and OBs catch previously undiagnosed cases of PCOS when women come in for birth control advice, infertility care, maternity care, or with questions about skipped periods.

The advantage of midwives is that they are generally more size-friendly than doctors, have training in gynecological issues, listen better, and take more time with you in appointments. However, not all are well-versed in such a specialized condition as PCOS.

Because of fertility issues, many women get their diagnosis of PCOS from OBs. And while many OBs are reasonably knowledgeable about PCOS, there's still a lot of misinformation about it even in the obstetric community. Furthermore, there's a lot of fat-phobia in medical training and in obstetrics in particular; this means that some OBs have a hard time treating a woman of size with compassion and objectivity.

Because PCOS is a hormonal and metabolic issue at heart, endocrinologists should be the go-to specialty for diagnosis of PCOS. They tend to be more well-versed in PCOS than the average care provider (especially the Reproductive Endocrinologist sub-specialty), and they have an intimate knowledge of the pros and cons of various tests and treatments for PCOS. Unfortunately, endocrinologists have an extremely well-deserved reputation for fat-phobia, and that can make it hard for fat people to get good care from them.

So what do you do?

Making a Decision

When deciding which type of care provider to see about testing for PCOS, there are a couple of important questions to ask. First, how important is it to you to avoid even the merest whiff of size bias; second, are you in a rush to have a child; and third, what do you know about the size-friendliness of various providers in your area?

If you can stand the possibility of size bias, an endocrinologist really is best place to start your diagnostic journey. They are the ones with the specialized knowledge about PCOS, the ones who know which tests to order to rule out other possibilities, and they are more inclined to treat PCOS with insulin-sensitizing agents instead of just birth control pills, which may be important for long-term health.

On the other hand, if you already have a good relationship with an OB, that can be a decent place to start. Just keep good track of the tests ordered so you can make sure the right tests are being used and the right follow-ups are being done.

If size-friendliness is really important to you and you don't know the weight-neutrality status of any local providers, the midwife or the family practice doctor may be a good place to start instead. Of course, title alone does not guarantee size-friendliness, but generally speaking you'll probably encounter less fat-phobia on average in these two groups.

If fertility is an issue for you or you are wanting to get started on having a child ASAP, go straight to a Reproductive Endocrinologist. They are the specialists in PCOS and tend to get you into treatment (and hopefully, fertile enough for pregnancy) a lot sooner than the other specialties.

Of course, the best option is finding a size-friendly/weight-neutral provider, whatever their title. Although it's certainly not comprehensive for all locations, remember the Fat-Friendly Health Professionals List, which has peer-to-peer recommendations for size-friendly providers in the USA, and this similar list for Australia.

Preparing for an Diagnostic Appointment

A little prep work can go a long way towards making your diagnostic appointment faster and easier.

First, write down a list of your symptoms so you don't forget to mention anything. Include both obvious PCOS symptoms and those that may not have anything to do with PCOS, since things like headaches and vision problems can sometimes be associated with conditions that can mimic PCOS (like a benign pituitary tumor). Have your list on a separate sheet of paper so you can just give it to the care provider, which will speed up the appointment considerably.

Also document your cycles for as long as you can ─ their length, regularity, and severity ─ and any concerns you have about them (length, heaviness, spotting, severe cramps, etc.) Make an extra copy of this for the care provider.

If you have been doing fertility charting, bring those charts along to document whether/when you ovulate, how long you bleed, etc. Some providers will take these seriously, some will not, but they are definitely worth doing because they are a very powerful tool for figuring out what's going on. Be sure to keep copies for yourself for future reference. (See the website or the book, Taking Charge of Your Fertility, for more information on how to do fertility charting.)

A list of your current medications (if any) and dosages would also be important, since medications can sometimes affect lab results or have side effects that mimic PCOS symptoms.

It's a good idea to have a list of questions you want to ask. You may not always have time to ask everything at the first appointment because care providers are usually on very strict schedules, but it can help you prioritize your questions so the most important ones get asked first, and help you remember your other questions for follow-up appointments.

Before your appointment, be sure to gather all your pertinent medical records together. If you have records of previous labs or other tests, have these sent ahead of time to the new provider, or bring copies of them yourself. This can save a lot of time and duplication. Some tests will need to be repeated, regardless, but it's useful to have a record of your results over time. Many people create a simple spread sheet, documenting pertinent tests over time, which can be useful in tracking any fluctuations in your condition.

The timing of your appointment may be important. If you want the care provider to order hormonal tests, the best time for such tests is shortly after your period. Avoid the time around mid-cycle or ovulation, as this can affect hormone levels.

Make your appointment for first thing in the morning, while you are in a fasting state. Certain tests need to have a 12-hour fast before doing the test. If you arrive fasting, you can do all these tests on the same day and won't have to come back to do them another day.

If you are concerned about finding a size-friendly provider, call or write a letter ahead of time that asks if the provider can provide size-friendly care, and whether they are able to respect your decision to avoid focusing on weight loss. Or bring an advocate with you, someone who can take notes and help you speak up for yourself if the provider starts focusing only on weight. (Obviously, this person should be someone you would be comfortable with hearing a discussion of intimate topics like menstrual periods, birth control, etc., and someone who shares your beliefs about size acceptance.)

Really thinking through your appointment ahead of time and even rehearsing what you are going to say can be very helpful if you have are nervous about the appointment or have had bad experiences with care providers in the past. Don't forget that YOU are the employer and the care provider is your employee; you always have the right to decline tests or treatment you do not want, or to terminate the relationship if needed.

The Diagnostic Appointment

At your diagnostic appointment, your care provider should take a medical history, do a physical exam, and start the blood work needed for diagnosis.

More than one appointment may be needed to do do follow-up lab work. Afterwards, there should be an appointment to discuss the results of testing and to develop a treatment plan, if needed.

Medical History

The first thing a care provider should do when trying to diagnose PCOS is to take a medical history This exam should look something like this:

A health care professional...will ask questions about your menstrual history, including how old you were when you started your period, how long your cycles are, how much time passes between cycles, and how much you bleed in a cycle. Your health care provider will also ask about your reproductive history, including any pregnancies, miscarriages, or abortions you have had, and birth control methods you are using or have used in the past. He or she will also ask about menstrual irregularities in other members of your family.

In addition, the woman should be asked about the presence of other symptoms, like hirsutism, acne, scalp hair loss, sebaceous cysts, or nipple discharge. Although sometimes neglected, a weight history should be taken as well, looking for episodes of unexplained weight gain, difficulty losing weight, etc.

Family medical history should also be asked about. There is a strong genetic predisposition in some families towards PCOS, with frequent history of irregular menstrual cycles, hirsutism, diabetes, hypertension, or infertility among females, and premature balding and the metabolic syndrome among males. A history of any of these in your family would increase the suspicion index for PCOS.

Finally, the care provider should review any medications you have been on. Although rare, some medications can cause PCOS-like symptoms to occur (for example, chronic use of corticosteroids, or anti-seizure medications like Depakote). In addition, certain medications (like birth control pills) can alter lab results on certain tests (like SHBG levels).

Physical Exam

Next, a physical exam should be done. The care provider will look for hirsutism (excess facial or body hair, especially along the midline of your body), acanthosis nigricans (dark, velvety patches of skin on the thighs, armpits, or back of the neck), skin tags, central obesity, etc. Be sure to tell your care provider about any symptoms you have, including thinning hair etc., so they are sure to take it into account.

Height, weight, and blood pressure will be checked. This is one occasion when it is appropriate for a woman to be weighed, if only to document "obesity" as a possible symptom ─ but preferably in a weight-neutral and non-judgmental manner. Blood pressure should be checked using an appropriately-sized cuff (a too-small cuff will falsely elevate blood pressure).

A pelvic exam is also common, with care providers checking to see if your ovaries seem enlarged or swollen. They will also check to see if your genitalia look normal (an unusual appearance can indicate adrenal hyperplasia) and whether there are any pelvic masses.

Some doctors order an ultrasound to check for the presence of ovarian cysts. Because of hormonal imbalances, women with PCOS often have difficulty finishing ovulation. This half-finished ovulation causes many small cysts all over the ovaries, giving it a characteristic "string of pearls" appearance, as in the picture at the top of this post. One diagnostic criteria for polycystic ovaries is 12 or more cysts of 2-9 mm size (but some practices have different guidelines).

Remember, even if the ovaries do appear normal, the absence of ovarian cysts does not mean that you don’t have PCOS. Not everyone with PCOS has ovarian cysts.

Bloodwork

Multiple blood tests are usually run. Lab work may include some or all of the following:

Follicle Stimulating Hormone (FSH)
Luteinizing Hormone (LH)
Total or Free testosterone
Other androgenic hormones like Androstenedione
DHEA-S (dehydroepiandrosterone sulfate)
Sex Hormone Binding Globulin (SHBG)
Cortisol (and/or other adrenal hormones)
Prolactin
TSH (Thyroid Stimulating Hormone)
Free T3 and free T4 levels
Thyroid antibody tests
Anti-Mullerian Hormone (AMH)
17-hydroxyprogesterone (17OH-progesterone)

In addition, most doctors will order labs for standard measures of health, like cholesterol, triglycerides, blood sugar, etc. Some will do these in conjunction with PCOS bloodwork; some will wait and only do these after PCOS has been confirmed.

Some providers add liver function tests to be sure you are not experiencing Non-Alcoholic Fatty Liver Disease (NAFLD). Others may also check levels of certain nutrients, like Vitamin D or iron, because these are often abnormal in women with PCOS.

Be aware that certain tests (like LH and FSH) need to be taken on certain days of your cycle in order to be interpreted correctly. Unfortunately, not all doctors are aware of this, and may test on inappropriate days. If you have been told you do not have PCOS but were tested without regard to day of your cycle, these tests should be repeated before ruling out PCOS.

Interpreting Results

Results on these tests can be confusing and it's very important that you get help interpreting them. Remember to ask for exact results, not just whether your levels are "normal" or "abnormal," because borderline results may be meaningful in some contexts.

It's best to ask for a copy of all lab results; this is your information and you have every right to it. That way you can take those results to another provider if needed, and you can also track your results over time.

The following are a few test results that seem common in women with PCOS, according to various resources online. However, tests results are always subject to interpretation and our understanding of these things changes over time, so be sure to discuss your results with a healthcare professional.

A high testosterone level is common with PCOS but is not an absolute requirement for it. Very high levels may indicate an adrenal tumor instead
The DHEA-S level is often mildly elevated in PCOS, but this could also indicate an adrenal issue instead of PCOS (or in addition to it)
Androstenedione is often somewhat elevated
Sex Hormone Binding Globulin (SHBG) is usually low in PCOS, and seems to be associated with insulin resistance and/or hypothyroidism
A high prolactin level probably indicates hyperprolactinemia; some women with PCOS have mildly elevated prolactin levels, but very high levels are usually due to hyperprolactinemia
FSH levels are usually low to normal, but LH levels are often high. A level of 2:1 or more in the LH:FSH ratio is usually considered diagnostic for PCOS
Lipid profiles are often abnormal; a common pattern is borderline to high LDL, low HDL, and high triglycerides
TSH is often borderline high but not quite high enough for diagnosis under the criteria some doctors use. However, some sources believe that any TSH over 2 or so should be treated

Blood Sugar and Insulin Testing

Blood sugar tests are a standard part of testing because of the high rate of diabetes associated with PCOS. However, there are several ways to test this.

Some providers use fasting glucose only, but some resources feel strongly that this misses some cases of diabetes. They think PCOS women should be tested using a 2-hour Oral Glucose Tolerance Test (OGTT) instead. However, many women with PCOS have a tendency towards reactive hypoglycemia (unstable blood sugar due to strong insulin surges) and find the OGTT makes them feel quite ill. Therefore which test should be used is a judgment call.

Checking insulin levels is controversial. Just about everyone agrees that insulin resistance is a major issue in PCOS, but how best to measure it is debated. The gold standard test is hyperinsulinemic/euglycemic clamp testing, but this is usually too cumbersome and expensive for anything but research studies.

Some doctors test fasting insulin levels, because this is an easy lab draw. Anything over 20 μU/mL is considered abnormal, but critics point out that the "normal" range for this is quite wide, and contend that levels much lower than 20 show insulin issues. Some prefer to use a fasting glucose/insulin ratio instead, looking for a ratio of less than 4.5, but critics point out that this ratio has not been validated using clamp techniques.

One technique that has been validated by clamp techniques is Homeostatic Model Assessment (HOMA) testing, which takes fasting glucose and fasting insulin and divides them by a constant. However, this (like all of the fasting tests) is criticized as missing many cases of insulin resistance, because many PCOS women have relatively normal levels while fasting but abnormal insulin and glucose levels in response to food intake. Therefore, many doctors prefer to order a 2-hour post-prandial insulin test or OGTT, where your insulin response is tested after eating food or the standardized glucose liquid.

Here is what one provider wrote about testing insulin levels. Other providers may find these criteria too liberal:

Fasting insulin is often elevated in PCOS. Some doctors don't order this test because the normal range (0-20) is so wide. However, we find that results greater than 9 indicate insulin resistance...Some doctors may also order a 2-hour post-prandial insulin test, along with a 2-hour post-prandial glucose test. For the post-prandial insulin, results over 25 or 30 may indicate insulin resistance.

On the other hand, some doctors don't test insulin levels at all, either because they believe that insulin levels are not as relevant as hormonal levels, or because they don't believe that insulin testing is that meaningful. They may go by clinical signs of insulin resistance instead (acanthosis nigricans, skin tags, abdominal obesity, etc.).

Other Tests

As previously noted, doctors used to do a vaginal ultrasound to see if the ovaries had a "string of pearls" look, studded with cysts. Now however, many providers do not consider cystic ovaries to be a very good measure of PCOS. Some will test for it, some will not.

Providers are becoming more aware that sleep apnea is fairly common among women with PCOS, so some have added sleep testing to the list of additional tests ordered after someone is diagnosed with PCOS. Some research suggests that testing for sleep apnea is underutilized in women with PCOS and should be expanded, especially for those with more severe insulin resistance/glucose intolerance.

If your preliminary labs or symptoms suggest that you may have non-classical congenital adrenal hyperplasia instead of PCOS, your doctor may want to order additional labs, including an ACTH (adrenocorticotropic hormone) stimulation test.

If your providers suspect Cushing's syndrome, they may order a 24-hour urine test for free cortisol, or suggest an overnight dexamethasone suppression test.

If you are someone who has no or very few menstrual cycles (less than 6 per year), care providers may also recommend an endometrial biopsy. Because of a hormonal imbalance, many women with PCOS do not completely slough off the endometrial lining that has built up during a cycle. Over time, this endometrial lining can build up ("endometrial hyperplasia") and cause problems.

The risk for endometrial cancer is signficantly higher in women who do not have at least six periods per year, so if you have missed a lot of periods, it's very important that you get checked periodically for this.

Changes in Diagnosis Protocols Over The Years

The protocol for diagnosing PCOS has changed over the years and remains controversial.

As noted, some doctors insist on an ultrasound of the ovaries, while others consider that outdated or unnecessary. Some demand biochemical evidence of abnormal hormone levels (i.e., abnormalities on lab tests), while others are content to rely on physical manifestations alone. Some run elaborate blood tests to rule out a wide variety of other possible conditions, while others are willing to move to a trial of meds and/or lifestyle more quickly based on symptoms alone. Much depends on the care provider you see.

Doctors used to look for a specific imbalance of hormones ─ specifically a ratio of luteinizing hormone (LH) to follicle-stimulating hormone (FSH) of more than 3:1. Some doctors still look for elevated LH levels (although not necessarily a 3:1 ratio anymore), while others do not test these levels at all.

Some doctors believe that insulin resistance (either through an insulin receptor defect or through post-receptor signaling) is the base cause of PCOS, while others believe that while common, not every woman with PCOS actually demonstrates insulin resistance. So while some doctors place a strong emphasis on insulin levels in PCOS, others don't.

A recent addition to testing protocols seems to be "anti-mullerian" hormone levels:

Anti Mullerian Hormone (AMH) or Mullerian Inhibiting Substance is a special protein released by cells that are involved with the growth of an egg follicle each month. AMH levels correlate with the number of antral follicles found on the ovary each month; the higher the antral follicle count, the higher the AMH levels. Because women with PCOS typically have high numbers of antral follicles, high AMH levels are often seen as well.

Apparently some doctors are considering AMH a classic marker for the disease now and want this tested; others do not routinely use it.

Obviously, diagnosing PCOS is an evolving science. Tests that were routine 10-15 years ago are not always considered necessary now, and new tests have emerged that didn't exist previously. This is why it's important to keep up on the latest testing protocols and the pros and cons of each test.

Conclusion

It should be apparent that diagnosing PCOS is not an easy task. Different protocols for testing and diagnosis exist, standards change over time, and the highly variable nature of PCOS makes diagnosis less than clear at times. A great deal is left up to the individual judgment of the care provider.

Therefore, it is not uncommon for women to hear different results from different doctors, with one saying she doesn't have PCOS, and another saying she does. Some women with PCOS go for years before they are diagnosed, even with obvious symptoms. Subtle cases may take even longer.

Persistence is very important in trying to figure out whether or not you have PCOS. Don't give up easily, and be prepared to see more than one care provider when trying to find answers. Most women go through multiple care providers and tests before they are able to definitively determine that they do or don't have PCOS.

Sometimes a person's results may be "borderline normal" and that can still be significant, especially if there is a cluster of similarly "borderline" results on other tests. As Dr. Samuel Thatcher says in PolyCystic Ovarian Syndrome: The Hidden Epidemic:

Virtually all patients with PCOS will have at least some subtle laboratory abnormalities. The reported results may be on the upper limits of the normal range, showing only a tendency rather than a discrete abnormality. Often a pattern will emerge only after considering a group of tests together, rather than as a result of a single test value.

Furthermore, don't accept a care provider's pronouncement about your PCOS status without looking at your own lab results, comparing them to what is considered "normal," and researching the results online. Because knowledge about PCOS is evolving, not all providers are "up" on the best ways to test it or changes in diagnostic protocols. Furthermore, anti-fat bias can lead some to dismiss or explain away results that clearly merit a second look. It's important to double-check their work.

Remember that diagnosis can be a judgment call at times, so you should plan to be actively involved in the process. Don't be a passive recipient of care; get copies of all of your lab results, create a spread sheet to track them over time, research PCOS online from a variety of sources, ask lots of questions, and don't be afraid to switch care providers if you don't feel your questions and concerns are being addressed adequately.

Don't forget that there is a spectrum of PCOS severity. Even if you do not officially "qualify" as having PCOS, it may still be something you should learn about because some cases are too "mild" for official diagnosis but may still benefit from treatment or careful monitoring of health indices.

Finally, if you don't have PCOS, don't be afraid to push for further testing to explain your symptoms. PCOS is not the only thing that can be wrong in people of size, and treatment for rarer conditions like Cushing's Syndrome or adrenal tumors can make a tremendous difference in your health. Explore all the possibilities.

Diagnosing PCOS is not an exact science, but finding answers can be critical for your long-term health status.

References

Finding Size-Friendly Care Providers

http://www.cat-and-dragon.com/stef/fat/ffp.html - United States, with a few entries for Canada, Ireland, Australia, and New Zealand
http://allbodies.wordpress.com/ - Australia
http://www.cfah.org/hbns/PreparedPatient/Prepared-Patient-Vol1-Issue9.cfm - finding size-friendly care and how to re-direct doctors with "fat distraction" (seeing and focusing only on weight)
http://www.cat-and-dragon.com/stef/fat/ffp1.html#friendly - What is size-friendly care, and how to submit suggestions to the Fat-Friendly Health Professionals List
http://www.cat-and-dragon.com/stef/fat/ffp2.html - Tips on finding size-friendly care and how to approach an appointment beforehand

General Resources for PCOS Support

General Information about PCOS

http://www.womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.cfm - general information about PCOS
http://www.inciid.org/faq.php?cat=complementarymed&id=2 - INCIID FAQ on PCOS

Book Resources

PolyCystic Ovarian Syndrome: The Hidden Epidemic - Samuel S. Thatcher MD, PhD
Androgen Disorders in Women: The Most Neglected Hormone Problem - Theresa Cheung
Taking Charge of Your Fertility - Toni Weschler; www.tcoyf.com

Information about PCOS Testing and Diagnosis

http://pcos.about.com/od/callingyourdoctor/f/bloodtests.htm - info on blood tests and PCOS
http://labtestsonline.org/understanding/conditions/pcos?start=2 - even more extensive blood tests
http://www.isletsofhope.com/diabetes/disorders/polycystic_ovarian_syndrome_pcos_1.html - info on PCOS and on diagnostic controversies
http://www.medscape.com/viewarticle/438597_3 - a guide to doctors on evaluating PCOS

Interpreting Lab Results - What is Normal?

http://www.fertilityplus.org/faq/hormonelevels.html - discusses what "normal" is on various lab tests commonly used in fertility testing
http://www.medscape.com/viewarticle/438597_3 - has some information about interpreting lab results in tests often used for PCOS diagnosis

Specific PCOS Diagnosis Studies

Reprod Biomed Online. 2004 Jun;8(6):644-8. PCOS: a diagnostic challenge. Azziz R. PMID: 15169578

"Useful research and diagnostic criteria for PCOS arose from a conference in 1990, whereby PCOS could be defined by: (i) clinical and/or biochemical hyperandrogenism, (ii) chronic anovulation, and (iii) exclusion of related disorders. The presence of "polycystic ovaries" was not included in this definition, which created significant concern since many women with PCOS have polycystic ovaries on ultrasound, and conversely women with this ovarian morphology have a higher prevalence of androgen excess and insulin resistance. More recently, at an expert meeting in 2003 in Rotterdam, it was recommended that PCOS be defined when at least two of the following three features were present, after exclusion of other aetiologies: (i) oligo- or anovulation, (ii) clinical and/or biochemical hyperandrogenism, or (iii) polycystic ovaries. These newer criteria effectively create additional phenotypes of PCOS (e.g. women with hyperandrogenism and polycystic ovaries but normal ovulatory function, and women with ovulatory dysfunction and polycystic ovaries but no clinical or biochemical evidence of hyperandrogenism). It remains to be demonstrated whether these phenotypes actually represent patients with PCOS. Nonetheless, the trend towards the use of uniform diagnostic criteria in studies of PCOS will increase the comparability and potentially the value of published research."

Fertil Steril. 2009 Feb;91(2):456-88. Epub 2008 Oct 23. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, Janssen OE, Legro RS, Norman RJ, Taylor AE, Witchel SF; Task Force on the Phenotype of the Polycystic Ovary Syndrome of The Androgen Excess and PCOS Society. PMID: 18950759

"Based on the available data, it is the view of the AE-PCOS Society Task Force that PCOS should be defined by the presence of hyperandrogenism (clinical and/or biochemical), ovarian dysfunction (oligo-anovulation and/or polycystic ovaries), and the exclusion of related disorders. However, a minority considered the possibility that there may be forms of PCOS without overt evidence of hyperandrogenism, but recognized that more data are required before validating this supposition. Finally, the Task Force recognized and fully expects that the definition of this syndrome will evolve over time to incorporate new research findings."

Can Fam Physician. 2007 Jun;53(6):1042-7, 1041. Polycystic ovary syndrome: validated questionnaire for use in diagnosis. Pedersen SD, Brar S, Faris P, Corenblum B. PMID: 17872783 Free full text at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1949220/?tool=pmcentrez

"Development of a questionnaire to help diagnose PCOS. "A history of infrequent menses, hirsutism, obesity, and acne were strongly predictive of a diagnosis of PCOS, whereas a history of failed pregnancy attempts was not useful. A history of nipple discharge outside of pregnancy strongly predicted no diagnosis of PCOS. We constructed a 4-item questionnaire for use in diagnosis of PCOS; the questionnaire yielded a sensitivity of 85% and a specificity of 85% on multivariate logistic regression and a sensitivity of 77% and a specificity of 94% using the 4-item questionnaire."

Hum Reprod. 2004 Jan;19(1):41-7. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. PMID: 14688154

"Since the 1990 NIH-sponsored conference on polycystic ovary syndrome (PCOS), it has become appreciated that the syndrome encompasses a broader spectrum of signs and symptoms of ovarian dysfunction than those defined by the original diagnostic criteria. The 2003 Rotterdam consensus workshop concluded that PCOS is a syndrome of ovarian dysfunction along with the cardinal features hyperandrogenism and polycystic ovary (PCO) morphology. PCOS remains a syndrome and, as such, no single diagnostic criterion (such as hyperandrogenism or PCO) is sufficient for clinical diagnosis. Its clinical manifestations may include: menstrual irregularities, signs of androgen excess, and obesity. Insulin resistance and elevated serum LH levels are also common features in PCOS. PCOS is associated with an increased risk of type 2 diabetes and cardiovascular events."

Clin Endocrinol (Oxf). 2005 Mar;62(3):289-95. Polycystic ovarian syndrome: marked differences between endocrinologists and gynaecologistsin diagnosis and management. Cussons AJ et al. PMID: 15730409

"...A mailed questionnaire containing a hypothetical patient's case history with varying presentations--oligomenorrhoea, hirsutism, infertility and obesity--was sent to Australian clinical endocrinologists and gynaecologists in teaching hospitals and private practice...Endocrinologists regarded androgenization (81%) and menstrual irregularity (70%) as essential diagnostic criteria, whereas gynaecologists required polycystic ovaries (61%), androgenization (59%), menstrual irregularity (47%) and an elevated LH/FSH ratio (47%) (all P-values less than 0.001). In investigation, gynaecologists were more likely to request ovarian ultrasound (91%vs. 44%, P less than 0.001) and endocrinologists more likely to measure adrenal androgens (80% vs. 58%, P less than 0.001) and lipids (67%vs. 34%, P less than 0.001). Gynaecologists were less likely to assess glucose homeostasis but more likely to use a glucose tolerance test to do so. Diet and exercise were chosen by most respondents as first-line treatment for all presentations. However, endocrinologists were more likely to use insulin sensitizers, particularly metformin, for these indications. In particular, for infertility, endocrinologists favoured metformin treatment whereas gynaecologists recommended clomiphene. CONCLUSIONS: There is a lack of consensus between endocrinologists and gynaecologists in the definition, diagnosis and treatment of PCOS. As a consequence, women may receive a different diagnosis or treatment depending on the type of specialist consulted.

Clin Endocrinol (Oxf). 2008 Jul;69(1):52-60. The evaluation of metabolic parameters and insulin sensitivity for a more robust diagnosis of thepolycystic ovary syndrome. Amato MC, et al. PMID: 18034780

PCOS diagnostic criteria [National Institute of Health (NIH), Rotterdam Consensus (ROT), Androgen Excess Society (AES)] are unanimous recognized. We aimed to assess in women with suspected PCOS whether the application of the three diagnostic criteria differently characterizes the metabolic profile and insulin sensitivity. Two hundred and four women with suspected PCOS in comparison to a group of normal, age-matched Sicilian women (N = 34) without signs of metabolic syndrome...The prevalence of PCOS was 51% according to NIH, 83% to ROT and 70.6% to AES, and only 100 patients were qualified simultaneously under these three criteria.

PCOS: How Does PCOS Affect Women?

2011-09-29T01:39:00.000-07:00

Poster by Amanda Kohn, www.implementingdesignism.org

We've just started a new series on Polycystic Ovarian Syndrome (PCOS) in honor of September, PCOS Awareness Month.

In the first entry, we discussed its definition and symptoms, and why PCOS is somewhat controversial in fat-acceptance circles.

In this post, we're going to describe how PCOS affects women, how if often develops and presents, and how it can affect women down the line as they age.

In later posts, we will discuss testing and diagnostic issues, its effects on fertility, pregnancy and breastfeeding, and give more details on how it affects menopause and aging.

Readers should know that we'll be doing this mostly from a size-acceptance point of view, rather than the usual "you have to diet" point of view present in most PCOS websites. Weight loss will be discussed as only one possible treatment ─ with an honest look at the potential benefits and drawbacks of weight loss as treatment ─ but other alternatives will be emphasized.

What Does PCOS Look Like?

As one article puts it, "Polycystic ovarian syndrome is a clinically, histologically, and biochemically heterogeneous condition." Translation: PCOS presents in each woman a little bit differently.

The Classic Presentation

The classic case is a woman who:

is quite heavy
has very irregular or totally absent periods
has facial hair growth on her upper lip and/or chin (and often elsewhere)
has dark patches of skin in various places on her body
has skin issues, with cystic acne well into adulthood
struggles with infertility issues
has trouble getting or staying pregnant
probably gained a lot of unexplained weight at some point
has struggled with her weight ever since, often yo-yoing up and down chronically
has slightly enlarged ovaries with many cysts on them
has health issues such as glucose intolerance/diabetes, high cholesterol, and blood pressure concerns

Women like these are fairly easy to diagnose with PCOS because their symptoms are so clear. The main markers looked for in PCOS (irregular periods, physical signs of too many androgens, and cystic ovaries) are obviously present.

Sadly, however, even women with obvious cases of PCOS often go undiagnosed. It's very common for these women to see many doctors for their symptoms before someone realizes what is going on. Too often, her weight is blamed as the source of her symptoms and all other possibilities are ignored. Sometimes, the woman figures out her PCOS status on her own from the internet or a friend, and only then can she get the testing she needs.

Although Stein and Leventhal first "discovered" this condition in 1935, it has taken a long time for doctors to really take it seriously. It is only in the last 10-20 years or so that awareness of it has really taken off. Even so, many providers still just want to blame the woman for being fat and not look deeper for other possible mechanisms. They view fatness as the cause, and refuse to believe fatness could merely be a symptom of a deeper problem instead.

Variations in Presentation

Of course, not every case of PCOS follows this classic profile. If it's hard for women with very obvious symptoms of PCOS to get diagnosed, imagine how hard it is for someone whose case is more subtle!

For example, not all women with PCOS are fat. Some women with PCOS are average-sized ─ but still have very strong issues with insulin resistance and fertility (like actress Emma Thompson). It is unknown why some women with PCOS have weight issues and others do not. It's probably not due to differences in eating patterns but rather to some unknown metabolic difference. Whatever the reason, it can be hard for the skinny woman with PCOS to get diagnosed.

But generally speaking, a lot of women with PCOS have very significant weight issues. The usual statistic quoted is that 50-60% of women with PCOS are "obese" ─ but because many doctors underdiagnose the condition in fat women, it's possible the percentage may actually be higher.

Hirsutism is extremely common in women with PCOS (some sites estimate it is present in 70-80%), but not every woman experiences it. Some have only a little body hair and no facial hair, yet because doctors really look for facial hair as a sign of androgen excess, women without this classic sign are sometimes told they don't have PCOS, despite other pertinent symptoms.

Thinning scalp hair is much less common than hirsutism as a symptom, but is often overlooked as a potential sign of androgen excess. And because many women find ways to cover this up or are too embarrassed to mention it to their doctors, it is underused as a symptom for diagnosis.

Fertility is another symptom that can vary. Many women with PCOS have significant fertility issues, yet not all do. For some, it's closely tied to co-morbidities like hypothyroidism; if they treat that, fertility is less of an issue. Sometimes, fertility for PCOS women is okay in younger years but declines over time, so some only develop infertility later on as the condition progresses.

Although some doctors consider fertility issues central to the diagnosis of PCOS, some women show clear skin and metabolic symptoms of PCOS yet never have problems conceiving or maintaining a pregnancy. Still, they may benefit greatly from treatment of the metabolic issues of PCOS, so many providers have begun to expand their definition of PCOS beyond its past focus on infertility.

Clearly, the heterogeneous nature of PCOS means that there are many gray areas in diagnosis.

How Does PCOS Develop?

PCOS tends to run in families, and can come from either side of the family (mother or father). If lots of women in your family struggle with their weight, have irregular periods, diabetes, hypertension, and other common consequences of PCOS, the chances that you might have PCOS are higher. Or if the males in your family have lots of premature balding and metabolic syndrome, this may also indicate a familial predisposition towards PCOS. However, it takes a combination of genetic and environmental factors for PCOS to manifest itself, so not every family member is always affected. Family history is a clue, not an automatic indication.

Often PCOS first presents a few years after periods begin (although some with very severe cases may show symptoms like acanthosis nigricans and significant fatness even well before puberty). Typically, menstruation begins normally, but within a few years, periods begin to skip here and there. Eventually, menstrual issues worsen; some develop long cycles (more than 35 days), some develop erratic cycles, some skip whole sets of periods, while the most severe cases stop cycling completely.

At some point most women with PCOS develop secondary skin-related symptoms like hirsutism, thinning hair, or significant acne (especially boil-like sebaceous cysts under the skin). These can be quite distressing socially, so this is often when these women begin to seek medical answers, often without success.

It's not unusual for many woman with PCOS to experience a significant, unexplainable weight gain ─ with no change in habits ─ in her late teens or twenties (and sometimes later too); this is often despite similar caloric intakes as women without PCOS. As one website notes:

Approximately 60% of women with PCOS have weight management issues which can lead to obesity with only normal caloric intake. Energy in the form of glucose (food) is stored right away as fat, instead of being made available for other functions within the body. This can lead to chronic fatigue and undernourishment, despite the fact that there is adequate food intake and even an appearance of overnourishment.

Those with the most severe cases of PCOS may become supersized because of a vicious cycle of insulin resistance and yo-yo dieting. High levels of insulin in the blood lead to weight gain, so women diet to lose weight, only to regain to an even higher weight as the body's metabolism reasserts itself. Concurrent hypothyroidism can greatly exacerbate this gain. Some women develop eating disorders (compulsive overeating or binge eating disorder) as a result of years of dieting, and many experience very strong carb cravings due to hyperinsulinemia. Thus it can be difficult to untie the influence of insulin issues, yo-yo dieting, eating issues, and disease co-morbidities on weight, but there is often a synergistic effect of all of them together.

In some women, PCOS symptoms accelerate and worsen with time. Those with the most severe cases usually have great difficulty conceiving, often develop diabetes and/or high blood pressure in their twenties or thirties, struggle with sleep apnea and other complications, and become "super obese" at some point from a combination of factors. Co-morbidities like sleep apnea are common, and as a result, many get so desperate they resort to bariatric surgery to try and mitigate their symptoms, regain some mobility, or have a chance at pregnancy.

In other women, the symptoms stay relatively mild throughout their life or progress much more slowly. Often, normal blood sugar and blood pressure are maintained for years, and the only signs of metabolic derangement are subtle differences in labs; a tendency towards weight gain, reactive hypoglycemia and/or gestational diabetes; and skin symptoms (like sebaceous cysts, acne, or thinning hair). However, the symptoms often worsen significantly around or just after menopause, and many are diagnosed with issues like hypertension or diabetes at this time.

A lot depends on the woman's pancreatic beta-cell function. If the pancreas is capable of producing enough insulin to compensate for the insulin resistance in the body, blood sugar remains in the normal range. In those whose beta cell function is compromised, the body is not able to produce enough insulin to overcome the insulin resistance and diabetes develops early.

Some women think that as long as their blood sugar and blood pressure is fine and they don't want children, PCOS is not a big worry. However, just because blood sugar is normal doesn't mean the body is okay; it still has to deal with the side effects of too much insulin and too many androgens in the body. And over the years, this can take a toll, even on those with milder cases.

How Does PCOS Affect Long-Term Health?

As women with PCOS age, the metabolic consequences of years of hyperinsulinemia and excess androgens begin to accrue.

Although you might expect that PCOS symptoms would disappear after the ovaries shut down at menopause, many find that some symptoms actually worsen after menopause instead.

Hirsutism on the face may get even worse, and the hair may thin even more than before. Acne doesn't go away, and problems like sleep apnea may worsen.

Chronic overproduction of insulin also tends to lead to hypertension over time, and it exhausts the pancreas. Therefore even those who had relatively good pancreatic beta cell function and normal blood sugar and blood pressure for years tend to develop diabetes and hypertension as they age.

This means that PCOS has life-long health implications. The tendency towards blood sugar, insulin resistance, blood pressure issues and perhaps an increased rate of clotting means that vascular disease often develops. Many women with PCOS develop heart disease, and may also have a tendency towards stroke.

High levels of androgens may also be connected to the development of non-alcoholic fatty liver disease (NAFLD). One study found more than three times the risk for NAFLD in women with PCOS, even after controlling for BMI and other factors. Higher androgen levels are thought to be the culprit but this still remains speculative.

Cancer is another potential risk. If the woman does not cycle regularly, the uterine lining can build up and endometrial hyperplasia (overgrowth) can develop. Unchecked, this can lead to a higher chance of endometrial cancer. PCOS is clearly associated with a higher risk for endometrial cancer.

Is PCOS connected to the development of other cancers? Some research ties PCOS to a higher rate of ovarian cancer, but research on this is contradictory and unclear. In addition, insulin resistance and hyperinsulinemia may be tied to a stronger risk for colo-rectal cancer. Many researchers speculate that the relatively high rate of unopposed estrogen in PCOS may increase the risk for postmenopausal breast cancer too, although nothing has really been proven at this point.

The connection between PCOS and these different cancers is still being untangled and answers are far from definitive, but clearly there is an increased risk for endometrial cancer at the very least.

Psychological Effects of PCOS

Psychologically, PCOS is a brutal condition.

In its most severe form, a woman is stripped of nearly everything that society sees as womanly, a "theft of womanhood," as some sources call it. She probably is very fat, balding, has a mustache or other facial hair, has acne and body tags, doesn't cycle regularly, and has difficulty having children. She is seen as sexually unattractive, epitomizes the image of the "ugly" woman in our society, and is the object of many jokes and much derision in the media. Is it any wonder some women find this condition incredibly demoralizing?

Adding into this is the lack of understanding around PCOS as a condition. Even when you have an official diagnosis, some friends and family consider it a dubious finding. In their view, you're just looking for an excuse for being fat, crying about how your "bad metabolism" causes your obesity, instead of taking responsibility for your supposedly poor eating. They roll their eyes or accuse you of closet binge-eating instead.

Doctors often don't believe you if you tell them you eat normally either, thinking you must be in denial about your eating, or that you are too uneducated about "proper" nutrition to really understand how to eat healthy. Furthermore, the shopping cart and food intake of a woman with PCOS are under continuous scrutiny and criticism, adding constant stress to daily life. The "obese" woman with PCOS always feels on the defensive about her food or exercise habits.

This disbelief about their experiences and the burden of constant surveillance often takes a considerable toll on PCOS women's self-esteem. And for those who truly do struggle with eating disorders after years of dieting, the shame around dealing with that on top of PCOS can be overwhelming.

Some resources list depression and/or anxiety as one of the possible side-effects of PCOS. It's not clear whether the tendency towards this has a physiological basis, is merely a by-product of mistreatment by society, or is a combination of both. Since many women with PCOS tend to have borderline hypothyroidism (and depression can be a symptom of hypothyroidism), there may be a good argument for a physiological basis. On the other hand, the harassment that women with PCOS receive in society could cause anyone to feel anxious or depressed. Or there may be a synergistic effect between the two.

Either way, there is no doubt that it is very difficult to be a woman with PCOS in our society. Yet the situation is not without hope. Many women with PCOS are able to develop a sense of peace with their body, an inner strength to help overcome the biases superimposed by society. Women with PCOS can be strong and assertive and body-positive; it isn't easy with negative messages all around, but it is possible..

Conclusions

Clearly, PCOS is a difficult condition that deserves to be taken more seriously.

Knowledge about PCOS is evolving, but not all care providers are familiar with this condition. Some don't believe it really exists, some believe it's far more about being fat than about metabolic abnormalities, some apply too-stringent diagnostic criteria, while others diagnose it without ruling out other possibilities first. Therefore it can be very difficult to get an accurate diagnosis.

Unfortunately, there's no one "official" test you can take that will tell you that you do or don't have PCOS. Often diagnosis is less than clear-cut because of co-morbidities and the variability of symptoms.

So even if you've been told that you don't have PCOS, you might simply be at a less severe level on the PCOS spectrum ─ not severe enough for diagnosis, but not clearly "normal" either. Or you might have a phenotype that your doctor did not recognize. Or you might have something that looks like PCOS but is actually caused by another condition. Or you might not have PCOS at all.

Sometimes the answers are elusive and what you are told will vary from provider to provider. This is why it's important to keep asking questions, keep searching for a really good provider, always get copies of your labs and tests, and keep a file of them over the years. It's not uncommon for it to take multiple visits for this condition to get recognized, for testing to be done (or interpreted) incorrectly, or for an optimal treatment plan to be developed. Persistence and good record-keeping is very important.

In the past, some doctors viewed PCOS as a concern only if you wanted to get pregnant, but research indicates it has significant life-long health implications, including higher rates of diabetes, hypertension, heart disease, and some types of cancer later in life.

Because of its implications for long-term health, PCOS deserves to be taken seriously, regardless of the patient's age or whether or not they want children. It needs to be seen as a life-long condition, not just a concern tied to pregnancy.

In the next entry in this series on PCOS, we will talk more about the testing and diagnosis of PCOS. Stay tuned for further entries about PCOS in the future as well.

References

*Trigger Warning: Not all resources/studies listed here are size-friendly but are listed because they may have some other valuable information or resources. Approach with caution.

General Information and Support for Women with PCOS

www.pcosupport.org
www.soulcysters.com

Genetics and PCOS

http://www.ncbi.nlm.nih.gov/pubmed/16728382 - interaction of genetics and environmental factors in PCOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1820621/?tool=pmcentrez - familial clustering in PCOS

PCOS and Dietary Intake

Int J Obes Relat Metab Disord. 2004 Aug;28(8):1026-32. Dietary intake, physical activity, and obesity in women with polycystic ovary syndrome. Wright CE, Zborowski JV, Talbott EO, McHugh-Pemu K, Youk A. PMID: 15159768

"Although women with PCOS had a higher BMI than control women, an overall comparison of women with and without PCOS showed no significant difference in dietary intake. However, stratification by BMI revealed that lean women with PCOS reported significantly lower energy intake than lean women without PCOS. CONCLUSION: Differences in dietary intake and physical activity alone are not sufficient to explain differences in weight between women with and without PCOS."

Gynecol Endocrinol. 2011 May 24. Diet composition and physical activity in overweight and obese premenopausal women with or without polycystic ovary syndrome. Alvarez-Blasco F, et al. PMID: 21609197

"We aimed to find differences in diet and life-style that might contribute to the development of PCOS among overweight or obese premenopausal women. We compared diet composition and self-reported physical activity among 22 patients with PCOS and 59 women without androgen excess recruited from a total of 113 consecutive premenopausal women reporting for management of weight excess. After correcting for a difference in age between women with PCOS and controls, there were no overall statistical significant differences between them in the total caloric intake, in the intake of macro- and micro-nutrients, caffeine, fiber and alcohol, in the proportion of women exercising regularly, or in the number of hours of exercise per week. The proportion of fat in the diets of the overweight and obese women irrespective of PCOS was well-above current recommendations, yet this excessive fat intake occurred at the expense of monounsaturated fatty acids mostly. In conclusion, diet composition and physical activity were apparently not decisive for the development of PCOS among overweight and obese premenopausal women."

PCOS and Psychological Effects

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3108690/?tool=pubmed - Psychological effects of PCOS, as well as possible long-term health risks
http://www.ncbi.nlm.nih.gov/pubmed/18672334 - Depression, anxiety, and suicide attempts among women with PCOS
http://www.ncbi.nlm.nih.gov/pubmed/19454378 - Depression and affective disorders in PCOS
http://www.ncbi.nlm.nih.gov/pubmed/18249398 - Depression, mood disorders, and binge eating disorder in women with PCOS over time

PCOS and Long-Term Health Risks

http://pcos.about.com/od/relatedconditions/a/endocancer.htm - PCOS and risk of endometrial cancer
http://humupd.oxfordjournals.org/content/7/6/522.full.pdf - PCOS and cancer risks
http://www.ncbi.nlm.nih.gov/pubmed/20111659 - PCOS and cardiovascular risks
http://www.ncbi.nlm.nih.gov/pubmed/21335359 - PCOS, heart disease, and strokes
http://www.ncbi.nlm.nih.gov/pubmed/21251033 - PCOS and non-alcoholic fatty liver disease

PCOS: A Condition Every Person of Size Should Know About

2011-09-20T01:42:00.000-07:00

Today, we start a new periodic series about PCOS (PolyCystic Ovarian Syndrome) in honor of PCOS Awareness Month.

This is an extremely important topic to understand when discussing pregnancy, birth, and breastfeeding in women of size ─ or even just general health in women of size ─ yet it's surprising how many "obese" people (and even medical professionals) are still under-informed about it.

PCOS can be a bit of a controversial topic in Fat-Acceptance communities because weight-loss regimens are so closely associated with it. PCOS support groups teem with women desperately trying to lose weight, and informational sites about PCOS almost always push weight loss. It can be very difficult to get information about PCOS without being bombarded with a weight loss agenda, yet many women in the FA community are desperately in need of weight-neutral information and support for PCOS.

Another problem is that PCOS can be very difficult to diagnose. As a result, many fat women with PCOS are erroneously told they don't have it, despite symptoms suggestive of it, while others are spuriously told they do have it, simply because they are fat. Often, PCOS exists with significant co-morbidities (like hypothyroidism, adrenal issues, and other hormonal imbalances) that muddy the diagnostic waters even further.

As a result, some in the fat-acceptance world dismiss the concept of PCOS entirely, or simply throw up their hands and give up trying to figure it all out. And honestly, figuring out PCOS can be incredibly complex, even for those well-read in the subject.

Yet many women of size are affected by PCOS, whether they know it or not. And it doesn't just impact fertility and pregnancy; PCOS has life-long health implications.

It doesn't matter whether you intend to have children or not, or whether you are even of childbearing age; PCOS is still relevant to every fat person because of its other health implications. Truly, this a condition every person of size should know about.

For those who don't know that much about PCOS, this series will be a primer about it. First we'll start with a description of it and its most common symtpoms. Next, we'll segue to a quick discussion of how it typically presents, and then to its testing and diagnosis. Eventually, we'll consider possible causes and controversies; its impact on fertility, pregnancy, and birth; its impact on breastfeeding; treatment options; and implications for menopause and long-term health.

For the sake of readability, we'll break this series up into a number of different posts; some may be periodic instead of continuous due to time constraints.

Hopefully, the series will serve as an introduction to basics about PCOS, a gateway to other information sources on the topic, and a weight-neutral "safe" space to discuss PCOS concerns in a weight-centric PCOS world.

What is PCOS?

First, a definition. From Wikipedia's entry on PCOS:

Polycystic Ovary Syndrome (PCOS) is one of the most common female endocrine disorders affecting approximately 5%-10% of women of reproductive age (12–45 years old) and is thought to be one of the leading causes of female infertility.

The principal features are obesity, anovulation (resulting in irregular menstruation) or amenorrhea, acne, and excessive amounts or effects of androgenic (masculinizing) hormones. The symptoms and severity of the syndrome vary greatly among women. While the causes are unknown, insulin resistance, diabetes, and obesity are all strongly correlated with PCOS

According to one study, "PCOS can be viewed as a heterogeneous androgen excess disorder with varying degrees of gonadotropic and metabolic abnormalities." Translated: PCOS is a disorder that presents differently in different people (heterogeneous), usually presents with abnormally high levels of "male" hormones (androgens), resulting in problems that impact the reproductive system and metabolism (gonadotropic and metabolic abnormalities).

PCOS was first identified in 1935 by doctors Stein and Leventhal, so for a while it was referred to as "Stein-Leventhal Syndrome." It later became known as "Polycystic Ovarian Syndrome" because many women with this syndrome had multiple cysts on the ovaries. This occurs in PCOS when egg follicles form and start to mature, but hormonal imbalances keep the follicles from fully developing and releasing. These incompletely developed follicles (cysts) on the ovaries have a characteristic "string of pearls" appearance, and the prevalence of these cysts gave the syndrome its name.

However, the name "PCOS" makes it sound like the problem begins in the ovaries, when instead it results from a complex endocrine disorder, affecting many systems of the body. The accumulation of multiple cysts on the ovaries is merely one of the many possible side effects of the condition, yet the name has stubbornly stuck because it is catchy and easy to remember.

So although the moniker of Polycystic Ovarian Syndrome is a less-than-ideal description of the condition, it remains the name most commonly used for it and that will probably never change.

Symptoms of PCOS

Symptom lists for PCOS vary quite a bit from source to source. Some only list a few symptoms, while others list everything but the kitchen sink.

The following seem to be the most common symptoms associated with PCOS, but be aware that the validity of some are debated:

Menstrual Cycle Difficulties

irregular/long, or completely absent menstrual cycles (oligomenorrhea or amenorrhea)
periods that can be abnormal when they do occur (excessively heavy or just spotting)

High androgen ("male hormone") levels, like testosterone

excessive facial and/or body hair (hirsutism)
cystic acne and/or a tendency to boil-like sores (sebaceous cysts) under the skin
male-pattern balding on the head (alopecia androgenetica)

Cystic ovaries in some women (but not all)

difficulty ovulating, which causes the irregular or long menstrual cycles
total absence of ovulation in some, intermittent ovulation or "weak" ovulation in others

Problems with Insulin Resistance

strong insulin resistance (difficulty utilizing the insulin present)
high insulin levels to compensate for the insulin resistance (hyperinsulinemia)
obesity and/or history of unexplained significant weight gain

great difficulty losing weight and keeping it off

dark velvety patches of skin on the armpits, neck, or groin (acanthosis nigricans )
body tags/little flaps of excess skin on the body (acrochordons)

Hormonal Disturbances and Fertility Issues

low progesterone levels and estrogen dominance
difficulty achieving pregnancy because of hormone imbalances
higher rate of miscarriage early in pregnancy

Metabolic abnormalities

higher rates of glucose intolerance and diabetes, often at early ages
high "bad" cholesterol (LDL), and low "good" cholesterol (HDL)
high triglycerides

Long-Term Health Issues

a tendency towards high blood pressure at some point
higher rates of heart disease later in life

higher rates of endometrial cancer later in life, possibly other cancers too

possibly a tendency towards depression and/or anxiety

This is not an exclusive list of symptoms; there may be others as well, including a tendency towards Irritable Bowel Syndrome (IBS) and/or gluten intolerance, Chronic Fatigue Syndrome, Sleep Apnea, Fibromyalgia, or auto-immune diseases like Hashimoto's Thyroiditis. However, because PCOS is often accompanied by co-morbidities (other conditions), it is not always easy to distinguish what is a symptom of PCOS itself versus a symptom of a co-morbidity, and the validity of these other conditions as tied to PCOS has been questioned.

PCOS is a Syndrome

It's very important to remember that PCOS is a syndrome, which means that not every symptom must be present in order to diagnose the condition.

The two symptoms considered most important to this condition include evidence of menstrual difficulties (past or present), and symptoms of androgen excess (like hirsutism, thinning hair, or cystic acne).

These are often accompanied by signs of insulin resistance (like acanthosis nigricans, body tags, or metabolic abnormalities like high blood sugar or high cholesterol).

Cystic ovaries used to be considered central to the diagnosis of PCOS, but are now considered less definitive, as some women with cystic ovaries do not have other symptoms of PCOS, and some women with strong symptoms of androgen excess do not present with cystic ovaries. Therefore, the importance of cystic ovaries is debated, but is still used at times.

Remember also that PCOS symptoms cross a wide spectrum of type and severity. This is why its diagnosis is so difficult at times.

Menstrual issues are very common in PCOS but vary in scope. Some women skip only an occasional period, while others skip constantly (or have few or no periods). Some instead have long cycles (more than 35 days); some have excessively heavy periods, or may have spotting in the middle of a cycle.

Some women have great difficulty getting pregnant, some have difficulty staying pregnant, while still others do not have trouble with either fertility or miscarriage. Some providers consider anovulation and fertility issues absolutely central to the diagnosis of PCOS (and will not diagnose it without these), while other providers have a more flexible definition.

The majority of women with PCOS have issues with hirsutism (extra facial or body hair), but not all do. Some have lots of skin issues (including cystic acne, sebaceous cysts/boils, and/or hair loss), some don't. Many women with PCOS tend to be heavy, but not all are.

So as you can see, PCOS is not a clear-cut, black-and-white condition, and its presentation varies a lot.

Generally speaking, the more symptoms you have, the more severe the PCOS ─ but not always. And women without a lot of symptoms may still have PCOS.

Many symptomatic women are never diagnosed because they don't have enough symptoms or the right symptoms to meet official diagnostic criteria. Many have difficulty getting diagnosed because of the relative lack of understanding about PCOS in the medical community, or the tendency to blame every problem of fat women on obesity alone. As a result, PCOS is often underdiagnosed.

On the other hand, sometimes care providers use PCOS as a catch-all diagnosis for every problem a fat woman experiences, without bothering to investigate other possible causes. So PCOS has the unenviable distinction of being both underdiagnosed and overdiagnosed.

In women with a lot of symptoms, the diagnosis is pretty clear, but in women without severe, classic symptoms, the diagnosis can be much harder to make. This is part of what makes this condition so difficult.

Below you can find a few links to further resources about PCOS; feel free to share more in the comments section. Next time, we'll discuss how PCOS often presents in women and what it means to them. Then we'll talk about its testing, diagnosis and controversies. Later, we'll cover how it affects pregnancy, breastfeeding, menopause, and long-term health.

(Note: Some women with PCOS are very well-read about the condition. Feel free to add in clarifications, further resources, links, and other thoughts about PCOS in the comments section. I encourage everyone to do their own research about PCOS, but remember that information about PCOS can vary greatly from source to source, and not all experts agree on its cause, presentation, or best treatment.)

Links to Further Information About PCOS*

General Information About PCOS

*Remember, these resources are generally not weight-neutral.

More on Unexplained Weight Gain

2011-09-16T16:56:00.000-07:00

Thank you to everyone who replied to my question about your experiences with unexplained weight gain....i.e. weight gain that can't be tied to specific outside causes like a side effect of meds or birth control, etc.

I personally experienced a major unexplained gain like this, and I was curious to see how many others had also experienced it. Thank you for sharing your stories both in comments and in private emails; it's reassuring to know that many others have experienced it too.

Honestly, I thought our stories would all be very much alike, and for the most part there are common threads running through many of them. But while there were some similarities, there were also differences at times. So my speculation is that while most stories are related to a couple of common paths, there can also be other paths to major weight gain, paths we have yet to discover.

But first, let's talk about the most common paths.

Possible Causes of Unexplained Weight Gain

The most common causes of unexplained weight gain seem to be two-fold:

Hypothyroidism (overt or borderline)
Polycystic Ovarian Syndrome (PCOS).

(Since I'm about to start a new series about PCOS, I was particularly interested to hear about weight gains associated with that one.)

These two causes seemed to be echoed in the stories sent in. Most gains in the stories were later discovered to be associated with hypothyroidism or PCOS. Many of the stories showed how hard it can be to get major gains diagnosed and taken seriously.

But it's not always clear what causes a major weight gain; it's not always due to PCOS and/or hypothyroidism. Best guess is that there is a complex interplay of hormones and metabolic issues, many of which we probably haven't discovered yet. The stories people shared made it clear that sometimes there seems to be something else going on too, something we can't put our finger on.
My top suspects for unexplained weight gain include adrenal issues, insulin-related issues, and perhaps pituitary issues (since that's the "master gland" that controls everything else). But who knows? The only thing that is clear is that we have much more to learn about the issue.

According to online sources, other possibilities for unexplained weight gain include:

Cushing's Syndrome (body produces too much cortisol, which tends to cause weight gain)
Adrenal or Ovarian Tumors (disturb hormone production, which can cause weight gain)
Food Allergies/Sensitivities (some people experience weight gain with food sensitivities)
Lack of Sleep/Sleep Apena (can cause biochemical changes which impact weight)
Stress (chronic stress increases cortisol production, which tends to cause weight gain)
Blood Sugar Issues (reactive hypoglycemia, unstable blood sugar, and too much insulin)

It's also worth noting that many medications do result in unexplained weight gain, including some forms of birth control, corticosteroids, antidepressants, anti-seizure meds, heartburn meds, migraine meds, blood pressure meds, and certain diabetes meds. And of course, fluid retention due to edema, kidney issues, or congestive heart failure can be serious source of very sudden gains.

But what we are most concerned about here is unexplained weight gain ─ weight gain not clearly related to outside causes like medications, quitting smoking, weight gain left after pregnancy, obvious disease, or poor eating.

My Story

For me personally, my unexplained gain was probably due to a combination of both hypothyroidism and PCOS at once. Although always considered "overweight" by the charts, I was never that heavy as a child or young teen ─ I was more of an "in-betweenie." But that changed a few years after puberty.

My large weight gain started in my mid-to-late teens, just after my PCOS symptoms began appearing, and worsened as my PCOS symptoms worsened. By my early 20s, I had gained a total of about 100 lbs. or so, despite everything I did to try to reverse it. That's one heck of a weight gain, and that was despite working extremely hard to try and reverse it.

Yet I couldn't get a doctor to take any possible metabolic causes seriously. When I pushed for testing to see what was going on, I was told I was "looking for an excuse for being fat." Although I eventually got tested and we found "borderline" thyroid levels, no doctors were willing to treat that, despite my overwhelming symptoms of hypothyroidism. And not one doctor ever mentioned the possibility of PCOS to me.

However, they were all happy to give me diet advice, telling me to do things I was already doing. When I would try to tell them that, they wouldn't believe me. So I quit going to doctors to try and figure it out.

Eventually, the weight gain slowed and stopped, then went into a pattern of fluctuating. In time, I finally found a doctor willing to do a trial of thyroid meds, based on my symptoms and my "borderline" labs. Oh, I felt soooo much better! After that, my weight was so much more stable. And treating the hypothyroidism seemed to lessen many of my PCOS symptoms. Truly, it was a "win win" situation for me, even though it didn't make me skinny.

Of course, TSH diagnostic levels are controversial; different providers use different scales to diagnose with, and many care providers do not believe in treating "borderline" levels. However, I'm a total believer in treating borderline numbers in symptomatic patients now. In my opinion, too many people have been helped by it to ignore this possibility. [Always ask for your exact results and the scale they used to diagnose you, and then research the controversy over diagnostic ranges; don't just accept the care provider's word about your thyroid levels being "normal."]

But that's my story. It has many things in common with other people's stories, including the difficulty in getting care providers to consider such gains as anything other than sloth and gluttony. But of course, not every story is exactly the same, and your causes may be different than mine.

Conclusion

Large, unexplained weight gains are certainly not unusual among people of size. Most often, they seem to be connected to borderline cases of hypothyroidism and/or PCOS, but there are probably other causes as well, things doctors fail to consider or don't yet understand.

We need to get doctors to take unexplained gains more seriously so we stop blaming everything on over-indulgence, laziness, and eating disorders. Those are relevant sometimes, but there has to be some sort of physiologic basis for why some people are so susceptible to gains that are unresponsive to normal nutrition and exercise.

I also wish we could offer better advice to those who experience this distressing situation. All I can say to someone experiencing it is that you are not alone, there are others who have experienced large gains like this, and it doesn't mean you are a "bad" or "weak" person. It's just a mystery that we don't understand yet.

Although the understandable response to a large weight gain is to try to lose that weight, it's important to remember that this may not work for you long-term if the underlying cause of the gain isn't discovered and addressed. That's why I encourage people to continue to push to investigate possible physiological causes, and to not be afraid to switch to a new care provider if the old one is unresponsive to your concerns.

And remember that the diet you use to lose the extra gain may end up resulting in even more gain in the long run, even when you only do "healthy" diets and exercise and "lifestyle changes." All too often, the things you do to deal with the gain only end up amplifying the gain. How is that advantageous?

So it's not easy to know what the best thing to do is in the face of an unexplained gain like this ─ live with the gain as is and put up with the discomforts and potential health risks, or try to lose the extra weight and risk ending up heavier than you began.

I would not presume to tell you what you should or should not do with your own body; you do what seems to make sense for your body and your situation. However, I would point out that weight loss is not your only choice.

A gain doesn't have to mean giving up and being unhealthy; nor does it mean you have to punish your body through starvation, mutilating surgery, or other extreme measures. You can focus on being healthy in nutrition and exercise without centering that on weight loss. That way, you pursue better health while avoiding worsening the situation via a lot of yo-yoing.

Unexplained weight gains are so mysterious and frustrating. They are not universal among people of size, but they are pretty common. Wouldn't it be nice if care providers would actually believe us when we say something is wrong, or better yet, focus on trying to understand these gains better so we could prevent them in the first place?

Have You Had Unexplained Weight Gain?

2011-09-02T13:08:00.000-07:00

Have you experienced a significant, unexplained weight gain during your life?

In other words, a weight gain clearly not related to other possible causes like poor eating habits, a side effect of a medication, aftereffect of a major diet, an eating disorder, etc.? If so, would you be willing to share your story?

I have a reason for asking but don't want to explain yet. I just would like to hear your stories; what age you were, how much weight you gained, what you tried to do about it, etc. Be brief, but include whatever you think is most relevant to your situation.

Share your stories in the comments section here, or if you prefer to share more privately, send me an email with a brief summary of your story.

Thank you for sharing. More on why I'm asking this later.

Fat Cat Walking

2011-08-23T12:25:00.000-07:00

This is our new cat, "Cheese." We adopted him about six months ago after somebody dumped him on a road in our area. He's a very affectionate dude and has been a nice addition to the family so far.

He doesn't really meow, but does this funny little sound, halfway between a purr and a chirp, and it's pretty comical. He is a bit of a "herder" ─ he likes to herd his humans to where he thinks they ought to be, and he'll just keep chirping at you until you do what he wants.

He's particularly taken with me; he loves to sit half-on and half-off my lap, purring up a storm, when I sit down on the couch. If he's not on my lap, he often settles between my feet on the floor. If I don't pet him enough to suit him, he bonks me with his head quite forcefully (way harder than your average cat) until I give him his proper due. He's my little head-banger.

His worst trait is that he sheds like crazy; I've never had a cat that shed so profusely. And of course, he sheds white hair, and I tend to wear dark colors. So there's way more laundry to do with him around, but in return I get a new lap/foot-warmer and #1 fan.

Alas, he does bring a difficult dilemma with him. More on that in a moment.

Pet Peeve #1, 462

Before I get to the point of my post, let me just air a pet peeve first, okay? Let's talk about abandoning animals. This is one of my many pet peeves, especially as someone who has worked in animal resuce before.

People sometimes take an animal they no longer want and dump them out on a country road (instead of surrendering them to a shelter) because they think that the animal will live a better life, dining on country mice and gophers and sleeping in a nice warm haystack.

They couldn't be more wrong. These animals usually die an awful death, ripped apart by a pack of coyotes, dying of starvation because they are domesticated and don't know how to hunt well enough to sustain themselves, or hit by a car as they try to find their way back home. Abandoning an animal in the country is a terribly cruel thing to do, and it's beyond me how people can do something so awful to a family pet. If you really can't keep your animal, far better to take them to a shelter where they at least have a decent chance at being adopted by a new family, or could get a quick and comparatively merciful death if they aren't adopted.

Fortunately, Cheese was one of the very few abandoned animals who got lucky. Some passing bikers saw him being tossed out of the car (the driver didn't even stop), and they kept him from running out into the road until I came by a little later and stopped to help. I took him to the shelter to be scanned for a microchip (there was none). When the mandatory hold time was over, we went back and adopted him because we felt so sorry for him.

I don't know why this animal was abandoned. He doesn't have any bad habits (like peeing on the rug, scratching up furniture, or spraying) that we've seen so far. He was not starving, his coat was clean, and he had a pretty collar with rhinestones on it. He was well-socialized and usually very friendly, although we've noticed that he can be scared of men sometimes (he's getting over this now).

My best guess is that his family fell on hard economic times and couldn't afford him anymore. Or perhaps someone gave him away to another family that didn't treat him well and finally abandoned him. Or a ticked-off neighbor or abusive person took someone's beloved cat and abandoned him in order to be cruel. But really, we'll never know for sure why he was abandoned.

It's frustrating. He's such a good kitty, and he did not deserve to be thrown away like that. He was just lucky we happened by at the right time and could take him in.

However, the hard reality is that we can't take in every animal that gets abandoned. We had the ability to adopt this one, but there's a limit on how many we can afford. This one had never had dental work, so last week it cost us nearly $1000 to get his teeth taken care of; a bunch of them had to be extracted because they were in such bad shape. I'm pissed that his former owners just cost me a thousand bucks that I needed for other things─ but I couldn't let this kitty suffer with abscessed teeth.

So my first point is, please don't ever abandon your animals out in the country because you think you're doing them a favor. You're NOT, trust me. A very few lucky animals do get adopted by country families, but there are limits on how many can be taken in by most families. And most abandoned animals don't even make it to a farm; most die painful, cruel deaths long before they could find a new family to love them. They have a much better chance at a shelter, either for a more merciful death or hopefully, for a new family to love them. And there are no-kill shelters available in many areas.

Augh. I just hate it when people abandon their animals!

The Fat Cat Talk

Okay, back to the topic. Why am I writing about my new cat on a fat-acceptance blog? Well, we took him recently for a check-up and to talk about his teeth, and got the "fat cat" talk as well.

This is always a difficult moment for anyone in the FA movement. How do you respond when you get "the talk" from a vet?

Usually I just tune such things out. I make non-committal noises and change the subject and move on. It's not worth arguing over with the vet. Mind, I do make an effort to give my kitties reasonably healthy food in reasonable amounts, and they get plenty of exercise catching mice on my property. Beyond that, I'm not going to get too worked up about their weight most of the time.

However, with this cat, I do think there's some reason for concern. He doesn't have any particular conditions (no, he's not diabetic), but in the six months we've had him, he's gained 3 lbs. He was no lightweight when we got him; he already weighed 12 lbs. Now he's up to 15 lbs. That's no small gain for a small animal in just a few months of time, and that concerned us all. I don't care if he's a big guy already, but I'm doubtful that a big further gain would be healthy for him, and especially over such a short period of time. So what to do?

Clearly, he is a much bigger kitty than our other kitties (who were adopted from the Humane Society a few years ago). One of them is your average-sized kitty, around 7-8 lbs. That makes Cheese nearly twice as big. The second kitty came to us "overweight" but has since stabilized at a lower weight that seems to suit her, slightly higher than what the vets want but which seems reasonable to us.

But this new kitty? He's HUGE. Clearly a much bigger kitty in natural build than the others; he has huge paws and a large frame. It's hard to see it from the picture above, but he really is a BIG guy. To expect him to weigh the same as my small-framed kitty is ridiculous. On the other hand, to be fair, his weight is not just all from his large frame, and that 3 lb. weight gain in six months really added to his belly. At the very least, we want to arrest that gain trend.

Yet we are puzzled as to what, if anything, to do about it. I think this cat has experienced food insecurity, because he is a bit of a chowhound. He's always trying to convince us to give him more food, and you can't leave food out on a counter around him. And yet, he doesn't eat that much. His intake really doesn't explain his size.

Now, in my cat rescue work, I've seen kitties who are chronically underfed or starving gain a disproportionate amount of weight once given regular access to food. Years ago, I had a group of cats that were a mix of shelter kitties and rescued ferals. The ferals were usually very big cats once they finally were fed regularly. They ate pretty much the same as my shelter kitties, but they were usually much heavier. My theory was that their metabolisms weren't programmed for regular food intake.

So I wonder if a recent bout of being underfed was the source of this rapid weight gain in Cheese, yet when we got him he didn't look or act starved. The vet didn't seem to think that this was a likely source of his gain, but she didn't have a good alternative explanation either.

To be fair, this vet was better than most; she handled the subject of weight loss pretty sensitively and was obviously a kind person. I usually feel defensive when vets press this topic; it seems like there is an underlying accusatory tone when you are a fat owner with a fat pet. The assumption is that you must be feeding them human food scraps (not good for animals), or just overfeeding them in general (as you obviously must be doing to yourself). She didn't seem to assume that, which was refreshing. But she did want us to reduce his caloric intake gradually.

Her recommendation was to feed him 2 small cans of wet food per day, one in the a.m. and one in the p.m., and to switch him to reduced-calorie wet food.

But the ironic thing is, we already feed him less than this. We feed a small can of wet food in the morning and one in the evening....for all three cats. That seems to be enough.

We could go to high-quality reduced-calorie food, but I always wonder if these really have sufficient nutrition for active cats. My kitties are not indoor, sedentary kitties; they go out and hunt and run around. Cheese is really an excellent mouser and mole-killer; he brings us many "presents" (but doesn't seem to eat them). A reduced-calorie canned food might be okay for indoor kitties who don't get much exercise, but for a farm cat? I wonder. Or maybe he'd just start eating his kills.

What we've done so far is to mostly take away the dry food. Dry food tends to be high in carbs. A cat's natural food is meat from animals, so carbs from dry food can add to a cat's weight. No, I'm not putting my cat on a "low carb" diet, just recognizing that the grains in dry food are not part of the food his body evolved to eat. Going back to a more natural diet might stabilize things for him.

Only time will tell if this will make any difference in his weight but hopefully it will keep him healthier overall. I've never been very convinced of the value of dry cat food (would they eat grains in the wild?) so eliminating dry food doesn't really seem like a "diet" to me, just common sense.

Honestly, I'm not sure how much concern to have about this gain, what might have caused it, or what to do about it. I normally don't get too worked up about a pet's weight, as long as I'm giving reasonable food in reasonable amounts. And this cat is clearly built along a much larger frame than many other kitties, so I think it's ridiculous to compare his weight to a smaller-framed kitty and say he's too heavy based on that.

On the other hand, such a large gain in such a short period of time is a bit worrisome to me. It seems abnormal. It's unclear to me why he experienced this, unless he was being starved at his previous home ─ though he certainly didn't look starved when we got him. We checked for diabetes and thyroid issues and he was negative. Yes, he is a bit of a chowhound, wanting more food than he really needs, but despite this, I don't think his intake has been excessive. We keep an eye on it.

So the question is whether this gain is a cause for alarm, and if so, what to do about it. The rapidity and scope of the gain is what seems most worrisome to me, especially if that trajectory continues. So I made the decision to try and stop that trajectory. But neither am I willing to put this cat on a major diet or give him a compromised-nutrient food if I can avoid it.

What seems least harmful is to take away the dry food (since it's probably not part of what he's biologically meant to eat anyhow) and see what happens. I don't know if it's going to make much difference but it seems worth a try. Other than that, we're not willing to get too drastic with him.

I'm sure other fatosphere bloggers have encountered a similar issue before. What do you do when you have a fat cat? How do you respond to the "fat cat talk" with a vet? What's reasonable and what's not?

*One other interesting tidbit that came out of the "fat cat" talk was her admonishment not to reduce his calories too quickly or too severely. Apparently, this can cause a fatty liver syndrome in cats that can be fatal. I have no idea if it's comparable at all to fatty liver disease in humans, but it certainly did make me go "hmmmmm." I know that fatty liver disease is one of the risks associated with obesity in humans, but like gallstones, is it associated with obesity or with dieting or a little of both? An interesting side question. Anyone know the answer?

The Fat Vagina Theory Strikes Again

2011-08-10T23:06:00.000-07:00

Here is a story someone left as a comment on my post on Soft Tissue Dystocia. The story, unfortunately, is all too common.

As I explain in the Soft Tissue Dystocia post, some care providers believe that very fat women have so much fatty tissue in the pelvic area around their vaginas that a baby is unlikely to get out safely.

Officially this is called "Soft Tissue Dystocia" but sometimes in the birth world we cynically call it the Fat Vagina Theory, based on a term that has actually been used by some doctors to explain to women of size why they had a cesarean.

Unfortunately, Fat Vagina Fear is yet another factor helping to drive the high cesarean rate in women of size.

Attack of the Killer Vagina

As I note in my previous post, there's little scientific evidence about soft tissue dystocia; it's mostly a dogma that has been taught to care providers over the years as if it is a hard-and-fast truth.....without the inconvenient detail of actually having proof.

But it's a dearly-held dogma, and one that care providers rarely even question. And the belief in it leads to many questionable interventions in women of size.

Providers who subscribe to this dogma believe that vaginal birth in very fat women is unlikely because of so much soft tissue in the way, or that the combination of a big baby and this "compromised" pelvic space will cause the baby's shoulders to get stuck, resulting in injury and lawsuits.

Therefore a common response to Fat Vagina Fears is to either schedule a cesarean or to induce labor early while the baby is theoretically more able to fit.

Unfortunately, research shows that inducing early for a big baby leads to a higher rate of cesareans, not a lower one, and may actually increase the rate of shoulder dystocia.

Let's say that again. The intervention they use to supposedly lessen risk may actually cause the very outcomes they are trying to avoid─yet they still do it anyhow.

The results are no better for a planned cesarean before labor. Babies don't do any better and moms' outcomes are worse.

To be fair, some of these care providers may have good intentions. Those who routinely section high-BMI women often do it because they are convinced that labor is likely to end in a c-section anyhow, and because they feel it's better to do the "inevitable" c-section under planned conditions instead of emergency ones.

Those who induce big moms early often do it because they feel inducing at least gives the mother a chance at vaginal birth, and because they feel they are less likely to get sued if they can show they took proactive measures ─ like inducing early.

Their intentions may be benign, but their interventions are not. They don't improve outcomes, and often cause MORE complications than they avoid.

Yet early inductions or planned cesareans with "obese" patients remain a very common practice, often with "soft tissue dystocia" as part of the reason.

Some providers are even beginning to be hassled if they don't follow these practices with women of size, as if they are behaving dangerously by not inducing or doing a cesarean.

One Mother's Story

This story sadly illustrates this scenario. The mother was induced at 37 weeks because of her size and the doctor's fear of shoulder dystocia.

Not surprisingly, it led to a cesarean. However, because the baby was not ready to be born, he had to go to the NICU and the mother didn't get to even hold her baby─for nearly a week.

Although most care providers now wait longer than 37 weeks to induce for suspected macrosomia, the story often ends very similarly. Mom's body is not truly ready for labor, baby is not in a good position yet, a long hard induced labor follows, and the mom ends up sectioned for "failure to progress," fetal distress, or fear of infection after a prolonged induction. Women are told their babies were too big, their vaginas too fat, or their pelvises were too small ─ but the real reason was that inducing before the mother/baby dyad is ready often ends in cesarean.

Afterwards, Mom and baby are often separated, sometimes for hours, sometimes for days, which is one of the most difficult and heartbreaking things for a new mother. Breastfeeding often gets off to a rocky start, and mother has to try and learn to care for her new baby while she is recovering from surgery. Not a recipe for an easy transition into motherhood, and one which probably negatively influences the rate of breastfeeding in women of size.

Alas, the Myth Of The Fat Vagina is alive and well in obstetrics, and combined with Fear Of The Monster Baby, helps drive the cesarean rate in women of size.

I had a c-section with my first baby seven years ago.

I was "warned" by my OB that since I was so big, 330, and had more fatty tissue in my vagina, that I could put my baby in jeopardy trying to deliver him naturally. She told me that i could break his collarbone, dislocate his shoulders or he could just get stuck.

I went against my gut and allowed myself to be induced 3 weeks early. When my doctor came in to check on me after the first couple of hours, she broke my water without my consent and the clock started ticking. After 24 hours of labor, I was so close and my doctor ordered me into an emergency c-section because my water had been broken for too long, putting my baby at risk.

Adding insult to injury, I had not had any pain medicine (I'm kind of granola). The anesthesiologist came in to give me the epidural and took one look at me and said that it is really tricky to do on such a fluffy girl. I begged for her to try. She told me that she was going to give me some oxygen before she started and put me to sleep. I woke up so confused. And worst of all I feel I missed the birth of my son.

He was very sick and had under developed spots on his lungs, he was taken away to the NICU immediately. I didn't get to hold him until he was 6 days old.

I really wish that I had trusted my instincts and had had a provider who listened. I am pregnant again. I am prayerful that this time around I will be able to have a natural birth free from all of the bullying that I experienced before. I have to believe that my body, big or not, would not grow a baby that it could not deliver.

*I hope this mom contacts ICAN, the International Cesarean Awareness Network, which can help her work through her feelings about her cesarean, find a more size-friendly provider, and support her as she works towards a VBAC.

Automatic Cesarean Section for Everyone with BMI Over 40?

2011-08-04T12:10:00.000-07:00

People don't always fully believe it when I tell them about the tendency of many doctors to just schedule an automatic cesarean for "morbidly obese" women these days, but it's really true in some practices.

Of course, it's important to point out that not all care providers do that......but quite a few do, and more and more providers are starting to feel the pressure to do so.

Here's yet another example.

This is from My OB Said What?!?, in the comments section of the entry, "Because of Your Weight, We'll Just Schedule Your Cesarean."

When an anonymous survey was conducted, 100% of the OBs at this hospital (yes, every last blinkin’ one of them) admitted that they would schedule a c-section automatically if a woman’s BMI was over 30 and there were any other risk factors, or BMI over 40 with no other problems!!!

As a woman with a BMI over 40, I find this trend offensive and troubling in the extreme.  I know it's not routine everywhere, but this is becoming the "standard of care" in many places, and woe to the caregiver who doesn't do it, or who dares to try and support one of these women for a natural birth.

I'm hearing now about care providers who are being hassled for daring to attend "morbidly obese" women at all (instead of sending them to the high-risk Bariatric Obstetrics practices), or even for not automatically sectioning those they do see. Really.

I know there are still good doctors and midwives out there who don't practice this way (and thank goodness for them!), but the birth politics around obesity in some areas are becoming so extreme that even the good care providers are feeling pressure to not attend women of size for normal birth.

This is a very ominous and deeply troubling trend.   If this trend becomes firmly established as the "standard of care," it will be very difficult for the good providers to fight against it because it opens them up to increased legal vulnerability.

If that happens, heaven help women of size.

Where is the outcry against such things? Where are the birth professionals willing to stand up for women of size and speak out against this?   How can we reverse this trend?

Framed: The Language of Media Articles on Obesity

2011-07-26T13:23:00.000-07:00

If you haven't yet read this article analyzing the way most media articles portray obesity and the obesity epidemic, run right over and read it NOW. Yes, it's that interesting. Go, read.

It's called, "Morality and Health: News Media Constructions of Overweight and Eating Disorders," by Saguy and Gruys. In it, they compare how news media articles from 1995-2005 frame discussions of obesity vs. discussions of eating disorders.

Here are some quotes from the article:

In the contemporary United States, thinness is associated with high social status and taken as evidence of moral virtue. In contrast, fatness is linked to low status and seen as a sign of sloth and gluttony. Drawing on an original data set of news reports, we examine how such social and moral meanings of body size inform news reporting on eating disorders and overweight.

We find that the news media in our sample typically discuss how a host of complex factors beyond individual control contribute to anorexia and bulimia. In that anorexics and bulimics are typically portrayed as young white women or girls, this reinforces cultural images of young white female victims.

In contrast, the media predominantly attribute overweight to bad individual choices and tend to treat binge eating disorder as ordinary and blameworthy overeating. In that the poor and minorities are more likely to be heavy, such reporting reinforces social stereotypes of fat people, ethnic minorities, and the poor as out of control and lazy.

Fascinating stuff. Discusses the moral framework the media places around obesity, and how it intersects with race and class. The contrast with the moral framework around eating disorders really points out how media messages both reflect and shape our society's perceptions about a topic.

If you haven't yet read this article, you should really go read it. Go!

Induction Triples the Risk for Cesareans in First-Time Moms

2011-07-21T12:25:00.000-07:00

Here is the abstract of a recent study (Thorsell 2011) on how induction of labor increases cesarean rates, especially in first-time mothers with an unripe cervix.

This is yet another reason why the very high induction rate in women of size plays such a strong role in the higher cesarean rate in "obese" women.

[For example, in Abenhaim and Benjamin, 2011 about 50% of "morbidly obese" women were induced; double the 24% rate in "normal BMI" women. In addition, more than half of the "morbidly obese" women had a very unripe cervix (dilation of 2 or less) upon admission. Is a high cesarean rate in this group therefore any surprise?]

In the Thorsell 2011 study (abstract below), first-time mothers with an unripe cervix who were induced had a 42% c-section rate in labor. Yes, you read that correctly; nearly half ended up with a cesarean. After controlling for other factors, inducing labor in a first-time mother with an unripe cervix tripled her risk for a cesarean.

The effect was much less strong in multips, whose cesarean rate after induction was a more modest 14%. Yet, after controlling for variables, their risk was still nearly doubled. So while the total numerical rate was much lower in multips, the odds ratio was still considerably increased.

Of course, it's important to point out that induction, even in a first-time mother, results in more vaginal births than cesareans. If you are induced, it doesn't mean that a cesarean will automatically follow; you still have a reasonable chance for a vaginal birth, especially if your cervix is ripe first or if you've had a previous vaginal birth.

But the risk for cesarean is greatly increased when labor is induced, and especially so in a first-time mother whose cervix is not very ripe.

How many of these cesareans could be avoided just by being a little more patient?

And how many cesareans in women of size could be avoided by refraining from induction until the cervix is very ripe, or by awaiting spontaneous labor as much as possible?

Acta Obstet Gynecol Scand. 2011 Jun 17. Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Thorsell M, Lyrenäs S, Andolf E, Kaijser M. PMID: 21679162

Source

Division of Obstetrics and Gynecology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden, and Clinical Epidemiology Unit, Department of Medicine at Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.

Abstract

Objective. To assess the risk for emergency cesarean section among women who were induced to labor in gestational week ≥ 41 and to evaluate if parity and mode of induction affected this association.

Design. Hospital based retrospective cohort study.

Population: Singleton pregnancies delivered after ≥41 gestational weeks at Danderyd Hospital, Stockholm, Sweden during 2002-2006.

Material and Methods. Of 23 030 singleton pregnancies meeting the entry criteria, 881 were induced with Bishop score of < 7. Obstetric outcome was assessed through linkage with the Swedish Medical Birth Registry and a local obstetrical database containing information from patients' medical files. Results were adjusted for BMI, age and the use of epidural analgesia.

Main outcome measure. Risk for emergency cesarean section.

Results. Among women who were induced, the proportions delivered by emergency cesarean section were 42% for nulliparous and 14% for multiparous. Compared to spontaneous onset, this corresponded to a more than threefold increase in risk for nulliparous women (OR 3.34, 95% CI 2.77-4.04) and an almost twofold increase in risk for multiparous women (OR 1.94, 95% CI 1.24-3.02). There was no significant difference in risk for emergency cesarean section between the two methods of induction (PGE(2) and transcervical catheter).

Conclusion. Compared to spontaneous onset of delivery, induction of labor is associated with an increased risk for emergency cesarean section both among nulliparous and multiparous women. When labor is induced the high risk for emergency cesarean must be kept in mind.

Taking Away the Fat Kids Again

2011-07-14T12:17:00.000-07:00

Well, the story that consistently strikes fear in the hearts of fat parents everywhere has resurfaced again: Should parents lose custody of super obese kids?

OMFG. There are actually people at the Journal of the American Medical Association who are promoting this crap? Who really believe that very fat children should be traumatized by being taken away from otherwise loving parents, simply because of weight? Who really believe that foster care ─ where many children are abused and mistreated ─ is going to be a better environment for these children?

Here we go again, blaming the parents for their children's obesity. Because, you know, no child could ever be that fat without their mothers actively force-feeding them deep-fried cupcakes, ice-cream IVs, and chocolate-covered french fries.*

This just ties into the popular notion that obesity is only ever about gluttony and sloth, that fat children only become that way because their parents' bad habits, and that if very fat children are just given proper nutrition they will become a "normal" weight and maintain it seamlessly for the rest of their lives. That putting these children in a controlled environment and giving their parents nutritional lectures is going to fix everything (and won't make things worse).

In the fat-acceptance community, we've been fighting this battle for SO many years, because authorities have been periodically taking fat children away from their parents and into enforced Fat Camp Foster Care for a long time. This is certainly no new trend; I have been in NAAFA for years and can remember cases like this going back quite a while.

Like with most diets, the "super obese" kids in foster care lose some weight at first.....but does the program result in lasting weight loss or "normalized" bodyweights? Not usually. But because some weight is lost for a while, the doctors and social workers and foster care system can tell themselves it worked. Then the parents get the kid back, the kid regains the weight because that is what happens after most diets, and the parents can again be blamed for the weight. What a vicious circle for those poor parents! And for that poor child.

But what's really going on in these situations? Is it always a case of ignorant, negligent, or just plain gluttonous parents feeding their children into the grave? Or might there be more at work here?

Even the experts who question taking away fat kids are caught up in the usual arguments; they just blame the obesogenic environment instead of directly blaming the parents:

University of Pennsylvania bioethicist Art Caplan said he worries that the debate risks putting too much blame on parents. Obese children are victims of advertising, marketing, peer pressure and bullying — things a parent can't control, he said.

I'm glad this guy is speaking up for the parents and I do think an "obesogenic" environment is relevant to some degree, but I believe he's missing an even bigger point.

What if there are other factors at work that doctors are missing because they are so focused on only the "personal responsibility" and "obesogenic environment" arguments?

I remember one case, quite a while ago, a Giant Toddler of Doom was publicized and much ado was made about the parents and how negligent they were to "let" their child get that fat. But this child was later found to have a genetic condition that caused him to be so fat at such a young age. Did this fact then get publicized? NO. The media uproar was focused on the beginning of the story, but when they later discovered the medical condition that caused this child's fatness, this fact went conveniently unpublicized. I only heard about it via my involvement with NAAFA. How much trauma was done to this young child because the doctors did not look deeply enough into his condition early on? And how much damage was done on a societal level because the media did not properly follow up on the story?

This is what I suspect in the cases of many of these "super obese" kids. How does a child get to be 400 lbs. without something being wrong in their metabolism? I just find it very hard to believe that a child could eat so much and move so little as to achieve that kind of weight in so little time without something being wrong. Sure, some kids are more genetically susceptible to fatness than others, but that much? Mightn't there be another factor at work?

Little children remarkably self-regulate their intake. I find it very hard to believe that someone could overfeed a child to such a point of extreme fatness in so little time, even with "bad" habits like too much junk food and sweets. Remember, lots of other children in the world eat waaaaay too much junk food and sweets, yet do not become "super obese." What makes these children so vulnerable to such fatness?

This is the problem around society's moral narratives around fatness in this country. It lets care providers settle for the easy answers and keeps them from looking at the problem more deeply.

When doctors focus on the moral interpretations around fatness in children (the mother must be overfeeding her child, the child must be neglected or abused and is filling its emotional needs through overeating), then medical personnel conveniently don't have to look any further for biological reasons for the child's fatness.

No onerous searches for difficult-to-detect genetic diseases or metabolic variations that might be causing (or adding to) such extreme adiposity. Just blame it on the parents, take away the child, and ta-dah, you're done. No messy complicating details. And it fits what authorities want to believe about fatness.

But how many of these children really lose weight permanently under these structures? This latest news story is careful to document several cases where the children are taken away and magically lose weight with "proper" parenting and nutrition. But as always, the question becomes.....what is the follow-up? If you look at only a year or two of follow-up, many weight loss efforts look successful. It's the longer-term look that reveals the weakness of a dieting or "lifestyle change" approach and the overall harm that usually follows such approaches.

And what is the cut-off of "too much" weight, when children need to be taken away? Who decides this? On what basis? And how do you weigh the potential benefit of even temporary weight loss against the tremendous trauma of being taken away from your parents?

I believe that foster care decisions should be made on the basis of other factors and not weight as the primary factor. If the child really is being neglected or abused, then yes, take him away. If not, but the parents really are feeding him terribly unhealthy food choices, get them nutritional help and support. If parents are completely unresponsive, refuse to feed the kids decent food, and really are promoting terribly unhealthy practices, then look more closely ─ that kind of attitude doesn't happen in a vacuum. Undoubtedly there is neglect happening in other ways too, and foster care can be considered on a combination of several factors.

But take away kids from otherwise loving and caring parents solely on the basis of fatness? No F*cking Way. That should be fought with every breath and every fiber in our beings.

Striking Fear in the Hearts of Fat Parents Everywhere

As you might guess, this story feels very personal to me, as I bet it does to every fat parent out there. Many of us already endure the condemnation of society for daring to have children at our size, and if those children also turn out to be fat (as genetically most will be prone to do), then we suffer from the condemnation of a society that assumes that therefore we must be making them fat.

Many of us endure the shame and stigma of frequent weight loss propaganda and lectures from doctors, school nurses, and teachers. We live with having every item in our shopping cart analyzed by friends and neighbors and grocery clerks, and our kids' school lunches critiqued by teachers and principals. Some have to live with BMI report cards and well-meaning but stigmatizing "obesity" programs at school.

Some of us are afraid to let our kids watch even occasional TV because we know we'll be accused of "too much screen time" making them fat....despite all the other kids we know who watch far more TV and aren't fat at all.

Some of us feel pressured to make our kids enroll in sports teams or exercise classes to show that they're fat despite getting regular exercise; sometimes we encourage them to participate even when they don't want to so we can point to their activity level and say, see, they do get plenty of exercise!

When our children gain weight and get more rounded shortly before puberty, we live with the guilt that gets heaped on us for "letting" our children get even fatter, even though "puberty pudge" is a common and natural process for many kids.

We constantly hear news stories that blame us as parents for every ounce of our children's weight and we endure the lectures from healthcare professionals and acquaintances about the supposed "bad" habits we're teaching our kids and how to "fix" them....based more on what they assume are our habits, rather than what our habits actually are. And we're supposed to just shut up and take these lectures or risk being labeled "uncooperative" or "non-compliant" parents.

And deep down, many of us fear that, sooner or later, someone will suggest that our children should be taken from us and put in the Fat Gulag because obviously we are doing something "wrong." And we fear fighting back from a HAES perspective because we are afraid of being labeled "non-compliant" and giving them even more reason for taking our children away. From the above article:

In a commentary in the medical journal BMJ last year, London pediatrician Dr. Russell Viner and colleagues said obesity was a factor in several child protection cases in Britain. They argued that child protection services should be considered if parents are neglectful or actively reject efforts to control an extremely obese child's weight.

My kids are nowhere even remotely near the size in these stories, yet my first reaction to this story was still a heart-clutching moment of fear.....how long till they suggest something similar to me? And if I fight back on a HAES basis, do I help or hurt my cause?

My eldest child looks pretty normal but qualifies as "overweight" (she wears a size 16); my second child is a very active, fit Scout and athlete but still has a little pudge around the waist; my youngest child is downright skinny (to the point of worrying about her lack of gain); and my third child is so round right now (just before puberty) that he would gain me at least a lecture and a "if he continues to gain weight" threat from some doctors. All of them eat the same food and have exactly the same parents...but all four are on vastly different weight tracks despite similar genetics and upbringing. How much control do we really have over our children's sizes?

I make a lot of effort to ensure that my children have plenty of fresh fruits and veggies, whole grains, healthy proteins, and exercise opportunities, but I try not to be too fascist about "bad" foods and make them the forbidden fruit kids long for, and I will not place my more-rounded children on diets in order to "normalize" their weights. We strive for moderation and a reasonable approach, but I know it wouldn't be considered enough by the Jamie Olivers and Jillian Michaels of the world. I screen my kids' healthcare professionals for that sort of nonsense, but what if I couldn't? What kind of harassment and threats might I endure as a parent if I refused to put my third child on a reducing program? Would they think I should lose custody of him?

In my saner moments, do I think it's likely that my children will be taken from me and placed in foster care because of such concerns? My head says no because they are not even remotely near the size of the children in these stories ─ but my heart doesn't believe it. My heart still clenches in fear every time I see one of these stories, wondering how long it will be till the cutoffs for taking away children drift lower and lower and even my children could be taken from me.

And I wonder if the day will come when some asinine "authority" somewhere suggests we start taking away babies from fat mothers because obviously they can't be trusted to raise their children in a healthy environment. Undoubtedly the motivations will be the best ─ to save those children from a lifetime of discrimination and supposed health issues ─ but oh my God, the trauma they will cause.

Remember, children have been taken "for their own good" from native and aboriginal peoples for a long time, and look at the havoc that wreaked on those societies. Look at the terrible abuses many of those children suffered in the name of "improving" their lot. Taking children away from their parents is a huge psychic wound and often has long-term personal and societal implications.

The horror stories I have heard (and seen) about some foster care situations make me terrified about what could happen to vulnerable children put into Fat Camp Foster Care "for their own good," and frankly, it makes me want to run and hide my children from the view of authorities.

I've worked with children for many years and have seen some horrible cases of abuse. I know that sometimes children do need to be taken from their families and that many foster families do a wonderful job.....but I also know that even in those cases, such separation is often tremendously traumatic to the children. And sadly, I also know that sometimes the place of "safety" is not always so safe, and occasionally even worse than what they came from.

So the idea of taking fat children away from their parents absolutely HORRIFIES me, and it strikes tremendous fear in me as a fat parent. And I bet every fat parent around the country is reacting similarly when they see that story.

Yes, we need to have some concern about children who are at such extreme weights so early in life because there can be accompanying health implications. But is taking them away from their parents solely on the basis of weight the right fix? I don't think so.

We must be careful that the "cure" is not more damaging than the original issue; we must not let our rights as fat parents be taken from us; we must protect our fat children from further damage by well-meaning but draconian measures; and we must stop letting society's moral narratives around fatness keep healthcare researchers from digging deeper into the mystery of these children's vulnerability to extreme weight gain.

This story just appalls me on so many levels.

*Thanks to Meowser for that last colorful phrase.

Manual Rotation for Posterior or Tranverse Babies

2011-07-05T10:57:00.000-07:00

This new study is just the latest in a series of studies that have shown that manual rotation lessens the need for cesarean during labor because of a malpositioned baby.

In these studies, a persistent posterior baby (baby facing mom's tummy instead of her back) is turned manually to the generally-easier-to-birth anterior position (baby facing mom's back). The question has been whether such techniques improve outcomes.

This study shows a dramatic improvement in outcomes with manual rotation.

This is a larger trial than many of the previous studies on manual rotation, which makes the findings even stronger. This study is interesting in that it also includes manual rotation for transverse arrest (baby gets stuck facing sideways, usually as they are trying to rotate from posterior to anterior). Not all manual rotation studies do.

Note that manual rotation is not without risks; there were more women in the rotation group with cervical lacerations, which is not fun. However, balance that against less need for cesareans, fewer severe perineal lacerations, less hemorrhage, and less infection, and I'd say manual rotation wins, hands down.

But Should We Intervene for a "Malpositioned" Baby?

One of the controversies within the natural childbirth community these days is whether persistent posterior babies should be considered malpositions or just variations of normal, and whether we really need to intervene at all in such cases or just be more patient.

Personally, I do believe that sometimes these positions are just a variation of normal and don't have to be a big deal. Sometimes all that's needed is just a tincture of patience and time, and the "malpositioned" baby is born just fine. Sometimes the baby's "malposition" is even actually needed because of a unique pelvic shape or some other factor we are not yet aware of. So I agree─up to a point─with folks who tell pregnant women not to obsess too much over their baby's position or to feel that if they have a posterior baby that they are doomed to a cesarean etc.

However, I think it's naive to believe that such positions are always benign and will always be born vaginally and without damage if just given enough time. I think research is quite clear that OP labors are often harder and longer, and that there are often poorer outcomes for mother and baby.

Yes, I do wish doctors would also study maternal repositioning and other less interventive alternatives so there were other options in the arsenal for a malpositioned baby. I bet some of these babies would rotate just fine with other, less-invasive techniques, and then the more-invasive manual rotation could be used only when truly needed. I also wish that care providers would be more patient in labors, because many positions will remedy themselves with a little extra time, or be born in that position just fine.

However, I don't believe that all malpositioned babies will be born safely "if just given enough time." Some babies and mothers will experience significant difficulties. Many more will be subjected to forceps/vacuum extraction and cesarean deliveries, with all the associated risks. The question is whether these complications and operative deliveries could have been avoided if manual rotation had just been tried.

This new study compared manual rotation with expectant management─just waiting─and found that outcomes were significantly improved in the active intervention group. Other studies have also found that prophylactic rotations improved outcomes. So perhaps "just waiting" is not always the best thing.

Remember, these malposition labors can sometimes be just HELL for both mother and baby. It's not always wise to wait to intervene until mother is exhausted and baby is in distress. Sometimes an earlier intervention like manual/digital rotation can be judicious and helpful.

So while I want care providers to have more patience and use other, less invasive techniques first, I am thankful that manual rotation is in the arsenal too. I think the results of these studies clearly show it should be learned by more care providers and applied when less-invasive techniques are not helping.

For the many many MANY of us out there who have had long hard labors and then cesareans for malpositioned babies, I say Hallelujah that care providers are re-learning this manual repositioning skill again. About time!

Huge thanks to the midwives and doctors who kept this technique alive when it went out of obstetric fashion. I hope they are teaching others and spreading the word to more midwives and especially doctors. Far too many women are being cut open because care providers don't know how to handle differences in fetal position.

Manual repositioning can be a very valuable skill to have and will surely improve outcomes in many cases. That doesn't mean it should be used too quickly or in place of less-interventive techniques, but that it clearly does have a place in the spectrum of options.

Shaffer BL, Cheng YW, Vargas JE, Caughey AB. Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. J Matern Fetal Neonatal Med 2011 Jan;24(1):65-72. Epub 2010 Mar 30. PMID: 20350240

Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Clinical and Policy Perinatal Research, University of California, San Francisco, CA 94143-0705, USA.

OBJECTIVE:

To examine mode of delivery and perinatal outcomes in women with occiput posterior (OP) or transverse (OT) position in the second stage of labour with a trial of manual rotation compared to expectant management.

METHODS:

A retrospective cohort study was designed to examine mode of delivery and perinatal morbidity in women who underwent a trial of manual rotation (n = 731) compared to expectant management (n = 2527) during the second stage of labour with the fetus in OP/OT position. Chi-square test was used to compare categorical outcomes and multivariable logistic regression models were used to control for potential confounders.

RESULTS:

Compared to expectant management, women with manual rotation were less likely to have: caesarean delivery (CD) [adjusted odds ratio (aOR) 0.12; 95% confidence interval (CI) 0.09-0.16], severe perineal laceration [aOR 0.64; (0.47-0.88)], postpartum haemorrhage [aOR 0.75; (0.62-0.98)], and chorioamnionitis [aOR 0.68; (0.50-0.92)]. The number of rotations attempted to avert one CD was 4. In contrast, women who had a trial of rotation had an increased risk of cervical laceration [aOR 2.46; (1.1-5.4)].

CONCLUSIONS:

Compared with expectant management, a trial of manual rotation with persistent fetal OP/OT position is associated with a reduction in CD and adverse maternal outcomes.

Blogiversary #2: State of the Blog

2011-06-29T10:42:00.000-07:00

♫ Happy Blogiversary to me, Happy Blogiversary to me.....! ♫

Yes, it's been 2 years since I started this blog. I can hardly believe it. Feels like I've been doing it a lot longer!

So in honor of the blog's birthday, let's take a moment to do a State of the Blog assessment, eh?

Purpose of the Blog

2 years ago, I started the blog to raise awareness about the issues of "obesity" and pregnancy.

I found little awareness or comment about pregnancy issues in the fat-acceptance world and wanted to raise the fatosphere's awareness of the discrimination and mistreatment many women of size face during their pregnancies and births. Size discrimination often starts in the womb, yet this has been a very overlooked area in the discussion about size bias.

I particularly wanted to reach out to pregnant women of size who might be looking for information on how weight could affect their pregnancy and care. I wanted to make sure they had in-depth information about their choices, risks, common care protocols, the pros and cons of interventions, etc., and that they had information about proactive things they could do to improve outcome. And I wanted to make sure they had a place to share their concerns and questions, and a space where they could see other pregnant women who looked like them so they would know that they are not alone.

I also wanted to reach out to the birth world and further its awareness of how pregnant women of size are often mistreated, ask birth workers to question the assumptions often made about women of size, to analyze the quality of the research on obesity and pregnancy, and to open a discussion of how to improve outcomes in women of size.

Whew. That's quite a wide-ranging mission and target audience. This means that sometimes my posts will appeal only to one segment of my readership. Some will really want the pregnancy pictures and birth stories, others really want the nuts-and-bolts research analysis, and still others are most interested in discussions of size bias or Health At Every Size instead. But hopefully, even when the posts don't appeal to your particular needs, they're still interesting enough to learn something new or to be diverted by for a few minutes.

Thank you to those of you who have linked to my blog or specific posts on your sites, or who have "liked" or tweeted about them on social media networks. It really helps increase the visibility of my blog, increase the readership, and get my message out. Keep linking, "liking" and tweeting!

My birth friends are pushing me (kicking and screaming all the way) towards the social media world, and I have been informed that I must get a Facebook page soon. I'm no fan of social media but I recognize its importance in getting out advocacy messages, so I'll probably be looking into this soon. Keep your eyes peeled for it.

Blog Stats

Alas, Blogger has only had stats available for my site for the last year, so I have no data on how many readers I had in the first year or what they read the most. But now that I have these stats available, it's been fun keeping track of them. It feeds my inner geek and my ego too, which is always nice!

Generally I average about 20,000-25,000 hits per month these days. That's up from the beginning of the year when it was more like 17,000-20,000 per month. So that's encouraging.

Here's the part that boggles my mind. All together, I've had nearly 275,000 hits in the last year alone. Whoa. Pretty amazing!

Yeah, okay, peanuts compared to some sites, but still pretty dang impressive to me! Starting this blog has been a big boost for getting out my message, even beyond my regular website, www.plus-size-pregnancy.org. I'm sure if I ever drag my reluctant backside over to Facebook, that would help boost readership even more.

Popularity-wise, my Top Five Posts of all time are:

Of these, the Plus-Size Pregnancy Photo Gallery is by far the most-viewed post. It has had nearly 70,000 views all on its own, compared to about 12,000 for the next most-viewed post.

Apparently there is just a tremendous need out there for images of women of size in pregnancy and birth, because nearly all the search terms commonly used to find my blog involve some variation of "overweight" or "obese" or "plus-size" and "pregnancy" or "photo" or "belly." So obviously, one of the most important things I've done is to try and meet that need for images and reassurance.

This is one reason why I hold my nose and still use the "o" words ("obesity" and "overweight") at times; I know those are the search terms used by people not familiar with fat acceptance. Frankly, those odious "o" terms are how most people find my blog. It helps me preach not just to the choir but to a lot of people unfamiliar with fat-acceptance and Health At Every Size. It helps me reach more of my most-desired target audience ─ people unfamiliar with size acceptance and new to the concept, whether those are people in the birth world or are people of size themselves.

So while I've had many approaches to the terminology issue over the 16 years I've been writing about this topic, in the end I've decided that getting the message out to those who need it most takes priority. As a result, I use a mix of terms on the blog, from the repulsive "o" words at times, to "fat" (which is my preferred term but which alienates some), to euphemisms that tend to be a bit more neutral. This makes my blog more likely to be found by a variety of people, not all of whom are on board with fat-acceptance yet. You can agree or disagree with that approach, but it's the compromise that seems to work best for me after many years of trying different ways of handling the terminology.

Geeky Stuff

I get a real charge out of my little "world" widget on the top right-hand side of my blog. It's always so much fun to look and see who's reading my blog right now and where they are from. I love that!

Not surprisingly, most of my readership comes from English-speaking countries, especially the U.S., the U.K., Australia, Canada, and New Zealand, but I get a fair amount of hits from Germany and the Netherlands. I also get quite a few hits from places I wouldn't have expected, like India, Russia, South Africa, and Iran. Very cool!

One thing I am working on for the future are reference pages with links to research studies....sort of a quick reference link page, as it were. I think some of my readers might find that useful; I know I find it useful on other people's blogs. (Thank you Fat Nutritionist!)

I also have a major series planned on the risks of pregnancy in women of size coming soon. We'll take each one of the risks, look at the research on it, dissect the quality of the research, and figure out the lessons to be learned from it (if any). This will be a major series, and it takes a huge amount of time to research and write each risk category, so it will definitely be a periodic series over a long period of time instead of a continuous short series. Still, even though it will be spread out over time, hopefully it will be of use to women of size as they try to sift through all the scare tactics and rhetoric around fatness and pregnancy.

Conclusion

So that's the State of the Blog─where we are right now, and some directions we plan to go in the future.

Thank you for reading the blog, for sharing links to it with others, and for spreading the message about it. Keep doing spreading the word, please!

Thank you to the Fatosphere for being open to this unique message about pregnancy in fat women. I know it can be hard to care about this topic if you are not personally planning to have children, but size discrimination matters, even if it doesn't personally affect you. Thank you to those who continue to read even with no personal investment in the topic, and thanks to those of you who are affected by the topic and who share your stories and concerns.

Thanks to the many gutsy maternity care providers and birth workers who have embraced the cause of better treatment for women of size too. It is so important that this message not be limited to this blog or to the size-acceptance world, but that it be actively discussed and pursued by those in the birth field. Special thanks to those birth workers who have done their best to help and advocate for women of size as clients.

Finally, special SPECIAL thanks to the many brave mamas of size who have shared their pictures, their thoughts, their comments, and their stories with the blog or my other website. Your experiences are the heart of why I do this; thank you so much for sharing. YOU ROCK. You'll never know what a difference you make in the lives of future women of size.

Happy Blogiversary, and I look forward to sharing many more blogiversaries with you!

Because Of Your Weight, We'll Schedule Your Cesarean

2011-06-22T18:44:00.000-07:00

Still find it hard to believe that fat women are being denied access to low-intervention care and are often railroaded into cesareans these days?

Try this story on for size, from the website, My OB Said What?!?

“Because Of Your Weight…We’re Going To …Schedule Your Cesarean.”

“Because of your weight, you’re just not a candidate for midwifery care, and we’re going to go ahead and get you to an OB to schedule your cesarean section.” – CNM to mother at 36 week appointment

Augh. Just AUGHHHHH!!! On sooooooo many levels.

New Health At Every Size Resource

2011-06-19T14:21:00.000-07:00

I'm delighted to hear that ASDAH (Association for Size Diversity and Health) has started a new, very important blog, the Health At Every Size blog. About time!

I'm sure my size-acceptance and fatosphere readers have heard about it already, but I wanted to make sure my birth-world readers (who may not be as familiar with HAES concepts) knew about it too.

If you don't know about Health At Every Size (HAES) yet, the basic principles of HAES are:

1. Accepting and respecting the diversity of body shapes and sizes.
2. Recognizing that health and well-being are multi-dimensional and that they include physical, social, spiritual, occupational, emotional, and intellectual aspects.
3. Promoting all aspects of health and well-being for people of all sizes.
4. Promoting eating in a manner which balances individual nutritional needs, hunger, satiety, appetite, and pleasure.
5. Promoting individually appropriate, enjoyable, life-enhancing physical activity, rather than exercise that is focused on a goal of weight loss.

Here is a summary about the HAES Files from the HAES blog's first post (I've broken it up a bit):

The Health At Every Size^SM approach is about the ways that people of all sizes can maximize their health.

This approach does not mean to give up or to let everything go. It is an active process by which people work positively with their bodies and within their lifestyles to achieve a level of health which is reasonable and above all, sustainable for them.

It means managing health within a framework of a life well lived as opposed to weight centric, thin at any cost methods.

It means managing nutrition and fitness within a global health framework that would include managing stress, sleeping well, maintaining social connectedness and much, much more. This is not passive, and it is not easy. It requires a lifetime of careful work in learning which foods nourish you and which leave you feeling unwell; in learning what forms of exercise strengthen you and energize you and which forms leave you depleted and hurting; and in learning to make positive, gradual changes based on self-care rather than self-hatred.

The HAES Files will serve as a means to push for a shift in paradigm from weight centered to health centered...

We have asked each of our bloggers to challenge us on how we address weight and diet and nutrition and physical activity and stigma and discrimination and ALL that our culture has deemed to wrap in a so-called “obesity crisis.”

We are no longer content with sitting in the back of the room, listening politely as policy makers, the media, and the food, diet and health industry dictate how this is going to play out. We are done asking for a seat at the table, we are taking one.

AMEN to that!

For those who are new to the idea of HAES, here are some more resources on it. There is also Linda Bacon's book, Health At Every Size, excerpts of which can be found here.

I look forward to many wonderful, informative, and empowering posts from this new resource. Go ASDAH!

Third Post at Science and Sensibility is up!

2011-06-15T11:55:00.000-07:00

Okay, my third and final post at Science and Sensibility is up!

You can access it here.

This one is about lowering the risks for complications in women of size, and exploring ALL the possibilities for doing that.

It's about not relying on weight loss, restricted weight gain, and/or a high-intervention model of care as the only ways to prevent complications in women of size. It's about the need to explore other options as well, and what some of those options might be.

Check it out! And give it some more link love, eh?

Second Post at Science and Sensibility Now Up!

2011-06-13T11:08:00.000-07:00

My next post, second in the series on obesity and pregnancy, is up now at the Science and Sensibility blog. You can find it here.

This one takes a critical look at the research for confounding factors that rarely get accounted for in the research, and suggests directions for more meaningful research in the future.

Go forth and give it some link love, "likes" and tweets!

Check Out My New Post at Science and Sensibility!

2011-06-10T11:26:00.000-07:00

On the childbirth blog, Science and Sensibility, there is currently an ongoing series about "obesity" and pregnancy. All the usual material is there, be warned, but to its credit, it has also solicited the views of women of size, something most of these discussions never do.

So I submitted some posts on the topic and my first one is up on the blog today. Huzzah!

Go forth and read it, link to it, "like" it, tweet it, digg it, and whatever else you can do to increase its visibility and readership. Give it some serious love, people. Having an alternate point of view represented is a major step forward.

I do have one request, though; if you comment on my post or anyone else's, be respectful and polite as you make your points. It's a radical thing to have our voice actually represented in these discussions and we want that voice heard and taken seriously.

There will be further follow-up posts from me there, so stay tuned to the Science and Sensibility blog for more!

A Note About Terminology

I'd also warn FA activists that I use the "o" words in the post at times. While I strongly dislike these terms, I've found over the years that the medical establishment doesn't take you seriously if you only use alternate terms, and the word "fat" is seriously alienating to a lot of women who aren't on board with the fat-acceptance thing yet.

Also, it's a search-engine optimization thing; the fact is that most of the terms used to search out this blog and my website involve "overweight" or "obesity" or variations thereof. Back in the days when I scrupulously avoided these like a good NAAFA-ite, it really limited who would find my information. Often it kept the people who MOST needed to hear it (newly pregnant fat women, those facing fat-phobic treatment and misinformation, or care providers looking for information about weight and pregnancy) from finding it altogether.

So I grit my teeth and use the "o" words at times, both here and when I write about the topic elsewhere. Here I use scare quotes around "obese" etc. to show that I GET it and I don't like those terms either. Elsewhere I don't always, for style reasons and to be taken more seriously by medicos. But it doesn't mean that I don't agree with the objections to these words.

In making this compromise, I am taking my cue from various researchers and authors who write about HAES topics and have also had to negotiate a compromise between ideals and practicality. Here's a summary from Saguy and Gruys, in their article on the way that the news media frames articles on obesity vs. eating disorders (an awesome article, BTW, if you've never read it):

The definition of “overweight” and “obesity,” and even these terms themselves, are contested. Fat acceptance activists, who advocate for civil rights on the basis of body size, argue that these terms pathologize normal biological variation and reclaim the word “fat” as a neutral descriptor like “tall” or “short” (Cooper 1998; Wann 1999). Similarly, many feminist scholars have avoided the term “eating disorder” because it situates “disorder” within individuals rather than in complex social structures. We do not use “overweight,” “obesity,” or “eating disorders” because we endorse a medical or public health framing, but because we seek to establish how these particular terms have been constructed in the news media. We note that a search for articles using the term “fat” produced very few relevant articles, which is not surprising given that this word is still taboo in most social circles in the contemporary United States. An article search using the term “eating problems” was similarly unproductive. For stylistic reasons we do not place the terms “overweight,” “obesity,” or “eating disorder” in quotations throughout the article, but we wish to be clear that this is the spirit in which we use them.

So hopefully that will explain why I use these terms at times, even as I hold my nose.

The best compromise I've found so far is to mix up my use of terms, using the "o" words mostly when discussing medical research, using "fat" as a descriptor of size or when talking about FA things, and using terms that are seen as more neutral (like "women of size") as much as possible in between.

You can agree or disagree with that compromise, just remember that I've done it for practicality reasons only.

Ties Into Upcoming Series

This series of posts on Science and Sensibility ties well into my upcoming series on this blog on the risks of "obesity" and pregnancy, one I've been working on for a long time but have had trouble finishing because it's so research-intensive and I've been so busy.

For that reason, it will be a periodic series. We'll do an overview first, then take one risk at a time and dissect the research on it, and finish by overviewing what might be done to help lessen the risk for that complication.

As I said, it will be a periodic series; other posts on other topics will get interspersed between to allow me time to work on each installment. I'm sure it will take me a long time to finish the whole series, but bit by bit we'll get there.

This can be a difficult subject to discuss, because the last thing I want to do is scare pregnant women or those considering whether or not to have a baby. And information about risks can certainly scare anyone considering pregnancy. But it's also a disservice to pretend there aren't any risks, or to not discuss ways in which women of size can be proactive about risks. To me, knowledge is power, and this is an important discussion to have. Just keep it in perspective.

Remember that risk discussion, by its very nature, tends to inflate people's perception of risk. Add in pregnancy, when women feel most vulnerable, and risk discussions can be a bit scary. They narrowly focus on the small minority of people who have complications, rather than the large majority of those who do not.

Just keep reminding yourself that most of the time, pregnancy goes perfectly well, and many MANY women of size have had healthy pregnancies, healthy babies, and healthy births.

Florida OBs Who Won't Take Fat Patients

2011-06-03T11:30:00.000-07:00

A number of people have blogged about the recent story of a group of OBs in Florida who won't accept fat women as clients because they are "too high risk" and therefore they are afraid they might get sued more.

Their cutoff for "too" fat? 200 lbs., a ridiculously low cutoff. There is no way the risks of complications at that size justify denying these women care across the board, and there is no way that they should be denying care to an entire group of women based on complications some individuals might develop.

Other people have covered the story just fine so I don't feel the need for extensive comments, but I do like the coverage from The Unnecesarean. One commenter ("Mel") there, had a good summary:

I think the point of it all, the reason this is such an ugly decision, is that this group of doctors (and many others) have isolated the risks of obesity as THE ONLY risk, right off the bat, that makes people "too risky" to serve. What can account for this?

...These are OBs, who by nature of their training, are best equipped to help people with any remotely moderate to high level of risk, right up to the sorts of very high risks that are better attended to by MFM [maternal fetal medicine] specialists. I don't see them passing on caring for multiple pregnancies, or a woman who will need a 5th c-section for instance.

Why single out obesity as a risk factor? The only plausible answer, given the scope of their practice, is bias. Prejudice. It's an excuse so they don't have to treat people they don't like and of whom they disapprove.

...I don't buy for a moment that these doctors won't treat overweight patients because it's SO risky! I could understand a person by person decision for women with really high risks that included being very obese. But that's not what they're doing here.

The Florida doctors use the excuse that it's more difficult to get a good quality image during an ultrasound of an obese woman, and their office machines can't handle that.

The answer to that? Train your docs and techs in techniques that improve the image for women of size, delay the scan by a few weeks, and if that isn't enough, send the woman to a specialty center with more advanced equipment....for the ULTRASOUND. No need to transfer all of her care to a high-risk maternal fetal medicine specialist just for ultrasounds!

The doctors also complain about their potential for being sued. Now, I generally have great sympathy for doctors who are sued unjustly (as does happen sometimes in obstetrics), and I do think many docs are between a rock and a hard place in terms of malpractice insurance.

But I'm sorry, many doctors face high malpractice rates and don't deny care to fat women. Other docs (and midwives) somehow manage to care for a variety of women, not all of whom are super low-risk.

Categorically denying care to "obese" women, regardless of actual complications, is the result of an inflated perception of risks around this group and sheer outright weight bias.

Another wrinkle to this story is that not only won't they see fat pregnant women, they won't see fat non-pregnant women either now. That's new...but it's a trend that started with obesity and pregnancy and is now extending to non-pregnant fat folk as well. So all of you in the fatosphere who read my posts about weight bias from OBs and think it doesn't apply to you because you don't plan to have children......au contraire. Now it's spread to GYN care. Apparently pregnancy weight bias is just the canary in the mine, warning of further dangers to come regarding equal access to care for all fat people.

Some in the birth world have commented cynically that the one bright spot in this story is that at least fat women in Florida know the worst fat-bigoted practices up front and will be able to avoid them. Too many doctors smile and nod and pretend to be size-friendly, then turn on the mom at term and tell her she "needs" a cesarean or an induction or whatever because of her size.

So, yeah, I suppose that's the one good side to all this. But I'm sorry, I just can't celebrate that.

This is just a further step along an ominous trend to segregate people of size into the care of ultra-high-risk docs, based on their size alone, regardless of whether or not they actually have poor health or develop complications, and regardless of whether such high-intervention care actually improves outcomes.

It's another step along the path of denying people of size health care choices and life choices, "for their own good," and I find that extremely ominous.

We've discussed before in "Ghettoizing Fat Women" that there is an increasing trend to shunt all women of size, regardless of actual complications, into specialized "bariatric obstetrics" practices and regional high-risk hospitals, and denying them access to midwives and a low-intervention model of care. Sadly, I only see that practice increasing. I've heard from women of size who have been denied care from homebirth midwives (despite prior births with them with good outcomes), from birth centers, from regular OBs, and even from some hospitals.....simply because of their size.

No, these are not "super obese" women; these are often "mid-sized" fat women. The idea now is that ALL "obese" women, pregnant or not (and regardless of actual health status and health habits), are being considered far too high risk for any care but the most centralized, most interventionist, most high-risk practices and centers─without actually proving that this sort of care improves outcomes.

And it's a very frightening step down the road of taking birth and healthcare choices away from a substantial group of women. Where is the respect for patient autonomy? For people having the right to choose the kind of care they prefer? For people having a say in their own care? For people being able to say no a style of care they don't want?

Each person needs to have their care individualized, based on their health status, their healthcare preferences, and their needs. We should not have our healthcare choices taken from us, simply because we are fat. And this latest story is just another step along the path of denying patient autonomy to people of size.

An ominous canary in the mine indeed.