Friday, September 19, 2014

PCOS and Birth Control Pills, Part 1: Information about Oral Contraceptives

In previous posts, we have talked about PCOS (Polycystic Ovarian Syndrome). We discussed its definition and symptoms, how it presents, its testing and diagnosis, and its possible causes.

Then we began discussing common treatment protocols for PCOS, and the pros and cons of each. We are discussing treatment options from a size-friendly point of view (meaning no diet talk, no weight loss promotion).

We've already discussed insulin-sensitizing medications like metformin, the TZDs, and inositol. Then we discussed glucose-lowering medications for those who have developed overt diabetes.

Now we are discussing treatments for PCOS, especially those for regulating the menstrual cycle. We talked about progesterone treatments for bringing on a long-overdue period; now we talk about using birth control pills to regulate the menstrual cycle, reduce androgen levels, and control unpleasant PCOS symptoms like hirsutism, acne, and alopecia.
Disclaimer: I am not a medical health-care professional. While the following information is based on my best understanding of the research, always do your own research. This information is not a complete explanation of all the risks and benefits of a particular medication, nor is it medical advice about a health condition or treatment. Consult your healthcare provider before making any decisions about your care plan.
Trigger Warning: Passing mention of the possible weight effects of several medications and of weight loss as a treatment for menstrual irregularity.
Treating for Menstrual Regularity

Many women with PCOS experience irregular periods, often because of progesterone-deficiency. They don't produce enough progesterone to bring on a period and flush out the uterine lining. They tend to be estrogen-dominant, and as a result, that remaining uterine lining is exposed to an excessive level of estrogen for prolonged periods. This can lead to abnormal overgrowth of the uterine lining and eventually, endometrial cancer in some.

Therefore, one of the most important treatment goals in PCOS is to regulate the menstrual cycle. There are two reasons that this is important:
  • to reduce the overgrowth of the endometrium and thereby reduce the chance for endometrial cancer later in life
  • to improve ovulation for the purposes of fertility (if children are desired)
If you've gone a long time without a period, many doctors will choose to use a progesterone medication to "flush out" the uterine lining before trying other medications and treatments to regulate the cycle.

But once the endometrial lining has been "flushed out," the most common medication used by care providers for PCOS is the birth control pill, or The Pill. Oral Contraceptives regulate the menstrual cycle and makes sure your body has a period every month. Most doctors see this as THE treatment of choice for cycle regulation in PCOS.

Remember, although the focus of these post is oral contraceptives, there are alternative treatments out there for regulating menstrual cycles.

These can include lifestyle approaches that are compatible with Health At Every Size® (like moderating carb intake, enhancing nutrition, increasing exercise, avoiding gluten), acupuncture, herbs like vitex/chasteberry, insulin-sensitizing medications like metformin and inositol, and perhaps vitamin D supplementation.

Women with PCOS should also be checked for hypothyroidism. A number of studies have found that women with PCOS have a higher rate of abnormal thyroid function. Some studies suggest that hypothyroidism is associated with menstrual disturbancesinsulin resistance, and infertility. A number of women with PCOS have found that treating even marginal cases of hypothyroidism helped improve menstrual regularity.

Of course, as anyone who has read traditional PCOS medical advice knows, care providers usually strongly promote weight loss for regulating menstrual cycles. They push the idea that "just a 5-10% weight loss" can improve menstrual regularity and fertility, although it remains unclear what type of diet is most optimal, nor that this type of weight loss results in long-term meaningful health effects or sustained weight loss.

It's true that weight loss can be effective in resuming ovulation for some women but remember that studies on this are often extremely small and very short-term. They typically do not show long-term results, nor do they show what happens if weight loss rebounds to more with time (as so often happens). Nor do they acknowledge that weight loss/weight cycling can have risks as well as benefits (see the Weight References section of this blog).

Nor is weight loss effective for regulating the periods or easing PCOS symptoms in everyone; a number of women with PCOS still experience missed periods and significant symptoms even after considerable weight loss. One research meta-analysis noted a distinct lack of high-quality research that examined clinical reproductive outcomes; in other words, it hasn't really been proven that significant weight loss results in more pregnancies and live births. And some research suggests that rapid weight loss or very low calorie diets could even be harmful in obese women undergoing infertility treatment.

The bottom line is that weight loss is another tool that can be considered if you wish, but weight loss is far from the magic bullet that doctors like to pretend it is. For many, it may actually be counter-productive, resulting in far more weight in the long run from rebound. For others, it can lead to eating disorders and unhealthy behaviors. Weight loss for PCOS should not be mandatory, nor should weight loss be a requirement for accessing fertility services or other treatment. 

Remember, there is no one "right" treatment protocol. Each woman must find the right combination of treatments that work best for her circumstances and needs.

For some, this may include oral contraceptives/birth control pills.

Birth Control Pills

Oral Contraceptives are helpful in regulating the menstrual cycle by providing the progesterone each month to prevent endometrial hyperplasia (overgrowth of the uterine lining) and to help bring on your period:
In PCOS, ovulation does not occur regularly, which prevents the rise and fall of progesterone which brings on a woman's period. Instead, the lining is not shed and is exposed to estrogen for a longer period of time causing the uterine lining to grow much thicker then normal. This can cause heavy and erratic bleeding. However, this is not a true period because ovulation has not occurred. Over time, lack of exposure to progesterone may cause endometrial hyperplasia (a fancy word for overgrowth of the uterine lining) which in rare cases can lead to endometrial cancer. Taking the birth control regulates your menstrual cycle by providing the progesterone that your body needs, causing the uterine lining to be shed frequently and reducing the risk of endometrial hyperplasia.
The advantage of The Pill is that it:
  • provides your body with the hormones it needs to have a normal cycle
  • prevents the build-up of uterine lining
  • lowers your chances for endometrial cancer later on, and probably for ovarian cancer too
  • provides contraception until children are desired
  • has an anti-androgenic effect, lessening acne and hirsutism for some
  • may also lessen the severity of symptoms in those who experience difficult and painful periods
The Pill should be taken every day, and at the same time every day, for it to be most effective.

The last few days of the cycle are typically sugar pills (placebos), to enable your period to start afterwards. Even though these have no hormones in them, using sugar pills keeps the habit of taking a daily pill going so there are no inadvertent gaps in coverage. (Not all types of oral contraceptives have a placebo with them, but most do.)

As a contraceptive, the Pill works in the following way:
Hormonal contraceptives (the pill, the patch, and the vaginal ring) all contain a small amount of synthetic estrogen and progestin hormones. These hormones work to inhibit the body's natural cyclical hormones to prevent pregnancy. Pregnancy is prevented by a combination of factors. The hormonal contraceptive usually stops the body from releasing an egg from the ovary. Hormonal contraceptives also change the cervical mucus to make it difficult for the sperm to find an egg. Hormonal contraceptives can also prevent pregnancy by making the lining of the womb inhospitable for implantation.
Our purpose in this post is not to discuss the pros and cons of the Pill as a contraceptive, but instead its utility for regulating the menstrual cycle in women with PCOS, as well as its anti-androgenic benefits.

Some basic information about the Pill's contraceptive properties is given in this post as a introduction to the subject, but it is by no means a complete discussion of the pros and cons of the Pill as contraception. Nor is this intended to be a discussion of potential ethical issues around oral contraceptives.

A thorough discussion of the Pill as contraceptive is a whole different post and not part of the mission of this blog, except in discussing the implications of its use in women with PCOS/women of size.

Our focus here is primarily on the pros and cons of the Pill for menstrual cycle regulation and treatment of PCOS symptoms. Please keep that in mind as you read and comment on the post.

Types of Birth Control Pills

There are many birth control pills to choose from. Unfortunately, a really complete discussion of types of birth control pills is far beyond the scope of this blog, especially since types of birth control pills change over time, but you can read some summaries about them here.

Basically there are two main types of pills:
  • Combination pills, which use a combination of progestin and estrogen
  • Progestin-only pills 
Combination Pills

Combination pills have both progestin and estrogen, and are about 99.9% effective, if used correctly. This drops to around 91% or so if they are used less than perfectly.

There are a number of different versions of combination pills, as written about here:
Combination pills can be differentiated on whether the dose of estrogen progestin stays the same throughout the pill pack (monophasic), if progestin increases once about halfway through the pill pack while the estrogen stays the same (biphasic) or if the levels of estrogen and progestin are different each week of the pill pack. 
Keep in mind that in each of these types of pills, the last week is only a sugar pill, which contains no active hormone. This allows for normal shedding of the uterine lining. 
Monophasic pills can be classified further based on the dosage of estrogen, known as ethinyl estradiol, in the pill. Low dose oral contraceptives contain 20mcg of estrogen plus the progestin. Regular dose contain(s) 30mcg to 35mcg of estrogen plus progestin and high dose contain 50mcg of estrogen plus the progestin.
The first generation of oral contraceptives contained ~150 micrograms (mcg, or ยต) of estrogen (ethinyl estradiol). Starting in the late 1960s, the estrogen dose was strongly reduced in order to improve efficacy and safety and to decrease side effects. Compare the numbers above; it's amazing how much lower the doses tend to be now (20-50 mcg vs. 150 mcg).

Another difference between combo pills can be the type of progestins that are used in the pill. As of now, these are the different types of progestins used in most combined pills; each with its own pros and cons:
  • Desogestrel
  • Norgestrel
  • Levonorgestrel
  • Norethindrone
  • Norethindrone acetate
  • Ethynodiol diacetate
  • Norgestimate
  • Drospirenone
Some of these progestins have strong androgenic effects (Norgestrol, Levonorgestrol, and to a lesser effect, Norethindrone and Norethindrone acetate) so most women with PCOS may be better off with a combined pill that uses other progestins.

Another couple of progestins (cyproterone acetate and dienogest) that have strong anti-androgen effects are available in combined oral contraceptives for use outside of the United States but are not available in the U.S.

Each combination pill has its own benefits and risks, and it is far beyond the scope of this post to discuss the pros and cons of each. Discuss the choice of combo pills in detail with your care provider, and then do your own research on your own as well. You can find discussions of the pros and cons of the various Pill choices here and here.

So, to summarize, combo pills differ in three main ways:
  1. Dose of estrogen used
  2. Types of progestins used 
  3. How the relative dose of progestin/estrogen changes (or doesn't change) during the month
The wide variety of combo pills available offers women many choices to see which suits their needs best. Women who experience uncomfortable side effects on one type of pill may well find that another type suits them better.

A careful and thorough consultation with a care provider is vital to using oral contraceptives wisely. Don't be afraid to get a second opinion.

Progestin-Only Pills

Progestin-only pills (also called the Mini-Pill) do not contain estrogen, unlike combination pills. They are usually prescribed for breastfeeding women (since estrogen can inhibit milk production, especially in the first few months after birth), and sometimes for those who experience nausea with estrogen. As a contraceptive, Mini-Pills work in the following way:
Mini pills work by thickening the cervical mucus so the sperm cannot reach the egg. The hormone in the pills also changes the lining of the uterus, so that implantation of a fertilized egg is much less likely to occur. In some cases, mini pills stop ovulation (the release of an egg). A pill is taken every day.

If mini pills are used consistently and correctly, they are about 95% effective -- somewhat less effective than standard birth control pills.
It is vitally important to take the Mini-Pill at the same time each day for the best efficacy. Any deviation from this timing can substantially reduce its effectiveness. Missing a dose also significantly increases the chances of inadvertent pregnancy and a back-up method should be used.

Because obese women are at higher risk for blood clots and the estrogen in combined pills can increase the risk for clots, some care providers prefer progestin-only oral contraceptives for this group. ACOG suggests considering progestin-only pills or IUDs with hormonal components for obese women, but does not rule out use of combination pills for this group.

While progestin-only oral contraceptives can help treat irregular periods so common with PCOS, they will not help reduce acne or hair growth issues. Therefore, progestin-only mini-pills may be useful for some women with PCOS, while others will prefer combination pills. Still others will choose to avoid oral contraceptives completely and use alternative methods to promote menstrual regularity and reduce androgenic side effects.

Side Effects and Contraindications

Like any medication, the Pill does come with side effects, contraindications, and interactions with other medications that users should be aware of.

Side Effects

The most common side effects are fairly minor:
  • Nausea
  • Weight gain
  • Sore or swollen breasts
  • Spotting between periods (especially with the Mini-Pill)
  • Lighter periods
  • Mood changes
Some women also report an increase in headaches and blood pressure while on The Pill. 

Some side effects are potentially very serious and need immediate medical attention. They can indicate problems such as liver or gallbladder disease, stroke, blood clots, heart disease, or hypertension. You can remember these by the acronym, ACHES:
  • Abdominal pain (stomach pain)
  • Chest pain
  • Headaches (severe)
  • Eye problems (blurred vision)
  • Swelling and/or aching in the legs and thighs
The risk for blood clots with the Pill seems to be greatest in the first year of use.

While the risk for blood clots, heart attacks and strokes with the Pill is higher than in women who do not use the Pill, it's also important to remember that the actual numerical risk is small, and is less than the risk for blood clots during pregnancy.

Low-dose combo pills seem to have less risk than higher-dose pills, and the risk for blood clots seems to disappear once oral contraceptives are stopped.

Some women who experience negative symptoms with one type of The Pill are able to tolerate a different type better, so it can be useful to try switching if you are bothered by side effects. Sometimes just waiting a few months or taking The Pill with meals (or in the evenings) is enough for side effects to lessen.

Side effects with the Mini-Pill tend to be less severe than with combo pills, but the trade-off is that it is somewhat less effective and can worsen depression in those already experiencing depression.

On the other hand, some women find that the Pill just doesn't feel right to them because of side effects. They may need to consider other options instead for regulating their cycles or birth control.

The question of whether the Pill increases a woman's risk for developing diabetes is more difficult to answer. Some studies have found an increase in insulin resistance/decrease in insulin sensitivity in women on oral contraceptives, while other studies have not. Some have found an increased rate of diabetes, while others have found lower blood glucose levels or no increase in diabetes cases.

Since there are so many formulations, a lot depends on the type of oral contraceptive used; high-dose combination pills (30+ mcg of ethinylestradiol) seem to have a more negative effect on insulin sensitivity. Low-dose pills seem to have less effect.

If there is an effect in most women, it probably is a very modest one, especially with low-dose combination pills. However, if you are borderline already, some types of oral contraceptives may increase your susceptibility to diabetes or glucose intolerance.

Some care providers prescribe a combination of low-dose combination oral contraceptives (for their anti-androgenic effects) and metformin (to help counteract any increase in insulin resistance from the oral contraceptives) for women with PCOS who they feel are particularly at risk for diabetes and metabolic syndrome. 


Women who should not take The Pill include:
  • Women over the age of 35 who smoke
  • Women who smoke
  • Women who have a history of blood clots 
  • Women with serious heart or liver disease
  • Women with serious heart valve problems
  • Women who have had breast cancer, uterine cancer or liver cancer
  • Those with brittle, severe, or long-term diabetes with complications
  • Those on prolonged bed rest
  • Those with a history of migraines with auras
  • Those with uncontrolled high blood pressure
  • Those who had cholestatic jaundice of pregnancy or jaundice with previous oral contraceptive pill use
Whether women with certain other conditions should use oral contraceptives is controversial. These conditions include lupus and poorly controlled hypertension.

Non-smoking women over age 35 is another controversial category. Doctors seem to be leaning towards the view that low-dose combination pills are relatively safe in this group, but that counseling should be individualized based on the woman's personal medical history.

Blood clots may be a significant consideration for women with PCOS on the Pill.

Research shows that women with PCOS tend to have a higher risk for blood clots than the rest of the population; the concern is that use of the Pill in women with PCOS might elevate that risk even further.

And in fact, one study showed that women with PCOS on the Pill had about twice the risk for blood clots as other women on the Pill, and an increased risk compared to women with PCOS not taking the Pill.

However, not all studies agree; some studies have found oral contraceptives to be protective against blood clots in women with PCOS.

All women with PCOS who are considering the Pill should discuss the risk for blood clots with their care providers. If you have further risk for clots, such as a first-degree relative who has experienced blood clots or poorly-controlled hypertension, you will need to consider the use of the Pill especially carefully with a care provider.

Interactions with Other Medications

It's important to remember that some medications may interfere with the efficacy of the Pill, including certain antibiotics, anti-fungals, anti-seizure meds, anti-depressants, and others.

In addition, some "natural" remedies like soy and St. John's Wort can also lessen the effectiveness of the Pill. Vomiting and diarrhea may also cause problems with intestinal absorption, as can weight loss surgery procedures like gastric bypass.

Some evidence also suggests that TZDs (insulin-sensitizing medications like Avandia and possibly Actos) can decrease the effectiveness of oral contraceptives. Since some women with PCOS may be treated with TZDs as well as birth control pills, this is an important possibility to discuss with your doctor.

You can read more about medications that may interfere with the efficacy of oral contraceptives here.


Most traditional care providers consider oral contraceptives as one of the best first-line treatments for PCOS.

They help regulate menstrual cycles, prevent endometrial hyperplasia, reduce the risk for endometrial cancer, and probably also decrease the risk for ovarian cancer. In addition, some oral contraceptives have an anti-androgenic effect, so problems such as hirsutism and acne may be lessened while on the Pill. These potential benefits are considerable and should not be shrugged off lightly.

However, it's important to point out that some women with PCOS feel that oral contraceptives are merely a band-aid approach to PCOS and may even be harmful. We will discuss that in more detail in the next post, but be aware that while most care providers consider oral contraceptives to be the treatment of choice for PCOS, some in the PCOS field believe they are counter-productive.

If you choose to use them, oral contraceptives come in a dizzying array of choices (monophasic, biphasic, triphasic, low-dose or regular-dose estrogen, type of progestin used, etc.). There are so many choices available that it is vitally important to consult a care provider who is extremely well-versed in the pros and cons of each to decide which might be the right choice for your situation.

Although the estrogen levels have been significantly decreased over time, there is still an increased risk for blood clots with oral contraceptives. These risks seem to be particularly potent in women who smoke and in those with a family history of blood clots. Other groups have some increase in risk as well, so it's important to consult a care provider who can examine all your individual risk factors when considering whether to try an oral contraceptive.

It is not clear at this time whether oral contraceptives present particularly high clotting risks for women with PCOS. Some research suggests that it does, but not all research agrees. This is an area that needs much more research, given how often oral contraceptives are prescribed for menstrual regulation in women with PCOS.

Remember that while oral contraceptives and/or progesterone treatments can be helpful in PCOS, they are not your only choices for treatment. For some, they can be the best choice; for others, they are not.

Some women with PCOS benefit most from a combination approach (oral contraceptives plus other medications like metformin), while others get the best results from alternative protocols (herbs, lifestyle modifications, alternative medicine). For some, weight loss is helpful (at least temporarily), while others do not gain much benefit from it and may even incur harm from it.

The point is that there are no clear answers as to the "best" protocol for treatment of PCOS. Most women find they need to experiment with several different approaches to find the best combination for their individual needs.

And of course, you always have the right to determine the best treatment protocol for your needs. While a knowledgeable care provider can be truly invaluable in this process, there are no protocols that you "have" to follow just because you have PCOS.

YOU are always the ultimate boss of your own body and your own treatment choices.


References About PCOS
General Information about The Pill
Information about Different Types of The Pill
Information about Side Effects of The Pill

Monday, September 15, 2014

PCOS Series Resumes

Image Credit: Jessi from 
September is PCOS Awareness Month.

In honor of the many women of size who suffer with Polycystic Ovarian Syndrome (PCOS), we will be resuming our series of posts about PCOS this month.

In previous posts, we have discussed the definition and symptoms of PCOS, how it presents, its testing and diagnosis, and its possible causes.

Then we began discussing common treatment protocols for PCOS, and the pros and cons of each.   We've already discussed insulin-sensitizing medications like metformin, the TZDs, and inositol. Then we discussed glucose-lowering medications for those who have developed overt diabetes. We also discussed the use of progesterone for menstrual irregularity. Now it's time to continue that discussion about other treatment options for various aspects of PCOS.

Next up is a discussion of Oral Contraceptives for menstrual regularity and control of androgenic symptoms. Then we will continue the series with a discussion of anti-androgen medications, and finish up with a discussion of cosmetic treatment options for some of the most distressing side effects of PCOS, like hirsutism, cystic acne, and alopecia.

One of the difficult things about PCOS is how differently it can present in different women. Very few women suffer all the possible symptoms. I'm fortunate that my case is fairly mild, but that makes it more challenging to write about things I haven't personally experienced. Although I can write about it from an intellectual point of view, it's really important to bring out the personal stories of women and how they've dealt with the challenges of this condition.

Therefore, I am particularly looking for more personal stories to share. Stories have already been submitted, but I would like to have many more. Please spread the word on PCOS forums and social media.

Your submission need not be long; just a quick summary of your experiences with an oral contraceptive, an anti-androgen medication, or how you have dealt with hirsutism, acne, or alopecia. Don't forget to give permission for me to share your story and how you want it attributed (anonymous or first name only). Send your submission to me at kmom AT  plus-size-pregnancy DOT  org. (But remember, we want to avoid weight loss talk.*)

As a springboard to the renewal of the PCOS series, I invite you to leave a comment (feel free to be anonymous) about the most challenging or distressing symptom/aspect of PCOS for you. It's a hard condition to have, and the symptoms can provide many social and emotional challenges. Sharing about those is important for healing and dealing with the condition more proactively. Please share about your particular challenges so other women will know that they are not alone.

More PCOS posts will be forthcoming in the future, but for now, this is the current focus. I welcome appropriate feedback on the posts and hope the information is helpful to you.

*Please note that we are discussing PCOS treatment options from a size-friendly point of view (meaning no promotion of/focus on weight loss; no diet talk/no hate talk allowed in comments). There are plenty of other PCOS resources out there that promote weight loss or dieting approaches as treatment. You are certainly welcome to pursue that if you wish, but if you are only interested in that, this is not the site for you. Please find the site that is right for your needs. 
Remember, though, weight loss is not the only way to treat PCOS! Lifestyle management does not have to include trying to lose weight. The Health At Every Size® and HAES® approach to improve health and manage PCOS symptoms can also be useful. What we want here is a safe place to discuss PCOS treatment that does not center on weight loss, radical diets, or body hate talk; sadly, a safe place like that can be hard to find on many PCOS forums. Considering the tremendous failure and regain rate of diets (and the huge profits this brings the weight-loss industry), a weight-neutral approach to PCOS is long overdue. 

Tuesday, September 9, 2014

Preparing Your Family for an Emergency

Among other things, September is National Preparedness Month.

This means it's time to shore up your preparations for unexpected emergencies. This kind of preparation is especially important if you have children or other family members dependent upon you.

You should be asking yourself, do I have enough supplies to get through an emergency where grocery and water supplies might be interrupted? Do I know my school or childcare's emergency plans? How will I reunite my family after an emergency?

Here is a link to an article about emergency planning for families. Among the important points of the article, the author points out that:
  • Despite their disaster risk concerns, the majority of parents (63 percent) are not very familiar with emergency plans at their child’s school or child care
  • Two thirds (67 percent) don’t know if emergency drills are held frequently, or at all
  • Two in five (42 percent) wouldn't know where to reunite with children if evacuated from school or child care
So let's talk about a few important points for family emergency planning:

  • Family Emergency Kits
  • Family Communication Plans
  • Evaluating School Emergency Plans 
Family Emergency Kits

Many parents haven’t set aside key disaster supplies, such as the bare minimum three-day supply of food and water. (Most experts agree that a five-to-seven-day supply is better, and many recommend at least a two-week supply.)

It's most optimal to have multiple kits; one for at home, one in an outbuilding or garage near your home in case you can't get into your home due to damage, and one for your car in case you are away from home when an emergency occurs. Some people choose to have a small emergency kit for their workplaces as well.

These kits don't need to be elaborate. Remember, something is better than nothing.

Yet nothing is what most people have. Even if your kit isn't perfect or doesn't have every recommended thing in it, get SOMETHING going.


The most critical thing to have on hand after a disaster is fresh drinking water ("potable" water). Have a gallon of fresh water in your car, just in case. Because a car is subject to extremes of temperatures, this water should be rotated every 6-12 months, but this is a very easy thing to do.

At home, store a few 5-gallon containers of drinking water in your house or outbuilding in case your regular water supply is disrupted. Each person in the household needs at least 1 gallon of water per day. Don't forget to add in some water for pets too.

Portable water bottles are an important part of any emergency kit. The best are stainless steel so they can be directly heated over a fire.

You should also have a way to filter and purify water in case the emergency extends beyond your stored water supply. You can read more about that process here. Water storage and purification supplies can be bought at most camping stores.


Ready-made snacks are helpful for your emergency kit. Foods such as granola bars, energy bars, and fruit leather pack well and last a long time. Don't forget food for your pets too.

Emergency Information Card

An emergency information card is helpful. This should contain a recent picture of your child, a recent picture of your family, emergency contact information for family members, home address and phone number, the name and number for your child's doctor, a physical description of your child, a list of any special conditions/medications, and an out-of-state emergency contact. 

Most children benefit from a small activity in their emergency bag. A deck of cards, a small game, or a few small toys give an evacuated child something to do and bring a sense of familiarity and safety to an insecure situation. Young children also benefit from a comfort object, like a small stuffed animal, as well as a hand-written letter from a parent to offer them reassurance and love.

Family Communication Plan

Think of all the time you spend separated from your children each day, either due to work or school or their various activities. If an emergency occurs when you are away from your children, how will you find each other? How will you communicate?

A Family Communication Plan can help family members reconnect after an emergency. This doesn't have to be an elaborate plan; it can be quite simple. The key is to have talked about your plan before an emergency occurs.

Create Paper Back-Ups of Important Numbers

Create a paper copy of important contact phone numbers; this can be combined with the emergency information card listed above. Store a copy in each person's backpack, purse, or vehicle.

Most kids today don't bother to memorize their parents' cell phone or work numbers, let alone their relatives' numbers. It's all in their cell phones, so they don't feel the need to memorize anything. But phones fail, get damaged, get lost, or run out of power. Having a paper copy with all contact information on it is important as a back-up.

Even if your child knows all these numbers by heart, a person under stress can forget everyday information like where they live or their own phone number.Memorizing important phone numbers is still a good thing to do, but it's best to have paper back-up too, just in case.

Also designate an out-of-state contact as your emergency notification number. Ironically, it is often easier to reach someone out of state than it is to reach someone locally after a disaster. Have someone far away be the person who helps facilitate communication between family members. Have that number programmed into everyone's phone and written into your emergency information card.


If a disaster occurs, your first priority is securing your own safety and that of those around you. As soon as you can manage, however, use your cell phone to send a text message to your family members. Remember, experts recommend that you TEXT, DON'T TALK. 

After an emergency, phone networks will be overwhelmed, and many cell towers will go down pretty quickly or have limited power. Texting takes only a brief amount of power and as a result texts are much more likely to go through during an emergency.

Create a texting tree for your most important contacts. Send a brief message as soon as you safely can after an emergency, as it is more likely to get through sooner than later. Briefly summarize how you are and where you are, remind everyone of your designated meeting place, and tell them to update their status with the out-of-state emergency contact.

You can also briefly post to social media like Facebook or Twitter to let a wider circle of people know that you are all right. Minimize contact, though, to reduce network congestion and help others get through to their families.

The Red Cross also has a program called "Safe and Well" which can help you communicate with loved ones in a disaster. This can help people who have been evacuated to a shelter but who may have very limited online access to connect with loved ones.

Put "ICE" Contacts Onto Your Phone

Identify several ICE ("In Case of Emergency") contacts and program them into your phone. There are smartphone ICE apps now (some free, some at a very low cost) that will show ICE numbers on the cover wallpaper of your cell phone (without someone having to know your phone code to unlock it).

Emergency Responders have been trained to look at your phone to see if there are ICE numbers available. If you are unconscious, they will contact those ICE numbers for you. The emergency information card in your wallet or purse can also serve this function if your phone is damaged or lost, but most Emergency Responders will look at your phone first.

Again, have the information in more than one place. Have it on your phone because that is the first place Emergency Responders will look, and also on a paper back-up in case your phone is broken or not accessible.

Designate a Family Meeting Place

If the family is apart when an emergency happens, where will you meet? The first choice is usually at home, but what if your home is damaged or the neighborhood off-limits because of road washouts from a storm or toxic fumes from a chemical spill?

Be specific about where you'll meet. If you are going to meet at a church, are you going to meet in on the front steps? The back entrance? By the announcements board?

Designate a back-up emergency meeting place in case your first choice doesn't work out. Experts also suggest a regional meeting place in case you have to evacuate out of the immediate area and are not allowed to return for a while.

Establish Retrieval Responsibilities 

Establish ahead of time who is responsible for retrieving which child. If you have multiple children in different schools or activities, having someone assigned ahead of time to each of those children will help minimize duplication of efforts and wasted time. If there is only one parent available, then establish a routine of which child will be fetched in what order (usually youngest to oldest).

Evaluating School Emergency Plans

By a certain age, most kids spend considerable time away from their parents at school or daycare or other activities. How can you help these organizations improve the students' safety profile for when you are not there?

One way to help them is to evaluate their emergency plans and press them to improve drills and planning. Another is to familiarize yourself with their Family Reunification Plan.

Improving Emergency Drills

Your school undoubtedly already holds regular fire drills, since this is required of all public and private schools by law. However, you should ask further questions about the types of drills your school holds. Some not only have fire drills, they also have drills unique to the potential disasters in their area, such as earthquakes, tornadoes, or tsunamis. In addition, many schools these days have Lock-Down Drills and Shelter-In-Place Drills. Ask your school which drills they are holding and press them to hold drills appropriate to the area they are in. 

Also encourage your school administrator to hold emergency drills with a twist. Many kids know exactly what to do if a fire drill occurs in the middle of class (which is when nearly all fire drills are held). But what if a fire occurs during recess? During passing time/bathroom breaks? What if your child's designated exit is blocked during the fire? It's important for schools to practice not just "plain vanilla" drills, but also Deluxe Drills, where unexpected things happen or where drills occur at times of more confusion. 

Reunification Plan

Become familiar with your school's Emergency Reunification Plan. Would you know where you should report to pick up your child in an emergency? Do you know what the protocol is to sign your student out?

Because schools are legally accountable for knowing where students are at all times, there must be an orderly reunification process that documents all actions. Parents will not be allowed to just rush in and grab their children and leave. 

Usually students will be evacuated to a designated area, away from parents and the school building. Parents come to an assigned reunification area and request their student. A runner brings the child to the reunification area, the parent shows ID verifying their identity and signs the child out, and then the parent may leave with the child.

You can save a lot of time and stress by knowing ahead of time where the reunification area is and heading straight there. Also ask how your school plans to communicate with parents in an emergency situation if power is out or phone networks are overwhelmed. It may be that the planned reunification area has to be moved.

As with emergency drills, work with your administrators to improve the planning around the family reunification process. Encourage them to actually do a dry run some time so they can see what the strengths and weaknesses of the procedure are before a true emergency occurs. 


Emergencies can be scary, but remember, most don't turn into life and death situations. Even so, having a good emergency kit, a family communication plan, and knowing your school's emergency plans can help keep an emergency situation more low-key and less confusing.

And in a true emergency, these things might just save some lives. So take the opportunity of National Preparedness Month and review your family emergency planning today.

Tuesday, September 2, 2014

Obstetric Insanity: An 80% Cesarean Rate in Super Obese Women?

Here is a recent study showing just how severe the problem of high cesarean rates in "obese" women is.

I have not read the full text of the study yet, but was so struck by the outrageous numbers in the abstract that I had to comment.

In this study, the authors unapologetically document a sky-high cesarean rate of 80% in women with a BMI above 50.

Women with a BMI over 50, by the way, is the newest scapegoat of bariatric obstetrics. By focusing on the most obese group, these docs can ratchet up hysteria around obesity and drum up support for extreme interventions (even though intentional weight loss and its rebound afterwards is usually a substantial contributor to this level of obesity).

Listen to the emotionally-loaded way the authors discuss "Globesity." It's no wonder their patients have an 80% cesarean rate; they obviously see this group as a ticking time-bomb waiting to explode.

It's not that we should ignore that this group can have significant complications; they can. Some of them are documented in this study, including a maternal death and an increased rate of stillbirths. We can and should be concerned about these complications and debate ways to lower their rate.

But an 80% c-section rate? A 44% primary cesarean rate? How in the world can they justify that, even when complications exist?

Especially when a British study of women in the same BMI group found that 70% were able to give birth vaginally when given the chance!

We must get away from this obstetric culture of hysteria around obesity. We shouldn't ignore or downplay the risks, but we must not respond to those risks by introducing these women to even more risk by exposing EIGHTY PERCENT of them to the substantial risks of surgery, infection, anesthesia problems, and the downstream effects of cesareans.


Obstet Gynecol. 2014 May;123 Suppl 1:159S-60S. doi: 10.1097/01.AOG.0000447159.35865.07. Perinatal outcomes in the super obese: a community hospital experience. Papp MM1, Lindsay A, Mariona F, Chatterjee S. PMID: 24770057
INTRODUCTION: Globesity is recognized by the World Health Organization as a pandemic issue. Obesity is considered the second leading cause of preventable death in the United States. Michigan is considered the fifth fattest state in the country. METHODS: Ongoing observational study involving pregnant women with body mass index equal or above 50 kg/m. The study was approved by the Wayne State University institutional review board. The patients were identified in the outpatient clinic and private practice offices and followed during their prenatal care and delivery. RESULTS: One hundred thirteen women are included. Body mass index was between 50 and 106 kg/m. Delivery occurred between 26 and 40 weeks of gestation. A total of 44.24% were delivered by primary cesarean delivery, 36% by repeat cesarean delivery, and 19% by vaginal delivery...Wound infection occurred in 17%. CONCLUSIONS: Pregnant women with extreme obesity incurred a significantly higher number of obstetric-medical complications during the prenatal, intrapartum, and postpartum periods than their counterparts with recommended body mass index. Public health officials and clinicians must join efforts to increase the population awareness of the implications of obesity during pregnancy and the postpartum period. The effect of maternal obesity on the offspring should prompt a community effort to improve preconception health and weight control to improve the maternal and neonatal health.