Oral Contraceptives and the Monthly Pill Pause

Feeling Sad

During normal menses it is not unusual for some women to experience an increase in a sad or anxious mood. This is due to the fairly rapid change in female hormones during this part of the menstrual cycle.

Does the same thing happen to women using combined oral contraceptives (OCP) the week when the pills do not contain hormones and when menstrual bleeding happens (the “pill pause”)?

Researchers wanted to find out [see the reference at the end of this article]. They compared women on OCP with women of the same age who were not taking oral contraceptives. The women recorded their moods during their menstrual cycle.

The results showed that the women using OCP “had significant mood deterioration during the pill pause.” The mood changes were comparable to what the women who were not on OCP experienced during their menses.

The researchers also noted that the “mood worsening during the pill pause was more pronounced in women with higher baseline depression scores.”

Thus, taking a one week pill pause each month did not benefit women in terms of reducing their experience of negative moods during menses.

As the researchers put it, “Therefore, whether a pill pause is advantageous from a mental health perspective is questionable.”

So, what benefit does the pill pause provide? It does reduce the risk of breakthrough bleeding, and having menses reassures the woman that she is not pregnant.

However, there are many women who do not believe that these benefits are reason enough to deal with a monthly menses and the associated mood changes while on OCP.

It is generally considered safe for many women to take an active pill continuously (i.e., omit the pill pause). However, before any woman decides to do that, she should consult her physician. There are situations in which omitting the pill pause would be contraindicated.

The reference for the research on mood changes during a pill pause, including all items within quotation marks, is:

Noachtar IA, Frokjaer VG, and Pletzer B. Mental health symptoms in oral contraceptive users during short-term hormone withdrawal. JAMA Network Open 2023; 6(9).e2335957.

[Comments about the purpose of the pill pause are not taken from the article but reflect how I was trained.]

Peter M. Hartmann, MD

Family Medicine & Psychiatry

Oral Contraceptives and Heart Disease

Heart Disease

Does taking oral birth control pills increase your risk of heart disease? Studies in the past have not given a clear answer.

However, a recent study published in the Journal of the American Heart Association has given an answer. The study was published in the journal by Dou W, Huang Y, Liu X and others on August 10, 2023; 12:e030105.

The study looked at 161,017 women. A comparison was made between those women who ever used oral contraceptives compared to those who never did.

Here is what the researchers concluded: “Oral contraceptive use was not associated with an increased risk of cardiovascular events and all-cause death in women and may even produce an apparent net benefit.”

In addition, they concluded that “… the beneficial effects appeared to be more apparent in participants with longer duration of use.” Longer duration meant more than 5 years of use.

All-cause death means dying for any reason, not just from heart disease. So, oral contraceptives appear to protect women from dying from heart disease as well as other causes.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Allergy to #Meat from Mammals

Cows

Did you know that people can develop an allergy to meat from mammals such as cows and pigs? This is called alpha-gal syndrome.

An interesting article on this topic was published in JAMA NETWORK by Mollah and colleagues online on December 8, 2023. It is intended to provide education to the general public and was made available on JAMA’s Patient Page.

This blog is based entirely on their article. At the end I will show you how to access the original article for free.

Alpha-gal syndrome is an allergy to a sugar molecule “present on the cells of most mammals (cows, pigs, lambs, goats).” If a person is allergic to this sugar molecule, “eating those animals or their products (such as milk, cheese, or gelatin) may result in an allergic reaction, typically within 2-6 hours.”

The reaction can be “mild to life-threatening…”. Symptoms “may include swelling of the lips, tongue, throat, or eyelids; hives; cough; difficulty breathing; wheezing; heartburn; nausea; vomiting; abdominal pain; diarrhea; or decreased blood pressure.”

Mild reactions can be treated with an antihistamine, but severe reactions may require an injection with epinephrine with or without other treatments in an emergency room.

People with the alpha-gal syndrome should have an “epinephrine auto-injector available in the event of a severe reaction in the future.”

This syndrome is “associated with tick bites, most commonly from the Lone Star tick in the US …” The “tick injects a type of sugar molecule (galactose-alpha-1,3-galactose), also called alpha-gal, which leads to the formation of an antibody,”

Diagnosis may require a blood test that can find antibodies “against the alpha-gal sugar molecule.”

Anyone allergic to alpha-gal should “stop eating mammalian meat (such as beef, pork, or lamb) and should be vigilant to avoid future tick bites.”

There are also certain medications that can trigger an alpha-gal reaction; these medications will need to be avoided in patients with alpha-gal syndrome. If you have the syndrome, be sure your doctor knows so he/she can avoid prescribing these medicines.

Allergic patients may also need to stop using “mammalian-based products (such as cow’s milk, cheese, or gelatin).”

To see the original article by Mollah and colleagues, type exactly what you see below on your search bar:

doi:10.1001/jama.2023.23097

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Obesity # Research

Overweight and Obesity

Research by Ma and colleagues published in the International Journal of Obesity on Nov. 8, 2023 compared alternate-day fasting (ADF) to 3 other weight loss approaches.

They found that ADF was superior to the three other methods with greater weight loss and greater loss of waist circumference. This was the case for both overweight and obese subjects.

If your current approach to weight loss is not working, you might consider looking up ADF online.

A research study by Aronne and colleagues was published in JAMA online on Dec. 11, 2023. The research compared obese patients given a new weight-loss medicine, tirzepatide for 36 months compared with others who took it for 52 months.

Tirzepatide is an injectable medication that was given at high doses (10-15 mg) once a week. All patients met criteria for obesity without diabetes.

All patients received lifestyle counseling (decrease calories and increase regular exercise).

Half the patients stopped receiving tirzepatide after 36 weeks and were given a placebo shot for 16 more weeks. The other half continued to receive tirzepatide during those 16 additional weeks (total of one year).

Comparing the outcomes for the two groups at the end of one year showed that those who remained on the tirzepatide did better than those who stopped receiving it after 36 weeks.

Those who continued the tirzepatide lost an additional 20.9% of their body weight, whereas those who were switched to a placebo injection gained 14% of their body weight.

The researchers concluded that tirzepatide is an effective weight loss medication at these high doses, but it needs to be continued for over a year. It may be that it needs to be taken indefinitely.

The FDA has approved tirzepatide for the treatment of obesity (brand name for the treatment of obesity is Zepbound). There is another brand-name tirzepatide product for diabetes (Mounjaro).

Peter M. Hartmann, MD

Family Medicine & Psychiatry

Best Day and Worst Day

Tell us about your first day at something — school, work, as a parent, etc.

Newborn Baby

It was the best day of my life and the worst day of my life. My first child, a boy was born in an Air Force hospital in the suburbs of Washington, D.C.

I was there for the birth. As soon as he was born, he was looking around and wasn’t crying. It was love at first sight. I experienced a supreme joy like never before.

In the morning, he was circumcised. His doctor came to talk to my wife and me. Our baby did not stop bleeding after the procedure so they wanted to transfer him urgently to a major military hospital in D.C. (Walter Reed).

They had pediatric blood specialists there. I planned to drive to the hospital while my son was transported by ambulance.

By pure chance, I saw him in a portable incubator as they took him to the ambulance. He was barely moving and his skin was gray in color.

I thought he was dying. With tears running down my cheeks, I quickly drove to Walter Reed Hospital. I have no idea how I found it.

The doctors there took great care of him. He was given a blood transfusion, which stopped the bleeding and replenished the blood he had lost.

A pediatric blood specialist (hematologist) talked with me. Tests showed that my son had a genetic bleeding disorder, hemophilia A. That is why he couldn’t stop his bleeding from the circumcision.

He was going to survive! Yes, he would need intravenous medication to stop abnormal bleeding, but he would otherwise do alright.

I will never forget that first day when my son was born (pure joy) and then almost died (pure agony).

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Diabetes Cure or Not?

Diabetes

There are a large number of “commercials” on Facebook that claim there is a cure for diabetes. Many of them claim that Dr. Oz has either developed the new treatment or endorses it.

Some say that he is an expert on diabetes. It should be noted that Dr. Oz is a heart surgeon and not an endocrinologist.

The treatment is said to reduce blood sugar, enable weight loss, and removes the need to watch what you eat. In short, it cures Type II Diabetes!

Some of these ads call the treatment PureHarmony CBD Gummies, others call it WellnessPeak CBD Gummies, and others call it something else.

One ad claims that two sisters, who are chemists at MIT, developed another version called, GreenVibe CBD Gummies.

Another one says that “a top scientist” developed a new treatment. Another one touted the use of a pre-meal plan based on practices by “ancient tribes in India.”

Generally, at the end they acknowledge that the FDA has not approved their “medication.”

A cure for diabetes that only takes a week or so would be a dramatic advance. One wonders why physicians don’t know about it.

My suspicion is that these treatments do not cure diabetes and likely don’t even lower blood glucose levels. It seems likely that these are attempts to get people who want a quick cure to buy their product.

One ad claimed to give a 100% guarantee, no questions asked “within 60 days. That is one year.” Not sure where on earth 60 days is a year.

If it sounds too good to be true, it probably isn’t true. Buyer beware!

Peter M. Hartmann, MD

Family Medicine & Psychiatry

#Magnetic Seizure Therapy versus #ECT

Magnetic Stimulation of Brain

Electroconvulsive Therapy (ECT) has been used to treat severe depression for many years. It is highly effective and can be lifesaving. However, it can cause temporary mild cognitive changes after the procedure.

There is a new method of giving seizure treatment for depression that uses a magnet instead of pulses of electricity. It is similar to transcranial magnetic stimulation (TMS), which treats depression but without causing a seizure. It is not as effective as ECT, but it does not require anesthesia and is routinely performed on outpatients.

The new treatment uses equipment similar to TMS but the dosing causes a seizure so anesthesia is needed. It works just as well as ECT but the temporary cognitive changes are more mild and return to normal cognition is much faster.

These results were reported in a research article published by Deng and colleagues in JAMA Psychiatry on Dec. 6, 2023.

ECT does get the patient to remission (full resolution of depressive symptoms) a bit faster than Magnetic Seizure Therapy. However, the end result is the same.

We now have a another treatment for severe depression, which is as effective as ECT but a more rapid resolution of temporary cognitive changes.

Peter M. Hartmann, MD

Family Medicine & Psychiatry

Being A Night Owl

Are you more of a night or morning person?

Night Owl

I prefer to stay up late and sleep in (when I can). I am a “night owl.”

That is at least partly because I have adult ADHD. Although being a night owl is not an official part of the diagnostic criteria for ADHD, people with this disorder tend to be night owls.

I have not been a teenager for a very long time, but my being a night owl is something I share with them. The internal rhythm in teens usually involves staying up late and being sleepy in the early AM.

That is why it is a challenge for teens to adhere to the standard school start time. Ideally, teens would start school later in the morning.

There are two practical problems with doing this. The first is that the school day would end later so there would be less time for after school activities.

The second problem is that the same school buses pick up all 3 age groups of kids, one group at a time. The high school kids are picked up first as it is safer for them to be out waiting for the bus when it may still be dark.

Then, the middle school kids are picked up, followed by grade school kids. In short, the same buses go the same route 3 times each school day. At least, that is what I have heard.

There does not appear to be an easy solution to this problem so teens (high school age) end up getting up early to get on a school bus Alas, that is not optimal for them based on their internal rhythm (circadian rhythm).

Peter M. Hartmann, MD

Family Medicine & Psychiatry