Amish & Mennonite Genetic-Based Illness
Pediatrician D. Holmes Morton, director of the Clinic for Special Children (Strasburg, Pennsylvania), investigates genetic-based diseases found among the Amish and Mennonites. Because members of these Anabaptist religions marry within their communities, the incidence of genetic-based illness is very high. Dr. Morton's work has given parents an understanding of many illnesses that disable and kill their children and, in some cases, provided protocols for preventing severe damage.

Over 30 genetic conditions have been identified among the Amish. Glutaric aciduria type 1 (GA-1), for example, resembles cerebral palsy. Children show no signs of the disease until they contract a cold or respiratory infection. The infection triggers a build-up of glutarate in the brain, leading to permanent paralysis of the arms and legs. Morton first became aware of the high occurrence of GA-1 among the 25,000 Amish in southeastern Pennsylvania in 1988. At that time, some children had untreatable severe paralysis, but Morton managed to help those with milder paralysis by using a treatment that includes a restricted-protein diet. Morton also performed genetic testing on his patients' siblings. By identifying those with the same genetic mutation before symptoms occur, Morton prevents their paralysis by giving them immediate hospital care when they contract a respiratory infection. During the crisis, children receive IV glucose and fluids, anticonvulsants, and little protein to prevent the build-up of glutarate and thereby protect the basal ganglia from damage.

Maple Syrup Urine Disease (MSUD) is another genetic disorder that affects children in these communities. MSUD, a genetic disorder common among the Mennonites, is caused by the lack of an enzyme used to break down the amino acids valine, leucine, and isoleucine. By alerting parents to the early signs of the disease and implementing treatment, Morton has prevented severe brain damage and death in affected children.

Morton's willingness to work with children in their community and visit their homes, instead of requiring them to travel to a big-city hospital, gained the enthusiastic cooperation of the Amish and Mennonite communities. The Clinic for Special Children, which Morton co-founded and directs, is supported primarily by auctions held in Amish and Mennonite communities throughout Pennsylvania and by outside private contributions. Clinic fees are very reasonable; families pay $50 for a test that costs $450 at a university hospital. In addition to money, Amish and Mennonite people donate blood samples so that Morton can track genetic-based diseases. Within a few years, Morton and his colleagues hope to create a microchip that contains DNA information for all genetic diseases known to affect the Amish and Mennonites. Then, they will be able to tell which genetic conditions affect a child, before disability and death occur, by comparing a single drop of an infant's blood to the chip.

Shachtman T. Medical sleuth. Smithsonian. February 2006: 23-30.

Bladder Problems in Women
Women are more likely to have problems with urine storage (urgency, frequency, discomfort, and/or incontinence) than men. While these problems are not life-threatening, they can be embarrassing and burdensome, and they can negatively affect a woman's quality of life. The May/June 2006 Journal of Midwifery & Women's Health has an excellent article by Katharine K. O'Dell, CNM, and Lisa C. Labin, MD, on overactive bladder, urge incontinence, and stress incontinence. Overactive bladder refers to a sudden, painless urgency to void urine that is unrelated to infection or other pathology. Frequency (voiding at less than two-hour intervals) and nocturia (voiding more than two times at night) are also signs of an overactive bladder. When involuntary urine loss accompanies this feeling of urgency, it is called urge incontinence. Urinary urgency and frequency have been associated with thyroid abnormalities, diabetes, and estrogen depletion. Stress urinary incontinence is the involuntary loss of urine with exertion, such as coughing, sneezing, laughing, lifting, or exercise.

The article includes several treatments for overactive bladder and urge incontinence. Using a voiding diary to keep track of consumed liquids and a schedule to help retrain the bladder improves symptoms in at least 50% of women, according to a Cochrane evidence review. Bladder control can be affected by drinking too much, too little, and/or by certain foods or drinks that irritate the bladder. O'Dell and Labin recommend drinking six to eight cups of liquid evenly spaced throughout the day. They refer readers to the Interstitial Cystitis Association website (www.ichelp.org) for information about foods and drinks that irritate the bladder. Retraining the bladder involves regular, timed voids, gradually increased by 15 to 30-minute increments, to teach the bladder to hold increasing amounts of urine. Herbalist Kathleen Maier suggests beginning with a scheduled void every 60-90 minutes, then gradually lengthening the time between voids until reaching every four hours. O'Dell and Labin emphasize that women need to understand that retraining takes time so that they do not become discouraged.

The authors offer some strategies for dealing with sudden urges to urinate. Self-distraction, such as counting backward from 100 by sevens or thinking about something else, and self-talk (e.g., "Calm down. I can wait.") may help a woman defer voiding until the urgency has passed and/or her scheduled time to void occurs. Also, relaxing and breathing while squeezing the pelvic muscles five times may stimulate reflex bladder relaxation. Pelvic muscle exercises can also help women with overactive bladder and/or urge incontinence. The authors say, "One regimen involves a goal of ten pelvic muscle contractions, held for five seconds, pulsed for five seconds, and followed by full perineal rest for 20 seconds between contractions." Pharmaceuticals that target muscarinic cholinergic receptors of the parasympathetic nervous system can be prescribed for women who do not respond to these measures. However, the authors note, "Medication alone is not enough: in one study, only 18% of patients continued bladder medication for more than six months." These drugs have several common side effects, including dry mouth, constipation, digestive upset, tachycardia, blurred vision, headache, sleep disturbances, and cognitive effects.

Stress incontinence occurs when pelvic floor muscles that support the urethra or the urethra itself are not strong enough to counteract pressure from the abdomen and bladder. For those with weak pelvic floor muscles, exercising the muscles using voluntary contractions is an effective way to decrease stress incontinence. Losing excess weight may also be helpful. Both urge and stress incontinence improved by up to 60% in overweight women who lost five percent to 15% of their weight, according to a study by L.L. Subak and colleagues (J Urol. 2005;174:190-5). Intravaginal support devices, such as tampons and vaginal pessaries, provide support for the urethra and decrease stress incontinence. A urethral insert, such as Femsoft, is another option. Women using any of these inserts must watch for signs of irritation and infection that may occur with their use. Oral estrogen has no effect on stress urinary incontinence. One pharmaceutical may provide relief for stress incontinence: duloxetine (Cymbalta), a serotonin and norepinephrine reuptake inhibitor that has already been approved for use in the treatment of depression and diabetic neuropathic pain. Duloxetine reduced stress incontinence episodes by 50%, compared to a 27% reduction in the placebo group. However, side effects led 24% of the duloxetine group to stop taking the medication (compared to four percent in the placebo group).

Maier K. "Menopause Naturally." (Lecture at SE Women's Herbal Conference, Black Mountain, NC; September 2005).
O'Dell KK, Labin LL. Common problems of urination in nonpregnant women: Causes, current management, and prevention strategies. Journal of Midwifery & Women's Health. 2006; 51: 159-173.
Subak LL, Brown JS, Kraus SR, et al. The "costs" of urinary incontinence for women. Obstetrics & Gynecology. 2006; 107: 908-916.

Cesarean Deliveries
"Can a 29% cesarean delivery rate possibly be justified?" asks Robert Resnik, MD, in his editorial for Obstetrics & Gynecology (April 2006). The number of cesarean deliveries has increased from 5.5% of US births in 1970 to 29.1% in 2004, according to the National Center for Health Statistics. Although a cesarean can be life-saving, this high percentage of cesarean deliveries is puzzling, given that vaginal delivery usually requires less medical intervention, has a faster recovery rate, and is associated with better maternal-child bonding. Resnik attributes the rise to the use of electronic fetal heart rate monitoring (EFM), which started in the 1960s, and to the increase in malpractice lawsuits shortly thereafter.

At its onset, EFM was promoted as a way to prevent cerebral palsy and decrease the risk of intrapartum fetal death (a rare event). Cerebral palsy was primarily attributed to intrapartum asphyxia (lack of oxygen during labor and delivery); but doctors have since learned that birth asphyxia in full-term babies accounts for only six to seven percent of the children born with cerebral palsy. Resnik says, "…although most labors are followed with EFM, there has been no reduction in the incidence of cerebral palsy over the last three decades." A Cochrane review of 13 randomized clinical studies found that concerns about abnormal fetal heart rate patterns, shown by EFM, led to a 40% increase in the cesarean delivery rate. However, use of EFM did not result in fewer cases of cerebral palsy, fewer admissions to neonatal intensive care, or fewer perinatal deaths.

The "zero-tolerance legal environment and expectation for a perfect outcome every time" have encouraged some obstetricians to turn to cesareans at the least sign of trouble. Links between vaginal deliveries and stress urinary incontinence and uterine and vaginal prolapse are other justifications for cesarean deliveries – although several factors other than vaginal deliveries contribute to pelvic floor dysfunction. Scheduling convenience and some mothers' mistaken belief that cesareans are less painful also have a part in cesarean's popularity.

Cesarean deliveries have several complications of their own, some of which are just beginning to be understood. Like other major surgeries, cesarean delivery has the risk of infection and hemorrhage. "Massive hemorrhage requiring transfusion occurs in five percent to six percent of cesarean deliveries," Dr. Resnik writes. "Furthermore, the prevalence of hysterectomy secondary to hemorrhage is ten times greater after cesarean delivery versus vaginal delivery." In addition, women who have a cesarean have an increased risk of abruptio placenta, placenta previa, and placenta accreta. The more cesareans that a woman has, the higher the risk for placenta abnormalities in subsequent pregnancies. In abruptio placenta, the placenta separates from the uterine wall in a pregnancy of 20 weeks or later. It may also separate during labor and before delivery. This separation causes severe hemorrhaging that threatens the lives of mother and baby. Placenta previa refers to a placenta that implants abnormally so that it blocks the opening to the cervix. It can also cause hemorrhaging. Placenta previa is associated with placenta accreta, a condition in which the placenta invades the uterine muscle. Referring to the American College of Obstetricians and Gynecologists Evaluation of Cesarean Delivery (2000), Resnik states: "Patients without a uterine scar and placenta previa have a 4.5% risk of placenta accreta, but patients with a uterine scar and placenta previa have an estimated risk for accreta of 24% to 38%." The incidence of placenta accreta was about one in 29,000 deliveries between 1960 and 1970. Now, the incidence of placenta accreta is one in 533 births, according to a 2005 analysis by University of Chicago researchers. Placenta accreta involves excessive blood loss and usually requires a hysterectomy. Resnik says, "..placenta accreta is rapidly becoming the most dreaded complication facing the obstetrician and, in the vast majority of cases, is the result of a previous cesarean delivery."

Jenkins TR. Patient-requested cesarean delivery: Is it time? The Female Patient. 2004; 29: 41-51.
Resnik R. Can a 29% cesarean delivery rate possibly be justified? Obstetrics & Gynecology. 2006; 107: 752-753.

Dermal Fillers
Injecting dermal fillers to erase facial lines and wrinkles is becoming increasingly popular with people in their 30s and 40s, according to a Wall Street Journal article. Most dermal fillers lose their effect within four to six months, but several longer-lasting products are undergoing FDA tests. The new products differ in the number of injections they require and the length of their effects. Radiesse, made by BioForm Medical Inc., consists of tiny calcium hydroxylapatite microspheres that form a scaffold for the patient's own collagen. It produces the desired effect with one injection, but at least one plastic surgeon in the Wall Street Journal has found that the effect "rarely last[s] more than a year."

Artefill, made by Artes Medical Inc., is believed to have a permanent effect. This product, which gained approval in Canada in 1998, consists of microscopic spheres of polymethylmethacrylate in a bovine collagen gel. Like Radiesse, the tiny spheres form a scaffold to support the patient's own collagen. Five-year results from 44 patients, injected with Artecoll (an earlier version of Artefill), reported "'no statistical change from the one-year results,'" according to Steven Cohen, a California cosmetic surgeon. Some practitioners report that the product may produce "unsightly bumps and ridges" although this may be partly due to poor injection technique. The synthetic microspheres may also cause a foreign body response.

A third dermal filler, Sculptra, manufactured by Dermik Laboratories, uses a "biodegradable material called ‘poly-L-lactic acid.'" This product requires a series of biweekly injections in order to increase skin thickness gradually. Sculptra has been used to erase wrinkles and repair lipaoatrophy, the loss of facial fat that is usually found in people with HIV. Sculptra's effects last about two years, although minor "touch-up" injections may be needed.

Artefill. Available at: www.artefill.com. Accessed August 30, 2006.
Radiesse. Available at: www.radiesse.com. Accessed August 30, 2006.
Rundle RL. Wrinkle treatments don't age well. The Wall Street Journal. September 27, 2005: D6.
Sculptra™. Available at: www.skintastic.com/services_sculptra.html. Accessed August 9, 2006.

Environment & Women's Health
A growing body of research is finding a "strong environmental association" to some diseases and conditions that affect women, according to a 2003 report from the Women's Foundation of California. Birth defects, infertility, autoimmune disease, some cancers, and endometriosis have all been linked to chemicals and environmental toxins. The chemicals, many of which are fat-soluble, may have a greater impact on women and their children than on men. Women have more body fat than men, providing more storage for the toxins. Also, chemicals and heavy metals have been found in umbilical cord blood, which sustains a fetus, as well as in breast milk.

Most occupational studies have focused on men, but women also work with toxic chemicals. Manicurists, housecleaners, pet groomers, and factory workers all use potentially harmful chemicals. Home environments can also be a source of exposure. City dwellers with low incomes tend to live near highly polluted industrial areas. Those living in farming communities are exposed to herbicides and pesticides. A 2003 study by D. Schreinemachers in Environmental Health Perspectives found that babies who were conceived during late spring in Midwest counties with high production of wheat were far more likely to have circulatory/respiratory and musculoskeletal/integument anomalies than babies born in counties with low wheat production. The peak use of chlorophenoxy herbicide by wheat farmers occurs in late spring. Chemical pesticides are also used in forests, landscapes, parks, schools, public facilities, and food preparation areas, along railroad right-of-ways, under electric wires, on pets and livestock, and in homes. A 2004 Environmental Health Perspectives epidemiologic study found an association between long-term occupational pesticide exposure (more than ten years) and non-Hodgkin's lymphoma in women (26 to 48 years after beginning the job). Because pesticide use is so widespread and has health consequences, the National Environmental Education Foundation wants all nursing and medical schools to include information about pesticide health risks in their core curriculum.

"Even in the face of ‘good' evidence, clinicians may hesitate to share environmental precautions with their clients because the environmental exposure cannot be avoided or because current information does not identify safe exposure levels," M.A. Faucher, CNM, PhD, writes in her editorial for the Journal of Midwifery & Women's Health (January/February 2006). Referring to unpublished data in their article for the same issue, certified nurse-midwives Robi Quackenbush and Barbara Hackley and co-author Jane Dixon, PhD, report that "only four percent of providers [in the Washington, DC, metropolitan area and surrounding rural counties] routinely asked questions about pesticide toxicity in patient histories." Even in high pesticide-use areas along the US-Mexican border, only 40% of nurse-midwives/midwives who responded to a survey said that they routinely screen for pesticide exposure.

When people become aware of the effect that some of these chemicals have on their health, they can take precautions and make changes. Practitioners can counsel women to avoid known toxicants during key trimesters of their pregnancy. They can also encourage women to use less toxic or non-toxic alternatives in personal care and household products. Housecleaners, for example, can use vinegar, vegetable soap, and baking soda instead of bleaches and strong chemicals. When a San Francisco Bay Area cleaning cooperative began using non-toxic cleaning materials, the women reported a reduction in headaches, dizziness, and skin irritations. Tennessee Valley Authority's Regional Waste Management Department has published a useful guide, available online, called "Safe Substitutes at Home: Non-toxic Household Products." Another guide to toxins in household and personal care products is The Safe Shopper's Bible by David Steinman & Samuel S. Epstein. Farm and industrial workers can reduce their exposure by washing their hands before eating, smoking, or using the bathroom; changing out of work clothes immediately after work and laundering them separately; and taking a shower at the end of the workday.

California has passed laws designed to reduce the amount of harmful synthetic chemicals now found in the human body. A 2001 law bans the sale of mercury-containing thermometers and other medical equipment and offers incentives to encourage the removal of all medical equipment containing the neurotoxin from California hospitals. Beginning in 2008, the manufacture, distribution, and sale of flame-retardants (polybrominated diphenyl ethers) will be prohibited. These carcinogenic chemicals, already banned in Europe, are in carpets, home furnishings, computers, children's clothing and bedding, and many other products.

Arnesen SJ. Environmental health information resources: Healthy environments for healthy women and children. Journal of Midwifery & Women's Health. 2006; 51: 35-38.
Faucher MA. How good is the science connecting environmental exposures to health? (Editorial) Journal of Midwifery & Women's Health. 2006; 51: 1-2
Quackenbush R, Hackley B, Dixon J. Screening for pesticide exposure: A case study. Journal of Midwifery & Women's Health. 2006; 51: 3-11.
Vesely R. Study: Women bear brunt of environmental toxins. (October 21, 2003) Available at: www.womensenews.org/article.cfm/dyn/aid/1570/context/archive. Accessed August 17, 2006.

US Fertility Clinics
Competition and patient demand are pushing some US fertility clinics to implant three or more embryos, obtained from in vitro fertilization (IVF), into mothers, according to The Wall Street Journal. The Centers for Disease Control and Prevention keeps track of clinics' pregnancy success rates -- information that clients often use in choosing a clinic and that clinics use in their advertising. If doctors are uncertain about the embryos' viability, they implant three or more in the hope of producing an infant. If the shape and appearance of the embryos, when viewed through a microscope, look "good," doctors may implant just one or two into the mother. Multiple implants, however, often produce multiple babies. One surrogate mother for an infertile couple endured a difficult pregnancy when all five implanted embryos took. The doctors had told her that "there was a one in 30 chance that one would take".

Fertility treatments and IVF are responsible for the increase in multiple births. Fertility treatments use hormones to increase the number of ovulated eggs and the likelihood of pregnancy. IVF also uses hormones to produce eggs, but the eggs are then extracted, fertilized, and permitted to grow before being implanted in a uterus. Less than 20% of the multiple births in the US are due to natural conception. About 35% of pregnancies with three or more babies are due to IVF (using 2002 data), and other fertility treatments account for the rest.

Because multiple pregnancies pose risks to mother and infants, several European countries prohibit implanting more than three embryos in a mother. Multiple birth infants have a greater risk of premature birth, low birth weight, and complications, including cerebral palsy. Women carrying more than one infant are more likely to have problems that include pregnancy-related high blood pressure and postpartum depression. Doctors in Britain, Germany, Sweden, and other European countries may lose their license, be fined, and/or jailed if they implant more than three embryos. US guidelines, however, are voluntary. The American Society for Reproductive Medicine recommends that women under 35 receive no more than two embryos, preferably one, in most cases. Women between ages 35 and 37 should get two embryos if the prognosis is good and no more than three if the prognosis is poor.

Westphal SP. Multiple births persist as doctors buck guidelines. The Wall Street Journal. October 7, 2005: A1, A10.

Hormone Replacement Therapy
How did we come to assume that the best remedy for menopausal symptoms is hormone replacement therapy (HRT)? In her book Managing Menopause Naturally Before, During and Forever, Emily Kane, ND, LAc, tracks HRT's beginnings to a 1960s book, commissioned by the manufacturers of the synthetic estrogen Premarin, called Feminine Forever. In it, Dr. Robert A. Wilson promoted estrogen as the way to "be sexually appealing to your husband, have lovely skin, keep your breasts perky, age more slowly, and ‘avoid the psychological problems that accompany the change of life,'" Kane writes. Women, particularly doctors' wives, held Tupperware-style parties to promote the book and encourage the use of estrogen replacement therapy. Since that time, research findings indicate that these heavily promoted synthetic estrogen products increase the risk of benign breast problems (such as cysts); blood clots; breast, ovarian, or uterine cancer; gallbladder disease; heart attacks; high blood pressure; kidney disease associated with fluid retention; migraines; seizures; liver disease (such as hepatitis C); strokes; unexplained vaginal bleeding; and uterine fibroids.

When diet, exercise, nutritional supplements, and herbs fail to resolve menopausal symptoms, Kane suggests trying bioidentical hormones. Both pharmaceutical and bio-identical hormones are synthesized in a laboratory. Bioidentical hormones, however, have the exact same chemical structure as the estrogen, progesterone, and testosterone hormones found in women's bodies. Pharmaceutical hormones do not; their slight alterations in biochemistry give drug companies the right to patent the formulas, making the products more profitable. These alterations, however, also produce unexpected negative effects. Thus far, bio-identical hormones appear to be as effective as the patentable ones and without their risks. Their safety, bargain prices, and effectiveness have made bioidentical hormones popular with Europeans and European national health plans. Kane writes, "Although I believe the bad side effects of Prempro and similar drugs derive largely from the fact that these hormones are not bioidentical, no hormone therapy can be considered completely safe until this is proven. That is why I always turn to hormone therapy as a last resort when helping women through their perimenopausal and menopausal symptoms."

Although several bioidentical estrogen, progesterone, and testosterone products are available, Kane prefers individualized preparations because of variations in hormone levels. Many symptoms – such as anxiety, heavy menstrual bleeding, hot flashes, night sweats, headaches, water retention, and sleep problems – may be caused by a decrease in progesterone, resulting in estrogen dominance. Progesterone levels fall before estrogen production does. Kane explains, "Only in the last year of perimenopause (which can start as early as the mid-thirties and last up to fifteen years) do estrogen levels drop significantly. In fact, estrogen levels may actually increase right before menopause, which spurs the rapid growth of uterine fibroids and breast and ovarian cysts." She encourages women to find a knowledgeable practitioner and a compounding pharmacist to get the right blend and dose of hormones.

Dr. Kane's book Managing Menopause Naturally (ISBN 1-59120-063-6) is an excellent resource for women of all ages and for practitioners looking for natural self-care ways to help their patients. It costs $14.95 ($23.95 Canadian) and is published by Basic Health Publications, Inc. (North Bergen, New Jersey).

WIC Program Nutrition Changes
Women, Infants, and Children (WIC), the nutrition program for low-income women, infants, and children, will be adding more whole fruits, vegetables, and whole grains – including corn tortillas and brown rice – to its approved shopping list in 2007. Breastfeeding mothers may also buy canned salmon in addition to canned tuna. Also, those with milk allergies or who have trouble digesting lactose may use WIC vouchers to buy soy milk and tofu instead of milk. To pay for these changes, WIC is reducing its allocations for juice, eggs, cheese, and milk. The processed, iron-fortified cereals on the list are apparently unaffected by the changes. Under the new guidelines, women and infants will receive more funding than children, ages one to five, do. Each participant gets vouchers or food checks, worth about $35 each month, which can be redeemed for infant formula or other approved items on the state's WIC list.

WIC provides nutrition education, referrals to health and other social services, breastfeeding support, as well as food vouchers or checks. The program is available in all 50 states, 34 Indian Tribal Organizations, and several US territories. Recipients include pregnant, postpartum, and breastfeeding mothers with medical risks (e.g., anemia, history of pregnancy complications or poor outcomes), their infants, and children up to age five, who are nutritionally at risk. The household income of participants cannot exceed about $36,000 for a family of four, depending upon the state or tribal guidelines. Those who take part in the Food Stamp Program, Medicaid, or Temporary Assistance for Needy Families automatically fulfill the income requirement. However, not all eligible people can take part in the program because WIC has limited funds. WIC is a federal grant program, not an entitlement program that enrolls every eligible person. In fiscal year 2006, Congress appropriated $5.204 billion for WIC to provide benefits for eight million people (most of whom are children) each month.

Thirty-seven states, the District of Columbia, Guam, Puerto Rico, and five Indian Tribal Organizations also operate a WIC Farmers' Market Nutrition Program (FMNP). Under this program, eligible WIC participants receive FMNP coupons along with their regular WIC vouchers. The coupons can be exchanged for fresh fruit, vegetables, and herbs from participating farmers, farmers' markets, and roadside stands. The Federal government pays for $10 to $30 per year, per recipient; but local agencies can add to that amount. Farmers redeemed over $26.9 million in FMNP coupons during fiscal year 2004.

Quaid L. Government adding fruits, veggies to WIC list. Associated Press (August 5, 2006). Available at: www.heraldsun.com/. Accessed August 17, 2006.
USDA. WIC. Available at: www.fns.usda.gov/wic. Accessed August 17, 2006.
USDA. WIC Farmers' Market Nutrition Program. Available at: www.fns.usda.gov/wic/FMNP/FMNPfaqs.htm. Accessed August 17, 2006.