Randi Hutter Epstein M.D. M.P.H.

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May 10, 2019 By Randi Hutter Epstein Leave a Comment

How To Celebrate The Birth Control Pill’s Birthday

Fifty-nine years ago this week—on May 9th, 1960, the U.S. Food and Drug Administration approved the birth control pill.

The story of the oral contraceptive is unique among hormone histories. It was the first drug prescribed to healthy people for social reasons—a drug that didn’t prevent a disease or even promote wellbeing. It’s the only pill called The Pill. You can’t say that about any other treatment, not even a headache tablet, a vaccine or an operation. That’s what Dr. Carl Djerassi, a pioneering pill researcher, once boasted.

The idea that hormones can be used to prevent conception was based on something doctors and farmers observed for centuries: You can’t get pregnant when you’re pregnant. But it wasn’t until the early twentieth century that an Austrian physiologist explored the notion.

In 1919, Ludwig Haberlandt, a professor of physiology at the University of Innsbruck, wondered if the pregnancy-infertile idea had something to do with the way ovaries change during pregnancy. He transplanted ovaries from pregnant rats into non-pregnant ones. The recipients could not get pregnant.

Twenty years later, in The New York Herald Tribune, William G. Lennox, a neurologist quipped: “An anti-pregnancy hormone which might help solve the growing problem of the overpopulation of the unfit.” (It was considered one way to promote this controversial notion of preventing conception.)

The history of the pill includes maverick scientists—some traipsing through the forests in Mexico for a plant that made an estrogen-like substance. It also includes feminists pushing for a hormone-based contraceptive when even the mention of birth control was considered obscene—not the news fit for print. Jonathan Eig, recounts the story in The Birth of The Pill: How Four Crusaders Reinvented Sex and Launched a Revolution, a page-turner tale for anyone who wants to dig into the history and get to know the personalities behind the discovery and dissemination.

When the FDA green-lit the first pill in 1960, the process was seen as a triumph of science and society, working together for a medical advance. Compared to all the other medical discoveries, hormones had seemed safer. They weren’t made from germs the way antibiotics and vaccines were. They weren’t toxins like many cancer drugs. They mimicked human chemistry. They were a seemingly natural remedy to control the most natural event of all—making babies.

By the 1970s, more than 6.5 million women were on it.

But the birth control pill came to symbolize a turning point in our relationship to hormone therapies. Fears mounted that this hormone contraceptive, in the doses delivered, was triggering headaches, bloating, and also life-threatening blood clots.

Today the pill comes in much lower doses than the original form. We also have package inserts that list all the potential side effects. This is, in part, thanks to such as Barbara Seaman, who wrote The Doctor’s Case Against the Pill, and Alice Wolfson, now a lawyer in San Francisco, who as a 29-year-old interrupted the 1970 Senate hearings to demand that women’s voices be heard.

Yet, despite these huge advances, we could do better. There are still women who feel depressed on the pill. Others who suffer from life-threatening blood clots. Too many women are denied access to affordable contraception. The 59th birthday of the birth control pill should be a time not just to consider the scientific and political feats that made this all possible, but to think deeply about where we are today and what we need to make contraception safer and available for all women who need it.

Filed Under: Uncategorized Tagged With: birth control pill, contraception, oral contraception, Pregnancy

April 2, 2019 By Randi Hutter Epstein Leave a Comment

Preventing PostPartum Depression Should Be Considered a Public Health Issue

I gave birth to my first son, Jack, 25 years ago in London. The birth went smoothly but I was a little freaked out when I was told that once I got home, a visiting nurse/midwife was going to stop by every day for at least 10 days.

I pictured Mary Poppins minus the show tunes. What I got was more Woodstock circa 1960. My motherhood-checker (I can’t remember her official title) wore Birkenstocks and a flowing multicolored skirt. Instead of reprimanding me, as I feared, she was encouraging and answered all kinds of new-mom questions. She also weighed my son in the same kind of antiquated scale used by my local fishmonger.

Six weeks postpartum, my earthy-crunchy helper returned. This time she wasn’t asking about Jack. She asked about me. We sat crossed-legged on the carpet and she ran through a checklist of postpartum depression signs sprinkled into a seemingly casual conversation. Had I needed help, I would have been funneled to the right place.

Two years later, as I once wrote in the New York Times, I delivered twins in a New York City hospital and left before 48 hours. The doctors signed discharge forms and I guess I waved goodbye and that was that. I went home to my toddler, husband and extended family. But I missed my English caregiver who blanketed me with support. She made me feel part of a supportive community.

I was thinking about my birth experiences again when I read the news about a new drug for postpartum depression, called brexanolone. Like most people who read the reports, I was stunned by the price tag ($34,000) and curious about the delivery system: a 60-hour infusion in a certified medical center during which time women have to pump and dump breast milk to ensure brexanolone doesn’t contaminate the baby’s food supply. Who was going to access this newfangled treatment?

Even if the price drops and it’s made into a pill (apparently one is in the works), medication, alone, isn’t a solution. We need networks to spot women in need and resources to get them help.

Last fall, I met a group of dynamic, compassionate experts at a conference in Pittsburgh called: Partnering for Change: Expanding Women’s Mental Health Treatment and Reducing Health Disparities. I was there to talk about the history of women’s health. They taught me about the future.

Dr. Sarah Homitsky is the medical director of the Women’s Behavioral Health at Allegheny Health Network there. Since August, 2016 her center has been providing psychological support to new mothers diagnosed with clinical depression.

Here’s how it works: When pregnant women are seen at the obstetrician’s office, they are provided with an electronic tablet. A few times during pregnancy and once after childbirth, they fill out a questionnaire and the responses go directly to their doctor who, in turns, alerts a therapist if the score indicates clinical depression.

“We get in touch with every woman within 48 hours and schedule an intake within two weeks,” Homitsky told me. That’s a pretty remarkable turnaround.

Women are then provided with weekly hour-long sessions in cognitive behavior therapy or interpersonal therapy. They can get medication, too. The program is funded in part by the Alexis Joy Foundation, founded by Steven D’Achille in memory of his wife who died by suicide six weeks after her daughter’s birth on October 10, 2013.

So far, some 2,500 women have been offered weekly counseling. There’s also an intensive program that provides three-hour sessions three times a week. Women are encouraged to bring their babies (where they do baby massage and learn about mother-baby bonding) and also their pre-school children (childcare is provided). In addition to psychotherapy women learn stress management techniques. Best of all, they realize they are not alone. Women get help not just from experts but from each other.

Let’s face it, motherhood is an awesome yet overwhelming time. Many of us are lucky to have family and/or friends around. Sure I missed my British-Birkenstock-wearing visitor. But I had other networks. After I gave birth to the twins, I heard about a local mother-of-twins support group and attended a few meetings and wrote about it, but never bothered going back. I think because at the time, I had two big dogs, a toddler and two babies in a double-stroller so I was like a magnet for advice-givers. I may not have loved all the unsolicited information but I never felt alone.

I’m not trying to over-simplify post partum depression. A group of friends isn’t going to prevent susceptible women from clinical depression.

Studies have documented that women who have had bouts of depression before pregnancy are more likely to suffer post partum depression. Other studies show a lack of support increases the risk of post partum depression. We seem to have accrued plenty of data, now we need real outreach.

The Pittsburgh center is one of twenty such clinics in the United States. But getting access to this kind of care shouldn’t be hit or miss. It should part of routine healthcare for all pregnant women and new mothers.

As Homisky said, maybe the media focus on the new drug will shine a spotlight on this crucial public health issue. “We need to do a better job supporting our mothers. We as perinatal providers need to advocate not just for medication, but for improved home visits and affordable child care.

As she said, we have to continue to ask ourselves: How do we strengthen the social support that postpartum women need and deserve?

At least, her center is one step in the right direction.

Filed Under: GENERAL BLOG Tagged With: childbirth, depression, motherhood, postpartum, postpartum depression, Pregnancy

February 23, 2019 By Randi Hutter Epstein Leave a Comment

A New Play Shines Light on Women Long Forgotten

In the years leading up to the Civil War, about a dozen or so female slaves were part of a series of gruesome experiments that culminated in a huge advance in gynecology.

They were operated on over and over in a ramshackle shed in Dr. J. Marion Sims’ Alabama backyard. Sims was determined to figure out a way to heal vaginal tears caused by long labors.

He succeeded and became world famous. In addition to his surgical cure—a technique that would spare women worldwide some of the ravaging consequences of giving birth—Sims also invented the speculum and founded a woman’s hospital in New York. For more than a century he was hailed as one of the great humanitarian physicians.

For years, the story of J. Marion Sims focused on his achievements. But lately, his story has been revived without glossing over his journey to prominence, culminating not only in heated discussions.

Yet, however the story is told, the spotlight has always been on Dr. Sims. Harriet A. Washington wrote about him in Medical Apartheid. Her book along with subsequent articles prompted protests that resulted in the removal of a Sims statue that had been on Fifth Avenue in New York City. Deborah Kuhn McGregor wrote about him in From Midwives to Medicine. I also wrote about Sims and his legacy in Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank.

But who are these women? There are no diaries, nothing about what they had to say. We know the names of three of them. Lucy. Betsey. Anarcha. So when we write, they become two-dimensional, lumped together in one group: “The slave women.” To be sure, Washington dug deep to bring a voice to Anarcha Wescott, but so many of the women have remained anonymous because we just don’t have the information.

Now, Charly Evon Simpson, a playwright, has given voice to the voiceless. Her new play, Behind the Sheet, is inspired by the real events allowing her to shift the spotlight from Simms to the slaves.

We meet these young pregnant slaves who endured operations—some of them had up to 30 surgeries. But for the first time we are forced to imagine them in three dimensions, as yearning, bonding, compassionate, jealous, hurting women. Simpson gives these women agency.

Ben Brantley in the New York Times said the production “takes on cumulative power in its steady, clear eyed depiction of a time when it was a given that pain would be borne uncomplainingly by human beings regarded as chattel.”

While some of the dialogue is lifted right from J. Marion Sim’s autobiography, Simpson adds a plot twist.

In her play, the doctor is George Barry. We also meet Philomena, his assistant/pregnant mistress/slave. In real life, there was no Philomena. Or rather, there’s no record of Sims having a mistress or impregnating a slave. I found the injected storyline added heft to the play—we see his own mistress suffering and we see happens to her after her child with him causes her to suffer from tears. We see what happens to her after Sims finds his cure and heads north.

Harriet Washington, the Medical Apartheid author, ethicist and historian, applauded the play as a must-see—but, as she wrote in Nature,  the Philomena addition “muddies the already murky ethical waters of volition, coercion, sentiment and motivations.”

The night I went, there were audible gasps from the audience. The woman behind me sobbed. I assumed people went for the reason I did. We knew the story and were curious to know how this fictionalized version would come alive on stage. But perhaps this was news to some of them. And that’s a good thing. This is an important chapter in medical history that needs to be debated in wide circles outside of academia.

Simpson, in an interview with Science Friday, said that her goal was not to bring what has been written to the stage but to infuse life to the women, long forgotten. “I’m a black woman and have ancestors who were enslaved,” Simpson said. “I wanted to give them back the humanity that society at the time stripped way.”

Behind the Sheet had sold-out performances at the Ensemble Studio Theatre and is now extended until March 10th. Here’s more information about the show.

Filed Under: Uncategorized Tagged With: childbirth, Fistula, history of medicine, Pregnancy, Racism, Slavery

July 6, 2018 By Randi Hutter Epstein Leave a Comment

Pregnancy Hormones but No Panda Pregnancy

The National Zoo in Washington D.C. announced today that Mei Xiang, a 19-year-old panda isn’t pregnant after all. It was just a “pseudo pregnancy,” or fake pregnancy. Seems she had all the signs (nesting, eating less) and even hormonal changes. But the one thing she didn’t have was a fetus in her womb.

So, what was going on with her hormones? In short, some animals after sex or artificial insemination, have a rise in certain pregnancy hormones can rise for a few weeks.   Then without a fetus gestating, the levels eventually go back to the non-pregnant state. That seems to have been Mei Xiang’s  story. She had a progesterone surge but an ultrasound didn’t find a fetus

In an article aptly called, “Pseudopregnancy in the Bitch,” and published in the Journal of Small Animal Practice in 1986, the authors explain that the condition has to do with the way post-coital hormones are released from the pituitary gland, a gland that dangles off the brain.  It’s not uncommon in mammals that go through estrus, which is different from humans that menstruate. (Estrus means that the lining of the womb is absorbed back into the body after the egg is released but there is no conception. For many species, the females are only sexually active during estrus. Humans menstruate—that means they bleed and sometimes have sex  when they aren’t fertile.) In humans (but not pandas) “pseudopregnancy” also called pseudocyesis and is listed in the DSM-5, the psychiatrists bible of mental disorders.

At 20, the Mei Xiang is considered on the older end for giving birth, but the National Zoo veterinarians aren’t giving up hope yet.

For further reading on pregnancy hormones and a pioneering researcher, check out Chapter Six in my latest book: Aroused: The History of Hormones and How They Control Just About Everything 

Filed Under: Uncategorized Tagged With: childbirth, hormones, Pregnancy

Randi Hutter Epstein, MD

Randi Hutter Epstein, M.D., M.P.H. is a medical writer, adjunct professor at Columbia University Graduate School of Journalism and a lecturer at Yale University.

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