From our anonymous insider…
“Lactation: Use it, or lose it” is our theme for two days. A family physician brought in one of her patients, a 30-year-old mother of two. When four-month-old “Nora” got hungry, she whipped her breasts out in front of the whole class. The physician explained that the breasts are made of 4-18 glandular ducts with suspensory connective tissue and fat. The baby needs to be rotated using different positions (e.g., the football hold) to ensure each duct is used.
Two hormones are important for lactation. Prolactin, secreted by the anterior pituitary gland, signals the glandular ducts to produce milk. If the ducts begin to build up in pressure, prolactin secretion will be inhibited. Once this cascade has begun, it is almost impossible to reverse the spiral, which is why breastfeeding in the first days after delivery is critical. Although prolactin produces milk, oxytocin (the love hormone) causes the release of milk. When a baby is on the nipple, the ducts contract, producing a let down. Other signals, such as a baby crying,can cause oxytocin release. We were fortunate enough to see a let down: Milk shot out of the nipple for several inches and sprayed all over the baby’s face and clothes. Nora was loving it.
“Breastfeeding should last for at least six months and up to one year plus/minus two months.” The physician continued, “A child will let you know when he or she is ready to wean. The child will start grabbing solid foods and teething on the nipple.” Current conventional wisdom, confirmed by the most heavily cited studies, is that breastfeeding for at least six months (1) builds mother-child bonds with oxytocin release, (2) decreases the child’s risk of obesity, increases IQ, improves immune system function and improves social skills, and (3) decreases the mother’s risk of breast and ovarian cancer.
The family physician noted that her specialty, increasingly rare in American cities, is the only one that follows both mother and child during pregnancy, labor, and after birth. “This allows a whole different perspective that used to be the norm. In most big city hospitals, the moment after delivery, the infant is whisked away by the pediatrician, while the mother is followed up by the Ob/Gyn. Family medicine bridges this patient divide by caring for both mother and child and sometimes grandmother too.”
On the advice of yesterday’s physicians, Americans abandoned breastfeeding in favor of formula. On the advice of today’s physicians, Breastfeeding rates are back up to roughly 50 percent and are tracked by the CDC. The mother explained how difficult breastfeeding was for her first child. “If it was not for my physician, I would have quit after one month.” She developed a severe case of mastitis (inflammation of the glandular ducts caused by an infection or obstruction). “Every time I breastfed, I would cry in pain.” The worst thing to do for mastitis is to stop feeding. Instead, you should feed or pump in short pulses. The physician noted, “A big misconception about breastfeeding is that it should not hurt. It will hurt. A lot.” In addition to the biting, oxytocin release in the first few weeks can cause painful uterine contractions similar to the experience of labor. The physician continued to explain the difficult decisions her patient’s face without extended maternity leave. “They ask themselves, ‘should I quit my job to breastfeed, pump, or switch to formula?’ Each presents challenges especially if the pump is not covered by insurance, or if the family gets insurance through their job.” (This seemed to support Ivanka Trump’s observation that motherhood has become the primary obstacle to women’s professional advancement, but Anita still isn’t in a positive mood about any Trump family member.)
The physician noted how there exists a black market for milk, especially for colostrum. Colostrum is the milk produced in late pregnancy that is rich in antibodies and protein. Our modern range of reproductive technologies, including surrogacy, has produced the largest number of families in which an infant is present and yet no adult is capable of lactation. “Colostrum is worth more than gold!”
That evening I attended an optional workshop on women’s health led by three female physicians, one of them an OB/GYN specialist. Fifteen students, including five men, from different years showed up. We practiced inserting different intrauterine devices (IUDs) in dummies. IUDs are shaped like a “T” with arms that spring out when deployed, thus anchoring the device in the uterine horns. The IUD is connected to two strings that exit the uterus through the cervix. A physician can pull on the strings to remove the IUD. The strings are trimmed during insertion so that they end just outside the cervix, which enables women with IUDs to check the strings every month to ensure the device has not been displaced. None of my classmates with IUDs knew that they were supposed to do this.
The first IUD marketed was Teva’s Paragard. “Paragard is the most cost-effective contraceptive ever created,” noted the gynecologist. Paragard uses copper to kill sperm before they can reach the egg for fertilization. It is is effective for ten years. Most women are choosing Skyla and Mirena, a progesterone IUD. These are more expensive but women like it because of the decreased bleeding. One family physician with experience with adolescents noted, “Paragard has this unfortunate misnomer that it causes heavy bleeding. It’s just a woman’s normal cycle. The progesterone IUDs give lighter bleeding. Some women on Skyla or Mirana stop having periods altogether.” I asked if older or younger women are more receptive to IUDs versus normal birth control methods. She responded, “Younger women (under 25) are by far more resistant to IUDs. They don’t want anything in their body but they want to have plenty of sex. I have to beg them to use some form of contraceptive.”
A pediatric gynecologist gave two lectures on puberty. My favorite fact: fifty percent of healthy adult weight is added during puberty. Females begin puberty, on average, at age nine with the growth spurt, followed by thelarche (breast development) at age 10 and finally menarche at age 12.5. These ages are delayed in larger families, higher altitudes, and rural settings. Males begin puberty, on average, at age 11 with an increase in testicular volume. This is followed by pubic hair, the all-important growth spurt, voice changes, axillary hair, the ability to ejaculate, and fertility. The class chuckled when he commented, “Males are shooting blanks for a bit. Males can ejaculate before fertility.”
In his practice, he evaluates “precocious puberty”. He deems puberty premature if the child reaches a stage three or more years before normal. The most severe cases are generally due to a hormone-secreting pituitary adenoma. Some of his patients undergo the growth spurt and menarche at age six. Black children typically undergo puberty 1-1.5 years before risk-adjusted white children. “My colleagues in other countries have it easier. Race cohorts are not as meaningful in the US because of genetic and ethnic mixing. Other countries these ‘normal’ numbers are more relevant.”
A week before exams and the library once again is crowded. Students stare at laptops (with peeks at an open Facebook window) or textbooks. The librarian brings her 12-cup coffee machine out for students to use during exam week. About half of us bring mugs while the rest walk across the street for Starbucks.
Pharmacology is a huge part of this exam and memorizing drug names is one of our toughest challenges to date. A friend’s mother advises companies on drug names, which may reflect millions of dollars of analysis. Names that “flow” are easily remembered: gliflozin is a typical suffix for drugs that make glucose flow in the urine (SGLT2 inhibitor); glutides keep the GLT1 incretin tide coming on. Classmates say that they are enjoying TV drug ads a lot more than they used to.
Statistics for the week… Study: 20 hours. Sleep: 7 hours/night; Fun: 1 day. Example fun: Jane and I ran a 5k trail run.
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