Chasteberry and fertility

An added bonus for those trying to conceive

Chastetree, vitus-agnus-castus
Top Tropicals Website

While reading about chasteberry for other gynecologic issues, one of the review papers mentioned a secondary effect of influencing both follicle stimulating hormone and luteinizing hormone, both hormones important in ovulation (Roemheld-Hamm, 2005).  This led me to look into the potential effect of chasteberry on fertility.

One reason that many patients find their way to my office is when they’ve been trying to have a baby without success.  At least being able to offer another option for women trying to conceive, when unable or unwilling to pay for more invasive infertility treatment methods, is a bonus.

I only found 3 randomized controlled studies evaluating chasteberry for fertility, two of which were published in Germany and one that was published in the United States.  If anyone found others, please share!

In 1993, a German study of 52 patients found that women taking chasteberry normalized the second half of their menstrual cycle by improving luteal phase progesterone and estradiol levels.  However, this study didn’t note any fertility outcomes (Milewicz et al, 1993).

Another study of 96 women suggested those individuals taking chasteberry in the form of Mastodynon® (a German product not available in the US containing 5 additional herbs – cyclamen, tiger lily, ignatius bean, blue cohosh and iris) became pregnant more often than those taking a placebo.  In women with amenorrhea or luteal phase problems, pregnancy occurred in the active treatment group twice as often as the placebo.  Of note, however, is that the absolute percentage of women conceiving over the three-month study was small (16%)(Gerhard, 1998).

After finding benefits with a pilot study, the final study performed by Stanford School of Medicine found Fertilityblend®, a United States nutritional supplement, led to more pregnancies.  It contains chasteberry, but also other antioxidants, vitamins, and folic acid.  This study evaluated 93 women, ages 24-42, who had been trying to conceive 6-36 months, one group received Fertilityblend and the other a placebo.  Mid-luteal progesterone levels, luteal-phase basal temperatures, and pregnancy outcomes were recorded over 3 months.

The group characteristics were very similar.  After 3 months of supplementation, those taking the supplement had an increase in mid-luteal phase progesterone levels, especially noted in those with the lowest values.  This also translated into normalized cycle lengths in those taking the supplementation. Interestingly, however, in their graph there was also an increase in the placebo group’s progesterone levels after 3 months (although not significant), which you would expect to stay relatively stable.  Made me wonder if the placebo group had some patients actually doing something different?

In terms of actual fertility outcomes, after 3 months those taking Fertilityblend® were more likely to conceive.  Twenty six percent (14 of 53 women) in the supplement group became pregnant compared to 10% (4 of 40) of the women in the placebo group.

Following completion of the study, the supplement was offered to both groups with 3 additional pregnancies in the remaining 17 (18%) women in the continuing supplement study compared to 4 of 36 (11%) of women who had previously been in the placebo group.  This value is significantly lower than would be expected based on the initial 3 months with the treatment group.

It’s difficult to make any conclusions about the open-label study based on these final results because they mention that not all women continued for an additional 3 months.  It would be interesting to know how many of the women in both groups actually continued with open-label supplementation with Fertilityblend® vs. went on to more intensive treatment or stopped trying all together.  The open-labeled segment of the study may demonstrate benefit of longer supplementation or may suggest that something may be different with the entire group that was in the initial placebo group, something not accounted for in their review of the characteristics initially.

Still, it seems in women who are not ready or able to move on to more invasive fertility treatments this offers an alternative by taking supplements.  From prior research, if nothing else, this may regulate their cycles, reduce breast tenderness during their periods, and potentially decrease symptoms of premenstrual syndrome (PMS).

In terms of pregnancy, younger women with irregularities of their periods or reduced progesterone levels may benefit most from chasteberry.  In older women with fewer follicles remaining (less eggs), more aggressive treatment will likely still be necessary. However, for some of my younger patient’s, with otherwise normal work-ups but short second halves of their cycles, I am going to start recommending chasteberry, in the form of Fertilityblend®.

REFERENCES:

1.  Gerhard I, Patek A, Monga B, Blank A, Gorkow C.  Mastodynon ® bei weiblicher Sterilitat Forsch Komplementarmed 1998; 5:272-8.

2.  Milewicz A, Gejdel E, Sworen H, Sienkiewicz K, Jedrzejak J, Teuher T, et al.  Vitex agnus castus extractin the treatment of luteal phase defects due to latent hyperprolactiemia.  Results of a randomized placebo controlled double-blind study [in geran].  Arzneimitteiforschung 1993; 43:752-6

3.  Roemheld-Hamm B (2005).  Chasteberry.  Am Fam Physician; 72,5:821-824.

4.  Westphal LM, Polan ML, Sontag T. (2006).  Double-blind, placebo-controlled study of Fertilityblend®: A nutritional supplement for improving fertility in women.  Clin Exp Obstet Gynecol, 33(4):205-8.

 

DISCLAIMER:  **Speak to your own gynecologist before starting any medication, as this product hasn’t been FDA approved.  Your personal physician should evaluate potential causes of your infertility before recommending management.**

 

Acupuncture and In Vitro Fertilization (IVF)

Together – does it equal more babies?

Ironically, this past week the question of acupuncture and IVF came to me from two different directions.  First, I received an e-mail from a patient who was going to be starting IVF in the near future and wondered if the addition of acupuncture would help increase her chances. Second, my sister mentioned she has a friend who is on her third cycle of IVF and plans to try acupuncture this time around, because she knows others who did it and now have children.

Because I didn’t know the answer I thought I’d look into so I could make a recommendation.  Being a little short on time this week I went straight to reviews and meta-analysis on this topic.

For both my patient and my sister’s friend, the answer is promising!  The best study I found was a meta-analysis from the British Medical Journal, suggesting that acupuncture done at the time of embryo transfer increased one’s chances of pregnancy and live birth.

The study by Manheimer 2007 identified 7 randomized controlled trials with a total of 1,366 participants that met their specific criteria.  They specifically were evaluating acupuncture as it pertains to embryo transfer, and there are many steps before one gets to this stage in the IVF process.  However, this review included those women who didn’t make it to the embryo transfer point, as they were often randomized at the start of their IVF “cycle”.   A cycle begins when a woman starts stimulating her ovary to produce eggs that are ultimately retrieved, fertilized with her partner’s/donor’s sperm, and then placed back into the uterus.  This has the effect of actually underestimating the potential benefits of acupuncture once a woman reaches the embryo transfer stage, however it prevents the researchers from saying there is a difference when in actuality there isn’t any.  They required that acupuncture be administered within one day of the procedure, which could be before, after or done both before and after an embryo transfer.  In fact, most of their studies had two sessions.

Ultimately, the bottom line is that they found the odds of a clinical pregnancy were increased by 65% in the group who underwent acupuncture compared to those who didn’t.  When they calculated the number of women who would need to be treated for one additional pregnancy, they found that for every 10 patients who received acupuncture an additional pregnancy would result.

After reading this article, it is something I’d recommend patients try, if they are open to the idea of Eastern medical practice.  Given the high cost of IVF treatment, in terms of actual monetary cost and time expended, it seems that anything that may increase the chances for success are worth trying and if nothing else, may give someone the sense of control over something where there is very little.  If one finds a reputable acupuncturist the risks are low and the benefits potentially life changing.

 

REFERENCES:

Manheimer E, Zhang G, Udoff L, Haramati A, Langenberg P, Berman B, Bouter L (2007).  Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilization: Systematic review and meta-analysis.  British Medical Journal; Online First; pg1-8.

Are “smart” meters dangerous…

for your health?

 

The Culprit or Innocent pawn?

When we bought our new house in Livermore and the technician came out to set up our power he remarked he was changing our meter to a “smart” meter.   I was just glad to have power at that time so didn’t really think anything of it.

We’ve been here a year now and my husband recently decided to ask me what I thought about the health concerns surrounding these meters.  If he was asking, I figured it was just a matter of time before my patients asked me about it.

With a quick web search, there are many claims about these types of meters.  Claims about inaccurate utility bills, increasing energy consumption, violations of civil liberties, including spying or monitoring an individuals activities, and their contribution to the unemployment rate.

However, most important to me, and what seems most debated, is the harm to one’s health by violating safe levels of electromagnetic field exposure.

What type of energy do smart meters exert? 

Smart meters exert radiofrequency signals that with direct exposure elicit changes at the cellular level.  SAGE Associates, an independent environmental consulting company that provides land use services and planning, aimed to determine levels of radiofrequency radiation associated with wireless smart meters depending on frequency of the radiofrequency signal, amount of time the meter is submitting information, and reflective properties of where the meter is placed.

How do smart meters work? 

Briefly, the smart meter in your home measures your utility use and sends it back via a wireless radiofrequency signal.  Power transmitters can then send messages about your general energy use or potentially be installed inside the home on appliances that send information via radiofrequency back to the smart meter.  New appliances have these installed in them.

Homes relay messages to collector meters that transmit between 500-5000 homes/buildings signals and relay the radiofrequency message to the utility company.  With these types of transmitters there are higher levels of radiofrequency microwave emissions and they send wireless signals more frequently.  These collector meters can be placed anywhere.

What is the actual exposure amount from these “smart meters”?

SAGE Associates used computer modeling to determine power density levels in multiple scenarios and tried to define under what conditions violations of Federal Communications Commission (FCC) safe levels may occur.  The FCC established a maximum time weighted average limit of 655 micro-Watts/cm squared. Peak power exposure limits (4milliwatts/cm2) have been designated for all parts of the body, except this limit is lower for the eyes and testes.

For most homes, the single meter radiofrequency evaluation will matter most, but they also reviewed collector meters.  Radiofrequency energy absorption is most influenced by frequency, with lower frequency standards being more restrictive. These meters aren’t running at all times, they instead send information intermittently, making exact exposure evaluation more complicated.  Finally, there is also the unknown amount of radiation from reflection on surfaces in or around the home.

This report studied distances starting at 3 inches out to 96 feet from the antenna center to estimate radiofrequency exposure levels.  The main examples they used are if a meter is placed on an exterior wall outside a bedroom or outside a kitchen.  Outside the bedroom, it’s estimated that an individual’s body could be as close at 11 inches from the meter antenna and for the kitchen as close as 28 inches.

There aren’t any baseline radiofrequency violations for a single meter at any distance, between 60-100% reflection factor, at any duty cycle, but would be expected to occur if the actual reflection factor were as high as 1000-2000 times greater than computer modeling, as suggested by an article by Hondou (2006).   This suggests that reflection could be a significant component with a single smart meter.

Another issue has to do with how often the meters emit radiofrequency signals from each of the antennas.  This is uncertain and subject to variation.  The SAGE report calculates estimates from infrequent (1%) to continuous radiofrequency emissions (100%).  Where the public has unlimited access to these meters, the FCC requires exposure to be calculated at 100% exposure.  This report suggests that if multiple meters or collector meters exist near a home, the risk for violations does occur.

The issue with the SAGE report is that it is based on computer models and not actual practice.  I could find only one actual study that reviewed a smart meter in practice.  One specific smart meter type, the Itron, evaluated in a study by Tell et al (2012) suggests that the exposure in practice may actually be well below dangerous levels.

Where multiple meters are installed near living spaces or near collector meters and if, for instance, viewed at a range 6 inches and/or near highly reflective surfaces may be situations where peak power limits could be violated.

What does the literature say about radiofrequency fields and health?

Since no studies exist evaluating direct health outcomes of smart meters, one has to extrapolate from prior studies on radiofrequency exposure.  Evaluations of communication methods already present (radio, television, wireless, cell towers) have been primarily reviewed in epidemiologic studies.

Even if you move to a deserted island or up to the mountains to live off the grid, there is a certain level of electromagnetic exposure from the earth.  However, if you live like most people, think about all the possible radiofrequency components in your home – mobile phones, wireless computer systems, and as my family’s personal case now, a home monitoring system.  How much is too much?’’

All studies of human health effects from radiofrequency are epidemiologic studies, which inherently have issues with bias and influenced by multiple variables, some which may not be appropriately considered.  A weakness of all the studies is that exact biologic mechanisms of relevance remain unclear.  This makes determining the sources of exposure, levels of exposure, and location of individuals to those sources in question.

There is concern that the eyes and testes are more vulnerable to damage but no scientific data exist to establish a safe limit for these organs. There is also concern that children’s’ tissues may absorb more radiofrequency than adults and respond differently (Christ et al, 2010; Wiart et al, 2008).  It has also been suggested in some reports that individuals like those on some medications, the elderly, or ill also may have different reactions to pulsed radiofrequency, but I could find no real evidence.

In fact, in a review of the literature where a report can be identified that suggests radiofrequency can cause neurological, cardiovascular disease, or increased levels of cancer, there are corresponding reports that refute those findings.  Nothing that I could find convinced me that radiofrequency in doses we are exposed to, particularly if not a direct exposure, cause illnesses alone.

What does the literature say about radiofrequency and reproduction?

Because of my particular interest in obstetrics-gynecology, I can’t help but focus a bit on articles reviewing the reproductive consequences of radiofrequency exposure.

It seems that spontaneous abortion and time to conception have the strongest association with radiofrequency effects in women, as studied in physiotherapists exposed to microwave diathermy (Taskinen et al 1990; Larsen et al, 1991; Ouellet-Hellstrom & Stewart, 1993).  This would require regular exposure in close contact to have an impact.

For men, those who have been in the military and exposed to microwaves and radar, studies appear to support a reduction in sperm density (Hjollund et al 1997; Lancranjan et al 1975; Weyandt et al, 1996), with variable findings in the other semen analysis parameters – movement, amount, and form.

So, does it matter?

Maybe if you were a physiotherapist and a military officer trying to have a baby, or have direct, extensive contact with radiofrequency sources would radiofrequency matter.  It may become the case, as we become a more wireless society, where the radiofrequency amounts do exceed safe amounts, but at this point I am not convinced it would be from smart meters alone.

That being said, I don’t plan to place my bed against a wall where a number of smart meters are positioned.

 

REFERENCES:

Christ A Gosselin MC Christopoulou M Kühn S Kuster N. Age dependent tissue-specific exposure of cell phone users. Physics in Medicine and Biology, Volume 55, Issue 7, pp. 1767–1783, 7 April 2010, online March 5

Hjollund NH, Bonde JP, Skotte J. (1997).  Semen analysis of personnel operating military radar equipment [letter].  Reproduc Toxicol 11:897.

Lancranjan I, Maicanescu M, Rafaila E, Klepsch I, Popescu HI, 1975.  Gonadic function in workmen with long-term exposure to microwaes.  Health Phys 29: 381-383.

Larsen, Al, Olsen J., Svane O 1991.  Gender-specific reproductive outcome and exposure to high-frequency electromagnetic radiation among physiotherapists.  Scand J Work Environ Health 17: 324-329.

Ouellet-Hellstrom R, Stewart WF.  1993.  Miscarriages among female physical therapists who report using radio- and microwave-frequency electromagnetic radiation.  Am J Epidemiol 138: 775-786.

SAGE Associates Report, January 2011.  Assessment of Radiofrequency Microwave Radiation Emissions from Smart Meters. http://sagereports.com/smart-meter-rf/Accessed: March 10, 2012.

Taskinen H, Kyyronen P, Hemminki K. (1990).  Effects of ultrasound, shortwaves, and physical exertion on pregnancy outcome in physiotherapists.  J Epidemiol Community Health 44; 196-201.

Tell RA, Sias GG, Vazquez A, Sahl J, Turman JP, Kavet RI, & Mezei G (2012).  Radiofrequency fields associated with the Irton smart meter.  Radiat Prot Dosimetry 10; Abstract.

Weyandt TB, Schrader SM, Turner TW, Simon SD.  1996.  Semen analysis of military personnel associated with military duty assignments.  Reprod Toxicol 10: 521-528.

Antiperspirant and Breast Feeding

Aluminum as cause for alarm?

“Doctor, what do you know about the risks of using antiperspirant?” asked my 26-week pregnant patient, “Should I be worried?”

Feeling pretty uninformed, I told her, “if it makes you feel better, switch to a natural deodorant instead”.

I also told her she just gave me my next homework assignment.

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The natural next question that my pregnant patient is going to ask is what my thoughts are on using antiperspirants while breastfeeding.  No need to review all the basics, which if you want to read them are contained in my prior post (12.22.11 – Aluminum in Antiperspirant).   In sum, after all my reading and research, I still continue to use my antiperspirant that contains aluminum.  I wonder however if we have another child if I’d continue to use it during breast-feeding.

However, because I am on obstetrician-gynecologist and I guarantee somewhere down the line, if not this patient, then another one, is going to ask if there is any danger to using aluminum containing antiperspirants while breastfeeding.  As the self-appointed Breastfeeding champion at my work, I better have an educated answer to this question.

How much of absorbed aluminum through the skin actually then goes on to get into breast milk, if any?

What effects does aluminum have on developing human neuro- and skeletal system?

How equipped is an infant to process and rid the body of aluminum?

How much aluminum is absorbed via the skin? ~

If you look at the back of any antiperspirant, an aluminum-based compound is the main/active ingredient. This ingredient functions to clog the sweat glands to reduce the amount of sweating that occurs.

Based on a small radioactive isotope tagging study, only 0.012% of applied aluminum is absorbed through the skin, a very minute amount compared to the amount we absorb in our digestive system.

The study authors concluded that a single use of aluminum applied to the skin does not appear a significant contribution to the body burden of aluminum (Flarend et al, 2001).  However, another case report found individual differences might vary in ability to absorb and eliminate aluminum.  There is the case report a 43-year-old woman applied around 1-gram of an aluminum chlorohydrate-containing cream on each underarm daily for four years and experienced bone pain and fatigue without another identified cause.  After a couple months of stopping the antiperspirant use, the aluminum levels in her blood plasma and urine had decreased and at eight months her symptoms resolved. The authors of this study suggest that, “although individual variations in aluminum absorption are likely, one should apply aluminum containing antiperspirants with caution” (Guillard et al, 2004).  Concluding, in essence, different people may have different abilities to eliminate aluminum.   We know, those individuals with renal problems and on dialysis are more subject to the toxic build-up effects of aluminum.

Does aluminum absorbed from the skin show up in breast milk? ~

From the prior study, we know that there is a small increase in the amount of aluminum when it is applied to the skin.  However, it is so minute, I imagine the amount that enters the breast milk to be a percentage less.  For the answer to this question I looked into research articles that may’ve been published on this topic and searched through a “Drugs on Pregnancy and Lactation” text.

Sadly, I couldn’t find one research article that looked at application of antiperspirant and subsequent aluminum amount found in breast milk.  Neither could I find anything in the textbooks that I looked through.  So, if anyone knows of a research or textbook discussing this topic, please let me know!

Since aluminum is a highly reactive element and it can cross the blood brain barrier, I’d have to assume it also gets in breast milk.  The amount is likely miniscule and an infant with well-functioning kidneys should have no problem eliminating this digested amount.  However, I can’t determine to what degree since no actual studies have been done.

What effect does aluminum have on the developing infant’s systems?  ~

Because infants are much smaller, the amount required for toxicity is much less and their system is not fully developed in its ability to rid the body of waste as readily. As demonstrated by studies in adults, different individuals process aluminum differently.  These differences could also be found in infants.  Additionally, given their size and immaturity of organs, the ability to process and eliminate the aluminum may be less efficient than adults.

If one is strictly breastfeeding, which the World Health Organization and the American Academy of Pediatrics recommends in most individuals for a minimum of 6 months, the amount of aluminum an infant is exposed to is minimal since the bulk of normal exposure comes from oral intake.  However, if formula feeding, the amount infants are exposed to is likely much higher from water sources and from the formula itself.

As mentioned before, the main risks of elevated aluminum levels are that they displace similarly sized elements that have physiologic purpose in our bodies.  It therefore, can do this to infant’s bodies’ causing injury to developing brains and bones.

What will I tell my patients?  ~

As always it is a risk/benefit evaluation.  If social isolation would be the result of not using antiperspirants, I’d say use the antiperspirant.  Because the amount transmitted to the breast milk from use of antiperspirants would likely barely be detected and in individuals with normally functioning kidneys oral intake of aluminum can be easily eliminated, the risk of toxicity to an infant is so low, especially if only breastfeeding.

Otherwise, if it makes you feel better using natural deodorants and it works for you; by all means make the switch.  As for me, if the time comes to breast-feed again I’ll likely make the switch when I can to natural deodorant but not hesitate to use my aluminum chlorohydrate filled antiperspirant on days I need something stronger.

 

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REFERENCES:

Flarend R, Bin T, Elmore D, Hem SL (2001).  A preliminary study of the dermal absorption of aluminum for antiperspirants using aluminum-26.  Food Chemical Toxicology; 39(2):163-8.

Guillard O, Fauconneau B, Olichon D, Dedieu G, Deloncle R (2004).  Hyperaluminemia in a woman using an aluminum-containing antiperspirant for 4 years.  American Journal of Medicine; 117(12): 969-70.

 

 

Aluminum in Antiperspirant

As a cause of human illness?

“Doctor, what do you know about the risks of using antiperspirant?” asked my 26-week pregnant patient, “Should I be worried?”

Feeling pretty uninformed, I told her, “if it makes you feel better, switch to a natural deodorant instead”.

I also told her she just gave me my next homework assignment.

Aluminum basics. ~

Aluminum is the most common element in the earth’s crust and third most common element in nature.  Because it is so reactive, aluminum is primarily bound to other elements. (Verstraeten et al, 2008).

What are the health risks of aluminum? ~

In humans, there is no known physiologic need for aluminum but it can be absorbed from the GI tract, the mucosa, and across the skin (the concern with antiperspirants).  In individuals who have normal kidney function, the aluminum absorbed is removed. When the kidneys don’t function well the aluminum can accumulate.  It then competes with other essential elements we do need, such as magnesium, calcium, and iron (Bernardo, 2010). Therefore, its negative effects have to do with displacing these important elements, resulting in effects seen in the central nervous system, bone, and skeletal muscle.

How much aluminum do we actually absorb from antiperspirants?  ~

If you look at the back of any antiperspirant, an aluminum-based compound is the main/active ingredient.  The maximum aluminum compound permitted is 25% of the product, with an average range of 10-25% (FDA, 2009). This ingredient functions to clog the sweat glands to reduce the amount of sweating that occurs.

Based on a small radioactive isotope tagging study, we absorb very little through the skin. In this study, 84 mg of labeled Aluminum chlorohydrate (ACH), the active ingredient in many antiperspirants, was applied to a single underarm of two adult subjects with blood and urine samples being collected over 7 weeks.  They also did skin cell collection for the first 6 days. They found only 0.012% of the applied aluminum was absorbed through the skin. At this rate, about 4 micrograms of aluminum is absorbed from a single use on both underarms. This is about 2.5% of the aluminum absorbed on average by the gut in food over the same time period. Therefore, they concluded that a single use of ACH applied to the skin does not appear a significant contribution to the body burden of aluminum (Flarend et al, 2001).  However, there study only included two individuals and each person may absorb and eliminate differing amounts of aluminum as demonstrated by another case report.

In this case report a 43-year-old woman applied around 1-gram of an aluminum chlorohydrate-containing cream on each underarm daily for four years providing circumstantial evidence of potential harm.  After experiencing bone pain and fatigue without another found cause, she discontinued her antiperspirant.  A couple months later the aluminum levels in her blood plasma and urine had decreased and at eight months her symptoms resolved. The authors of this study suggest that, “although individual variations in aluminum absorption are likely, one should apply aluminum containing antiperspirants with caution” (Guillard et al, 2004).

Aluminums effect in humans.  ~

As mentioned before, the main risks of elevated aluminum levels are that they displace similarly sized elements that have physiologic purpose in our bodies, but can it cause some of our familiar diseases?

There are a number of discussions going on about the potential influence of aluminum on Parkinson and Alzheimer’s, as it has been shown to cross the blood-brain barrier, and in Breast cancer, due to absorption near the breast tissue.

An example often cited to refute aluminum as a cause of these disease, is that individuals on dialysis have higher levels of aluminum [when compared to those with normal functioning kidneys] and they don’t have any higher risk of developing these diseases (Brown et al, 2008).  There is concern, however, that when the digestive tract is bypassed there may be a higher risk of accumulation.

Does aluminum cause Parkinson’s? ~

The link between these diseases and aluminum come from many different conflicting studies.

For instance, people who live in areas with high aluminum concentration in the water have been found to have higher rates of Parkinson’s (Muhlenberg, 1998).  High aluminum concentrations have also been found in post-mortem brain specimens of patients with Parkinson’s and there is suggestion from animal models where aluminum administration caused a decrease in dopamine content, that via this mechanism it may influence development of the disease. (Bolt & Hengstler, 2008) However, simply because there is a presence and at supra-physiologic doses causes harm, does not indicate it is the cause.

Does aluminum cause Alzheimer’s? ~

Aluminums suspect involvement in the development of Alzheimer’s disease was introduced in the 1960’s (Terry & Pena, 1965 and Klatzo et al, 1965).  Since that time, no causal relationship has been established and a link seems more unlikely.

Again, some studies have found higher levels of aluminum in the brains of people with Alzheimer’s (Crapper et al, 1976), but other researchers have found no difference (Trapp et al, 1978).  Again, even if present this does not indicate cause and is more likely a secondary effect.  No positive association of antiperspirant use with Alzheimer’s disease has been shown (Flaten & Odegard, 1988).

Does aluminum cause Breast Cancer? ~

 Some research suggests that aluminum-based compounds have estrogenic properties and can alter DNA replication by increasing the rate of errors during replication (Darbre, 2005).  Therefore, it was concluded that aluminum in antiperspirants may influence the development of breast cancer given its proximity to breast tissue (Fakri et al, 2006).

Two studies, one in 2002 and another in 2006 interviewed women with or without breast cancer and evaluated their use of antiperspirants and shaving practices.  These studies found no difference between the groups (Fakri et al 2006, Mirick et al 2002).  While these two studies found no apparent link, a study in 2003 seemed to suggest earlier diagnosis of breast cancer in women who shaved and used antiperspirants.  This effect was especially noted in women who started younger than 16 years of age (McGrath, 2003).

So, while there have been a number of studies examining this question, overall the research seems to suggest a potential for earlier development of breast cancer, potentially in women who are susceptible to breast cancer, but not necessarily the cause of the breast cancer.

What will I tell my patient? ~

The risks are not fully supported.  In fact, it is likely there are multiple factors contributing to the development of these human illnesses.  There is definitely a risk of aluminum toxicity due to displacement of other elements; however, the amount absorbed via the skin is so miniscule it would require excessive application of aluminum antiperspirants and a poor functioning renal system for toxicity to occur.

For both Parkinson’s and Alzheimer’s, it seems that aluminum is most likely a secondary findings and not the cause of the disease.

In women who are susceptible to the development of estrogen-positive breast cancer, anything that has an estrogen-stimulating effect may lead to earlier development of the disease.  As mentioned in an earlier post about parabens, the cumulative effect of estrogenic like substances in our environment may lead to earlier development, but are in all probability not the only cause.  Other risk factors such as genetics, hormone replacement therapy, and long-standing obesity are greater contributors to risk.

So, what will I tell my patient who is pregnant about risks to the fetus?  Since aluminum has been shown to cross the blood-brain barrier by hijacking the iron transport system, it is also the case that aluminum could use the same mechanism to travel across the placenta to the developing fetus and displace essential elements during growth.  If the cumulative amount is significant enough, this could make a difference during critical periods of time.  From antiperspirants alone though, the amount one would have to absorb is so great that this is highly unlikely to have any influence on development.

As with all things, there is a risk/benefit analysis that has to take place.  Based on available research, the risk from the aluminum in antiperspirants appears so low in general that even during pregnancy, if you perspire heavily and need an antiperspirant, don’t hesitate to use it.  However, if a natural deodorant will suffice and it makes one feel better about limiting their aluminum exposure, then switch to that on lower activity days.

The amount of aluminum through other sources such as drinking water and aluminum pots and pans through the gastrointestinal tract is significantly greater and generally one can rid this if they have well-functioning kidneys.  However, that is for another blog post.

As for this patient, I have a feeling the next question coming from her will be…do you think aluminum antiperspirant is safe to use during breastfeeding?

Hmmmm, while I now know potential risks and absorption amount have to review amount in breast milk and newborn’s ability to eliminate aluminum.  I’ll be getting back to this question, off to review the research!

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REFERENCES:

Bernardo J (2010).  Aluminum toxicity.  Medscape Website.  Accessed: November 15, 2011 http://emedicine.medscape.com/article/165315-overview

Bolt HM, Hengstler JG (2008). Aluminum and lead toxicity revisited: mechanisms explaining the particular sensitivity of the brain to oxidative damage. Archives of Toxicology; 82(11): 787-8.

Brown RO, Morgan LM, Bhattacharya SK, Johnson PL, Minard G, Dickerson RN (2008). Potential aluminum exposure from parenteral nutrition in patients with acute kidney injury. Annals of Pharmacotherapy; 42(10): 1410-5.

Crapper D R, Krishnan S S and Quittkat S (1976).  Aluminum, neurofibrillary degeneration and Alzheimer’s disease. Brain; 99: 67-80.

Darbre PD (2005). Aluminum, antiperspirants and breast cancer. Journal of Inorganic Biochemistry; 99(9):1912–1919.

Exley C (2001).  Aluminum in antiperspirants: more than just skin deep.  Food Chemical Toxicology; 39(2): 163-8.

Fakri S, Al-Azzawi A, Al-Tawil N. (2006). Antiperspirant use as a risk factor for breast cancer in Iraq. Eastern Mediterranean Health Journal; 12(3–4): 478–482.

FDA Website (Last updated 2009).  Accessed: December 21, 2011 http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Over-the-CounterOTCDrugs/StatusofOTCRulemakings/ucm070826.htm#Original

Flarend R, Bin T, Elmore D, Hem SL (2001).  A preliminary study of the dermal absorption of aluminum from antiperspirants using aluminum-26.  Food Chemical Toxicology; 39(2): 163-8.

Flaten, T., and Odegard, M. (1988). Tea, aluminum and Alzheimer’s disease. Chemical Toxicology; 26: 959-960.

Guillard O, Fauconneau B, Olichon D, Dedieu G, Deloncle R (2004).  Hyperaluminemia in a woman using an aluminum-containing antiperspirant for 4 years.  American Journal of Medicine; 117(12): 969-70.

Klatzo I, Wisniewski H and Streicher E (1965).  Experimental production of neurofibrillary pathology: 1. Light microscopic observations. Journal of Neuropathology and Experimental Neurology; 24: 187-99.

McGrath KG. An earlier age of breast cancer diagnosis related to more frequent use of antiperspirants/deodorants and underarm shaving (2003). European Journal of Cancer; 12(6): 479–485.

Mirick DK, Davis S, Thomas DB (2002). Antiperspirant use and the risk of breast cancer. Journal of the National Cancer Institute; 94(20): 1578–1580.

Muhlenberg, W (1990). High aluminum concentrations in well water of southern Lower Saxony sandy soil areas caused by acid precipitation: evaluation from the public health and ecologic viewpoint. Offentliche Gesundheitswesen; 52, 1-8.

Terry R D and Pena C (1965).  Experimental production of neurofibrillary pathology: electron microscopy, phosphate histochemistry and electron probe analysis’. Journal of Neuropathology and Experimental Neurology; 24: 200-10.

Trapp G A, Miner G D, Zimmerman R L, Mastri A R, Heston L L (1978).  Aluminum levels in brain in Alzheimer’s disease. Biological Psychiatry; 13 (6): 709-18.

Verstraeten SV, Aimo L, Oteiza PI (2008). Aluminum and lead: molecular mechanisms of brain toxicity. Archives of Toxicology; 82(11):789-802

=================================================================

Organization information:

National Parkinson Foundation –  http://www.parkinson.org/

Alzheimer’s Society –  http://alzheimers.org.uk/site/scripts/documents_info.php?documentID=99

National Cancer Institute (fact sheet) – http://www.cancer.gov/cancertopics/factsheet/Risk/AP-Deo

 

Adjustment of Bikram Sequence for Pregnancy

For Preggers

In general, no postures should be done that compress the heart, diaphragm or abdomen, with backbends avoid pushing hips forward of knees, and separate feet slightly in standing and forward bend poses for balance.  No standing head to knee, separate leg forehead to knee, rabbit, cobra, locus, full locust, or floor bow.  These are substituted with pregnancy safe postures.  In Savasana pregnant women rest on their side and utilize long, deep, slow breathing.

Here’s a compilation of Rajashree’s pregnancy video and review of other Bikram yoga websites for maintaining a Bikram yoga practice during pregnancy safely and with integrity in your current class:

First Breathing Exercise:  Pranayama breathing – does not change, feet together as comfortable as one can, this may be adjusted for balance as the pregnancy progresses.

Posture #1:  Half-Moon/Back Bend – feet opened to hip width distance, during the back bend hips do not go forward beyond your toes.

Posture #2:  Hands to Feet – feet hip distance and grasp back of heels with hands, bringing head between legs.

Posture #3 & #4:  Awkward & Eagle Poses – essentially the same.

Posture #5:  Standing Head to Knee – can be altered by simply raising a bent leg up or taking this time to rest, remember to be considerate of your fellow yogis by standing or sitting still as possible, drink water if you feel you must.

Posture #6-9:  Standing Bow, Balancing Stick, Standing Separate Leg Stretching, & Triangle are all done the same, being aware that balance may be more difficult in the standing bow posture and doing near a wall/balancing bar may be needed.

Posture #10:  Standing Separate Leg Head to Knee – adjusted by bending at the waist and leaning forward only slightly with arms on back, stretching without compression.

Posture #11 & #12: Tree and Toe Stand Posture – no change
.

Posture #13:  Savasana (ie. Dead Body Pose) – initial Savasana is done on back with knees bent before wind removing pose and then remainder is done on the side, alternating sides between the postures.

Posture #14: Wind Removing Pose – each side is done regularly but when both legs are brought up during the first set the legs are pulled to side, around abdomen, on second set the knees are brought up, feet grasped with hands and the soles brought together and knees drop out without any pressure on abdomen.

In between postures in Bikram a sit up is conducted, in pregnancy getting up you simply push yourself up with your arms from the side.

The spine segment of the series is where most of the changes of the original Bikram series are altered to avoid pressure on the abdomen but continuing to strengthen the spine.

Posture #15-18: Cobra, Locust, Full Locust, and Floor Bow are not done.  Instead these are substituted with the following:

Posture #15: Half-fish posture in place of Cobra- lie on back, arms are brought over head and palms placed flat on floor at shoulder by the ears, fingertips pointing down and palms are pushed with the upper body being brought toward the ceiling and top of head placed on floor, arms are brought down to side of body, hands on floor palms facing down, both legs are kept straight on the floor from hips to heels and chest brought toward the ceiling as high as possible.  To release bring hands next to head again, push against the floor and release head.

Posture #16 & 17: Kneeling Locust pose in place of Locust and Full Locust – come on all fours, knees below heels and arms below shoulders, chin up, inhale and lift right leg up as far as goes, then left leg, role forward.  Between these postures, practitioner sits back on heels. Rest on heels during Full Locust and move to side Savasana when the remainder of class moves to Savasana prior to Floor Bow.

Posture #18: Bridge replaces Floor Bow – bend both knees, separate feet hip distance apart and bring to hips, grab heels from side, lift hips off the floor, neck straight and shoulders on the ground, hold.  Push arms and elbows against the floor.  To come out slowly bring hips down and legs down.

Posture #19:  Fixed Firm Pose – the same.

Posture #20:  Half-Tortoise – sit down with knees open, otherwise, no change.

Posture #21 Camel – done without change, just be gentle with pushing your hips forward.

Posture #22:  Bound angle or Cat-Cow can be done in place of Rabbit. Rajashree in her video does Bound Angle – sit and bring soles of the feet together and gently press knees down.
 A Denver yoga studio suggests substituting Cat-Cow – start on all fours, bringing the wrists underneath the shoulders and knees under the hips, head in neutral position.  On an inhale curl the toes under, drop the belly, gaze toward the ceiling working from spine to tailbone, so neck is the last movement.  On the exhale, the feet tops are released to the floor, the spine is rounded, head is dropped, and eyes look toward the navel.  Repeat.

Posture #23:  Head to Knee – adjusted by grasping feet and bending to side, avoiding compression.

Posture #24:  Stretching pose is done as separate leg stretching on first set.  Legs are separated apart as much as possible and toes are grasped, bend knees if necessary.  Second set is completed with Gentle Pose- sit and bring soles together to body, hands on knees, push and lift shoulder up one by one, until both elbows are straight.

Posture #25 Spine Twist – done with a straight leg on the ground.

Posture #26 and final breathing exercise:  Blowing in Firm Pose is the same.
Instead of a final Savasana on the back, her yoga pregnancy video is completed with another breathing exercise.  Sitting in lotus position with relaxed breathing in and out, each to a count of six and between a brief pause, completing this with the rest of your class.

~Namaste

References
Bikram Yoga Website.  (Accessed: August 15, 2011) http://www.bikramyoga.com/Rajashree/rajashree_preg_yoga.php

Choudhury R. Pregnancy Yoga Video.

Breastfeeding — Fundamental to Survival

…and yet, one of the hardest things I’ve ever done!

I lecture my patients about the benefits of breastfeeding.  For babe this results in reduced rates of asthma and eczema along with childhood obesity and diabetes.  Benefits for mom include more rapid weight loss following pregnancy and reduced breast cancer rates.  The science supports breastfeeding!

As a species, we’ve been doing it for millennia.  Babies in many countries are strictly breastfed.  How hard could it be?  I was not prepared for how truly difficult it could be!!  Why didn’t anyone tell me???

After my midwife handed me our new little bundle of joy, I recall asking, “now what?”  It all started with the fun game of trying to latch. I’d borrowed a Boppy breastfeeding pillow from my sister-in-law, which helped with support.  The latch was indeed a struggle but besides the intense pain, bleeding, and lipstick shape of my nipples (sorry, TMI) following feeding I thought he was at least getting something.

We continued to think we were latching just fine and since those first couple days only colostrum is produced, it seemed as though he was getting enough.  Likely, because I was an obstetrician-gynecologist the lactation consultant came in and checked, provided a mini lesion, and gave me a rapid seal of approval.  We thought things were going well except for the pain I was experiencing.  Just figured this was standard and onward we went, leaving the hospital 26 hours after his birth and admittedly, feeling a little lost.  I was used to just delivering the babies and handing them to new parents, what happened after that was beyond me.

Fortunately, because of our type of insurance we had a home health aid come to see us after being home for just two days.  I thought actually that those patients who needed this most probably wouldn’t receive a home health visit, because of their insurance (that is for another blog:).  We’d noticed he was looking a little yellow from our partly opened eyelids. However, in a state of exhaustion and shear overwhelmingness of bringing home this little creature that depends entirely on you, I wasn’t up to making medical judgments at that point.  His bilirubin was high, but not necessitating a trip to the hospital for bili-lights, just some window sunlight and working on getting more feedings in. He’d also lost more than 10% of his weight by this time so that meant we’d be seeing the pediatrician sooner.  It also meant we had to supplement with formula, which was a devastating blow to my well laid out plan.

The paper we were sent home with to record this information became too chaotic.  So, Kadin got his own iPhone to start recording on an everything-Kadin app.…time on each breast, which breast, weight before and after each feed (yup, we rented a scale), weight of each pee and poop, and keeping a timer set so he received his every two hour feeds.  I recall more than once being in the middle of feeding and the alarm would go off and it’d be time to feed again.  “But we’re still feeding”, I recall asking my husband tearfully, “What should we do?”  I’d already been curling my toes for the past two hours and he got, oh about 2 mL of breastmilk. (yes, that’s basically 4 drops).  In between the attempts at feeding I was pumping so that there was milk to supplement him with in addition to the formula.  I was also trying to stock up so that when I did have to go back to work at the end of the month, I’d be able to have a store in the freezer.

Ugh, feeling like you are a dairy cow your first days home with your new baby, while being sleep deprived, hormonal and stressing over how much your little one is getting made things a little rough in the beginning.  Thank goodness for a very supportive husband!  I could see how easy it would be to just say, “Okay, go ahead and give him formula.  I’m sleeping tonight”.  Ahhh, it would’ve been so easy but my husband believed in breastfeeding as much as I did.  It’s hard to deny the literature when you are scientifically minded.

There was a “Day One” center near our home in San Francisco and near daily trips filled our first week to get breastfeeding supplies.  Thank goodness for such a resource!  I’d love to be a resource for others in such a way.  A Medela Supplemental Nursing System was our first attempt.  That was no easy task to tape that to the nipple, wear a necklace with a small plastic container on it and get him to take it in.  It was constant feeding, weighing, diaper changing, weighing, and pumping, repeat.

I recall our first pediatrician visit.  Immediately before the appointment he had a pee and I cried, “that’s 30mL lighter he is going to weigh!”  The pressure to weigh in daily a pound or so heavier was intense.  Looking back, it was a lot of pressure that I put on myself to breastfeed.  How can I counsel my patients about it, if I couldn’t do it myself?

Our first visit was with a nurse practitioner who was a lactation specialist.  She helped us latch and yet he still only got a minimal amount.  I cried.  I’d asked her about a breast shield and she recommended we wait.  We sat in there an hour trying to get him to feed.  Our new assignment was to get additional breastmilk/formula mix via a syringe following attempts at breast feeds.  We’d see her tomorrow.  So, for the next 24 hours I remember stressing about getting enough into him and hoping he didn’t pee or poop right before our appointment weigh in.

So, the cycle continued.  This next 24-hour cycle, intermittently giving syringe feeds to get enough in.  I’d been pumping like mad in between feeds too so that we could get rid of the formula.  Oh, how obsessive we were about this whole breastfeeding thing.  It’s all recorded on Kadin’s App on the iPhone.  I’ll have to figure out if I can download this data at a later date, just to show.

We had an appointment the next day with another lactation consultant in addition to the pediatric nurse.  Thanks to syringe feedings overnight he got enough and made his weigh-in that visit.  We again tried to feed in the office and the amount was minimal, again she recommended we wait on the breast shield.  I wanted to try something and was beginning to feel more than a little frustrated.

Later that afternoon I had another appointment with a different lactation consultant.  She worked with us for nearly two hours and we had moments of success.  Again, I asked if a nipple shield will help and yippee, she gave me approval to give it a shot.

Thank you Medela!  The partial coverage nipple shield maintained a sense of contact with my little one and amazingly, once I figured out how to put it on, our feedings instantly improved.

We still had to supplement with syringe feeds and he seemed to always be feeding but by the end of the first week we were released from further regular weigh-ins and we returned the scale.  We finally got to enjoy our little one and stopped our obsessive recordings.

It took about a week to finally get rid of our “training wheels” so to speak.  One day when feeling particularly confidant I decided to pull it off mid-feed.  While I wouldn’t say it was comfortable exactly, I had nowhere near the pain I’d experienced before and it finally seemed he got enough during the feed, we both just clicked and it FINALLY, seemed like the natural thing to do.

Even with it being my Chief year of residency we actually made it nearly ten months of exclusive breastfeeding!  My goal was a year so I was shy of that goal but felt okay when the day came that production was down, the stores in the freezer were decreasing, and he was taking in more solid food.  However, the benefit of that effort was worth it!  He got all the benefits of breast milk and I got to bond with my child.  It’s hard when you are in the midst of a hormonal and sleep deprivation haze to be rational so I decided to write down for myself what I’d um, tell myself next time.

Basic Breastfeeding Recommendations:

  1. Don’t stress too much!  If you are pumping and feeding your little one breast milk, they are getting the needed nutrients and immune cells, even if it’s administered via a bottle.  It’s okay if you have to supplement with a little formula, it won’t kill them.  Plenty of children were raised on formula alone.  I even found out from my mom that starting with my second week of life she switched to formula only.  I like to think I turned out OK. Get support from family/friends!  Thank goodness for my husband who was so incredibly supportive and when Kadin and I would get frustrated, he was a calming voice.
  2. Get support from family/friends!  Thank goodness for my husband who was so incredibly supportive and when Kadin and I would get frustrated, he was a calming voice.
  3. Get outside help early!  It helped to know that I had appointments with lactation specialists.  Even if we weren’t solving all the problems yet I was checking in with someone else who always had some new suggestions to try.
  4. Breast shields may actually help!  I understand the concern of the pediatric nurse and Kadin not getting enough milk or using it as a crutch but once we started using it things seemed to dramatically improve.   At least I wasn’t in tremendous pain anymore and I could help express milk into the shield for Kadin to drink.  It was a crutch for just about a week but allowed us to get the feeding latch down so when I took it off we were both ready.
  5. Breastfeeding pillows can help!  Borrow from others and use your own cover until you find something that works for you.  I know people who bought a bunch of different ones.  Seems kinda wasteful to me but when you have a new little one you are just trying to find the best thing around.  I found the borrowed Boppy worked fine for me.  My sister-in-law ended up using My Brest Friend.

Since I’ve been reading more about organic products, while the Boppy and My Brest Friend have organic versions of their products, there are a couple of smaller companies that I wish I had known about before.  If you are thinking about buying one maybe support one of these smaller companies who practice a sustainable business model.

Holy lamb is a company with a great ‘feel’ when you read about them.  They produce essentially an organic wool Boppy.  They make their products in the United States using locally raised wool, re-use, recycle or compost all their materials, and subscribe to green practices in their facilities.

Another small company with sustainable practices and a small town feel is Blessed Nest.  ”Made locally by hand, by moms, aunties and grandmas” as their website proclaims.  They make an intriguing half-moon nursing pillow I would’ve liked to try, may be more comfortable for larger women or those who had a cesarean section and don’t want to put something around their middle.  It’s made from 100% organic cotton fabric and stuffed with buckwheat hull filling.  They claim the buckwheat hull filling latches and help it conform for support.

Just keep working at it and it will eventually click!  You may have to feel a little like a dairy cow, pumping to keep up your supply, but persistence really did pay off.  I feel like I gave my little one the best start possible and once we both got it, it was sooo worth it!

Friends of ours recent birth of a little boy, who are having difficulty breastfeeding, reminded me of our own experience, not that long ago and yet a lifetime ago.  This is dedicated to all mommies having a tough time breastfeeding and thanks to their support crew.  Keep it up; you’ll get there!!

Be sure to see your lactation consultant if you are having difficulties!

 

Bikram, Baby!

Pregnancy and Bikram Yoga

As an obstetrician-gynecologist whose primary mode of exercise and personal well-being has become Bikram yoga, I wondered what was out there in terms of research on Bikram yoga and pregnancy.  There has been so few pregnant women attending the classes I’ve been in; I began to wonder if women just stopped during pregnancy. There are no prenatal Bikram yoga classes, so an entire group of women seemed alienated from the practice.  So, what is there in terms of research pertaining to pregnancy outcomes in Bikram yoga practitioners?  Basically nothing!

Given that fact, one has to extrapolate from physiologic changes in pregnancy and those occurring during the Bikram series to make recommendations. Here’s what I’ve concluded to tell my patients who are Bikram yoga practitioners and want to continue during pregnancy.

A woman has to consider that there are numerous changes that take place to maintain a pregnancy.  Briefly, in the first trimester, basal metabolism begins to increase and ultimately requires an increase by as much as 300kcal/day to support mother and growing fetus, while increased rates of filtration at the level of the kidneys can lead to loss of important nutrients (Weissgerber 2006).  The addition of any exercise requires additional calorie intake to support a growing pregnancy.  Blood volume increases but with greater plasma volume than red blood cell volume, resulting in physiologic anemia.  This makes the transport of oxygen to the mother decrease to some degree.  Systemic vascular resistance decreases, leading to a decrease in blood pressure and this leads to an increased heart rate, which nadirs in the second trimester. Decreased blood pressure can lead to decreased blood flow to some important areas of the body such as brain or placenta potentially.  As uterine size increases there is increased pressure on the venous system that can lead to lower extremity swelling, influences respiratory changes that lead to an increased perception of need to breath, and alters a woman’s center of gravity.  All aspects of exercise tolerance. The hormone relaxin leads to musculoskeletal system changes with softening and relaxation of joints in preparation for childbirth, increasing flexility but also increasing risk of injury.

Research now supports that pregnancy should include a component of exercise, as moderate intensity activity has been shown to be beneficial in healthy women with normal pregnancies.  Key in that statement is HEALTHY women with NORMAL pregnancies.  In 2006, a Cochrane Review found 11 studies, with 472 participants, looking at exercise effects on maternal and newborn outcomes (Kramer 2006).  The conclusion was that exercise improved or maintained fitness, but they ultimately determined that data were “insufficient to conclude that exercise during pregnancy influences maternal and newborn outcomes”.  More recently, a Medscape review article, “The Effect of Exercise During Pregnancy on Maternal Outcomes: Literature Review of Exercise During Pregnancy” (Lewis 2008) identified 40 articles including observational and randomized studies and concluded there were reduced rates of hypertensive disorders of pregnancy, gestational diabetes, cesarean section rates, pregnancy symptoms, decreased weight gain, and psychological issues during pregnancy in women who exercised (Morris 2005, Impact 2006).  The American College of Obstetricians and Gynecologists now recommends that women with low risk pregnancies participate in moderate intensity activity, a minimum of 30 minutes, most days of the week (ACOG Committee Opinion).   This does not apply to anyone deemed a high-risk pregnancy and there are obvious activities that pregnant women should avoid such as anything where impact may occur (ie. football, soccer), falls could be sustained (ie. horseback riding, biking) or significant pressure changes encountered (ie. scuba diving).

So, given the physiologic changes in pregnancy and recommendations for some exercise with pregnancy, how does Bikram Yoga fit into this recommendation and what are some of the concerns?  The 90-minute, 26 posture series, can be intense at times especially given the heat of between 95-105 degrees fahrenheit and 40-60 percent humidity.  However, for practitioners who have been doing the series for a minimum of 6 months regularly, there appears to be no reason it can’t be continued with precautions and modifications.  One should proceed with exercise after approval by one’s personal obstetrician-gynecologist, knowledge of your pregnancy by your Bikram yoga instructor, and at the practitioner’s discretion.  The main concerns that arise with practicing Bikram yoga during pregnancy are what occurs with core body temperature during the series.  This is especially true during early pregnancy when the neural tube (ie. central nervous system) is forming.  An additional concern throughout the pregnancy is uteroplacental blood flow with adequate oxygenation, hydration, and substrates to support a growing fetus.

A core body temperature of greater than 102 degrees fahrenheit for more than 10 minutes has been shown to increase risks of neural tube defects in a developing fetus and in a more developed fetus lead to dehydration and potentially reduced amniotic fluid volume.  This most often occurs during fevers but also can be caused by extremely heavy exercise or prolonged exposure to heat sources such as hot tubs or saunas.  Although there are suggestions that extreme temperatures may increase the risks of gastrointestinal and cardiac defects, the only consistently seen defect are those of the neural tube.  Avoiding excessively increased core body temperatures in the first trimester is one way to reduce the risk of neural tube defects, along with taking supplemental folic acid.

The key question is:  If Bikram yoga or ‘hot’ yoga changes core body temperature to above the 102 degrees fahrenheit level for long enough to cause neural tube defects or dehydration in a developing fetus?

Normal range of oral temperatures for females is 36.5-37.3 celsius (97.7-99.1 fahrenheit), with the lowest temperatures being in the early morning hours and peaking in the late afternoon and early evening.  Therefore, ‘hot’ yoga in the morning would be less likely to increase core body temperatures to a concerning level.  Our bodies are expert at regulating and maintaining our core temperature when the surrounding temperature changes, especially if the body grows accustomed to the heat and humidity.  This is one reason why only women who have been practicing Bikram yoga should even consider continuing. This is not a form of exercise I’d suggest starting during pregnancy.  Studies have shown that individuals become acclimatized to heat, developing increased tolerance in hot and humid conditions in 1 to 3 weeks (Guyton, 2006).  The primary way the body maintains the internal temperature in Bikram yoga is through evaporation in the form of sweat glands and dilation of blood vessels, which helps to cool the body.  However, with increasing humidity thermoregulation can be inhibited by limiting sweat evaporation and heat loss (Guyton 2006) and external cooling, with a cool towel or water may aid with temperature regulation.  Increased blood flow to the skin and expanded skin surface area actually have been shown to increase a pregnant woman’s efficiency with temperature regulation, helping her rid her body of excess heat when compared to non-pregnant women.

Over the course of pregnancy, potentially because of an increasing metabolic rate and body surface area, core temperatures have been shown to decrease.  A small longitudinal study of 15 women (GA 8, 16, 26, 36, and 12, 24, 52 weeks postpartum) found maternal core temperature to be highest in the first trimester with a decrease during pregnancy.  At 8 weeks temperatures averaged 37.1 celsius and decreased to term with the nadir of 36.4 celsius at 12wks postpartum, then stabilized by 24 weeks postpartum (Hartgill 2011).  In a general search on the web and in speaking with my yoga instructors, there are many anecdotal stories of women who continued with Bikram yoga during pregnancy without complications.  Simply because there are reports of women and their infants doing fine when the woman practiced Bikram yoga during her pregnancy, does or does not mean it is necessarily not hazardous.  I’d equate it with women who smoke or drink during pregnancy, there are reports of normal pregnancies in those situations as well.  Even initial studies are needed.  Something as simple as a retrospective review of rates of complications in women continuing Bikram yoga practice while pregnant are lacking.

In trying to find information about core body temperature changes during Bikram yoga, one yoga studio conducted an informal “experiment” by having two pregnant women take their oral temperatures before class, three different times during class and again following class.  Neither saw a noticeable rise in temperature, with one reporting lower temperatures during class than at other times during the day.  During another class this studio took the temperatures of 12 non-pregnant individuals before and immediately following class and noted the highest body temperature recorded of 101.5 with an average post-class temperature of 99.7.  However, considering core body temperature differs from oral temperatures by approximately 0.8 degrees, the highest temperature of 101.5 would be above the recommended maximum of 102 degrees. However, we do not know how this fluctuated during class or how long the temperature was maintained.  Although they do not specify women versus men or the time of day these temperatures were taken.  Some general recommendations, if a woman wanted to continue practicing, would be to go in the morning, ask the instructor where the coolest spot in the room may be, drink plenty of fluids to maintain hydration, take a thermometer to monitor one’s temperature during the sequence as everyone will have a different range, take a squirt bottle with cold water in to provide external cooling if necessary, listen to your body by substituting the postures with appropriate pregnancy postures and by taking breaks to cool down and if it requires leaving the class to cool down, yoga etiquette or not, for your safety, exit quietly.

Another issue of concern is uteroplacental blood flow, dehydration and maintenance of nutrients to the fetus throughout Bikram yoga practice.  With increasing basal metabolism and increased filtration at the kidneys it is important that pregnant women maintain adequate nutrition through diet and supplements.  I’ve heard that a session of Bikram yoga burns 600-800 calories for the average woman, increasing calorie intake and taking appropriate supplements is necessary for women to continue practicing.  Eating before class and taking a snack for immediately after would be encouraged.  Even when not pregnant, going to class hydrated and maintaining hydration throughout class is important.  Supplying additional electrolyte rich fluids can help maintain osmotic pressure intravascularly to prevent further decreased blood pressure.  With further vasodilation for cooling, pregnant women may begin to feel light-headed easier as the blood flow is diverted to the skin.  Fetal hemoglobin will insure the fetus will obtain sufficiently oxygenated blood flow but staying well hydrated and sitting if any indication of feeling light headed would be important for mom.

Some general concerns is that first trimester is very critical to fetal development with organogenesis occurring by the end of the twelfth week of gestation.  Any teratogen will have it’s greatest influence at this critical time.  A difficult aspect is that women often don’t know they are pregnant in the very early weeks and because spontaneous miscarriage rates are greater during the first trimester, the legal climate of obstetrics, and often a fear of the unknown, most physicians would likely recommend avoiding many activities in the first trimester.  Rajashree, Bikram’s wife, states that from the second trimester on you can practice her pregnancy yoga sequence.  I was unable to find a statement from Bikram or Rajashree regarding practicing during the first trimester. Think I’ll send her an email.  However, for myself, the thought of not going to Bikram yoga for twelve weeks, if I were to be pregnant, and the effect it would have on my physical and mental well-being would be worth the theoretical risk as long as precautions mentioned above were taken.  Although as I recall during my first pregnancy, from about 7-12 weeks gestation I have never been as tired or nauseous in my entire life so one may not feel up to going to class anyway.  Because of the hormonal mileau wrecking havoc and the energy requirements of the first trimester, there may be times where fewer classes would be in order, more breaks during the series, or incorporating the pregnancy sequence should prevail.

As the pregnancy progresses and the uterus grows, the change of the center of gravity may lead to imbalance during the yoga series.  Taking this into consideration, positioning oneself near a wall, using a bar during some of the series, or adjusting the series as necessary may be required.  Additionally, the hormone relaxin allows for softening of the joints and increased flexibility.  Keeping this in mind, the heat already improves flexibility so women should be particularly cautious when doing postures as to not overstrain or injure themselves by doing something they wouldn’t normally be capable of doing prior to pregnancy.

So, how does the Bikram yoga pregnancy sequence differ?  First, according to the Bikram Yoga Website and Bikram’s wife Rajashree’s pregnancy video she recommends seeking the advice of a doctor before proceeding with Bikram Yoga (I would agree!).  If medically cleared by a physician, without any high risk pregnancy issues, have been practicing Bikram yoga for a minimum of six months, but preferably a year, and plan to continue Bikram yoga throughout your pregnancy then the following adjustments are recommended.  While Rajashree’s pregnancy video provides an alternative sequence and can be done at home, practicing with your normal class requires a few adjustments.   She notes that from the second trimester on you can practice her pregnancy yoga sequence and it can be practiced in a Bikram Yoga Class, but at the pregnant woman’s discretion.

 

Wishing you health and happiness in your pregnancy. In the end we all want a healthy mom and baby.  Please be certain to seek the advice of your physician to ensure safety during this or any other exercise during pregnancy!

While I am a physician, this article in no way a substitute for someone who knows you well, it an attempt to organize my thoughts for myself and for any patients who may ask me about Bikram in pregnancy.

Namaste.

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REFERENCES:

ACOG committee opinion: exercise during pregnancy and the postpartum period.  Number 267, January 2002.  American College of Obstetricians and Gynecologists.  Int J Gynaecol Obstet.  2002; 77:79-81.

Bikram Yoga Website.  (Accessed: August 15, 2011) http://www.bikramyoga.com/Rajashree/rajashree_preg_yoga.php

Choudhury R. Pregnancy Yoga Video.

Guyton, AC & Hall JE (2006).  Textbook of Medical Physiology.  Philadelphia: Elselvier Saunders.

Hartgill TW, Bergersen TK, Pirhonen J. 2011  Core body temperature and the thermoneutral zone: a longitudinal study of normal human pregnancy.  Acta Phisiol Apr;201(4):467-74.

Impact of physical activity during pregnancy and postpartum on chronic disease risk. Med Sci Sports Exerc. 2006;38: 989-1006.

Jennings E (2010).  Online posting from Bikram Yoga Decatur.  http://bikramyogadecatur.com/node/430 (Accessed 08.09.11).

Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Cochrane Database Syst Rev. 2006;(3): CD000180.

Lewis B, Avery M, Jennings E, Sherwood N, Martinson B, Crain L.  The Effect of Exercise During Pregnancy on Maternal Outcomes: Literature Review of Exercise During Pregnancy.  http://www.medscape.com/viewarticle/580466_5 (Accessed: August 8, 2011).

Morris SN, Johnson NR. Exercise during pregnancy: a critical appraisal of the literature. J Reprod Med. 2005;50:181-188.

Weissgerber TL, Wolfe LA. Physiological adaptation in early human pregnancy: adaptation to balance maternal-fetal demands. Appl Physiol Nutr Metab. 2006;31:1-11.