Guest guest Posted January 25, 2006 Report Share Posted January 25, 2006 Even the Cochrane database (in the body of the eval) notes about a 75% drop in Preterm labor for those at high risk, when using Prog supplem, though somehow they conclude that there’s not enough evidence that it works. Your last sentence may not at all be conjecture. I would wait (for level) and see, and check periodically. , MD Shenandoah Valley FPR Front Royal, VA From: nfpprofessionals [mailto:nfpprofessionals ] On Behalf Of D. Poehailos, MD Sent: Wednesday, January 25, 2006 2:10 PM To: nfpprofessionals Subject: Help with patient To the list, I just got a phone call from one of my patients that she just had a positive pregnancy test. Her first pregnancy was achieved with progesterone supplementation due to short luteal phases and low peak +7 levels. I prescribed initially, and then when she became pregnant, her OB wasn't as interested in maintaining it and tapered it off after the first TM. Interestingly, she nearly lost the pregnancy due to preterm labor at 22 weeks, and made it due to a lot of prayers, a terbutaline pump, and an internal cerclage that stayed in for delivery (36 weeks via csection.) She is not on progesterone supplementation now, so she achieved this one on her own. My questions, since her OB is not so progesterone-concerned. I'm going to check a level on her tomorrow--35 days after LMP. Should I start supplementation now while awaiting results? If her level comes out ok on the nomogram in Hilgers' book, or do we just then do a wait and see and check frequently. She and I cannot help but wonder if she had stayed on the progesterone in the first pregnancy if she would have had the problems she did--conjecture, we know. Any thoughts? D. Poehailos, MD Family Physician STM Instructor-Dioc of burg Curriculum Charlottesville, VA " Let us thank God that he makes us live among the present problems. It is no longer permitted to anyone to be mediocre. " --Pope Pius VI Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 25, 2006 Report Share Posted January 25, 2006 As a patient of Hilgers with the EXACT same problem, I can tell you what he did for me. Take progesterone in the meantime, while awaiting results (after all, it can only help and not hurt!). Check progesterone levels once a month (every two weeks in the end). Have the patient stop taking progesterone enough time prior to the blood draw to get an accurate level of what HER body is producing. (With IM shot, last shot 72 hours prior to draw). The patient may be on progesterone for awhile, then off, then on again, depending on monthly results. Kim Help with patient To the list, I just got a phone call from one of my patients that she just had a positive pregnancy test. Her first pregnancy was achieved with progesterone supplementation due to short luteal phases and low peak +7 levels. I prescribed initially, and then when she became pregnant, her OB wasn't as interested in maintaining it and tapered it off after the first TM. Interestingly, she nearly lost the pregnancy due to preterm labor at 22 weeks, and made it due to a lot of prayers, a terbutaline pump, and an internal cerclage that stayed in for delivery (36 weeks via csection.) She is not on progesterone supplementation now, so she achieved this one on her own. My questions, since her OB is not so progesterone-concerned. I'm going to check a level on her tomorrow--35 days after LMP. Should I start supplementation now while awaiting results? If her level comes out ok on the nomogram in Hilgers' book, or do we just then do a wait and see and check frequently. She and I cannot help but wonder if she had stayed on the progesterone in the first pregnancy if she would have had the problems she did--conjecture, we know. Any thoughts? D. Poehailos, MD Family Physician STM Instructor-Dioc of burg Curriculum Charlottesville, VA " Let us thank God that he makes us live among the present problems. It is no longer permitted to anyone to be mediocre. " --Pope Pius VI Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 25, 2006 Report Share Posted January 25, 2006 -----Original Message----- From: " D. Poehailos, MD" To the list, I just got a phone call from one of my patients that she just had a positive pregnancy test. Her first pregnancy was achieved with progesterone supplementation due to short luteal phases and low peak +7 levels. I prescribed initially, and then when she became pregnant, her OB wasn't as interested in maintaining it and tapered it off after the first TM. Interestingly, she nearly lost the pregnancy due to preterm labor at 22 weeks, and made it due to a lot of prayers, a terbutaline pump, and an internal cerclage that stayed in for delivery (36 weeks via csection.) She is not on progesterone supplementation now, so she achieved this one on her own. My questions, since her OB is not so progesterone-concerned. I'm going to check a level on her tomorrow--35 days after LMP. Should I start supplementation now while awaiting results? If her level comes out ok on the nomogram in Hilgers' book, or do we just then do a wait and see and check frequently. She and I cannot help but wonder if she had stayed on the progesterone in the first pregnancy if she would have had the problems she did--conjecture, we know. Any thoughts? D. Poehailos, MD ************************************** personally, I'd test her and follow Hilger's nomogram. Have a pt right now that I persuaded the docs to keep on progesterone (I'd started her in 1st trimester) she has: 1) hx of previable preterm loss at 22 wks (Heartbreaking, baby born alive, came in dilated to 4 cm with intact membranes and we tried like crazy to keep the baby in there) 2)bicornuate uterus 3) cervical shortening on US so just got a cerclage 4) documented low progesterone in the first trimester Of course, the docs don't believe in titrating progesterone to blood levels, they are just following the cookbook recipe of one injection a week of the hydroxyprogesterone caproate..... I get so frustrated sometimes! Anyone out there looking for a CNM with LOTS of experience with normal and high risk pregnancy care? Who speaks reasonable OB Spanish? I've done part of on the CrM training....... Seriously - my daughter graduates from High School in June. My husband is getting fed up with his job. And I am getting fed up with New England. I'm open to offers and am willing to relocate almost anywhere that will let me practice (which unfortunately eliminates alabama and georgia as their practice acts are too constrictive). alicia huntley cnm msn ahuntley@... http://fructusventris.stblogs.org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 26, 2006 Report Share Posted January 26, 2006 --------------------------------- -----Original Message----- From: " D. Poehailos, MD " To the list, Should I start supplementation now while awaiting results? ***************************************************** Speaking as someone who lost a baby while waiting for the progesterone results (it took over two weeks to get results, and I was already spotting when we drew the level- this was before I knew much about the Creighton Model!!), I would most definitely start her on the Progesterone- 200mg IM in Sesame Oil. As said, it won't hurt. There is a huge difference in absorbtion between the IM and the PO, and a small difference between the IM and the vag. The IM is superior. Now, I would also ask about her cycles prior to conceiving, just to get an idea of what they were like (another baby conceived with a short Post-peak/luteal phase?). *************************************************************** *************************************************************** If her level comes out ok on the nomogram in Hilgers' book, or do we just then do a wait and see and check frequently. ************************************************************* **************************************************************** If the level is normal, I would give her the choice. Check every month, or wait to see if she has any symptoms (Spotting, cramping, extreme mood swings, etc.), then check. ********************************************************* ********************************************************* She and I cannot help but wonder if she had stayed on the progesterone in the first pregnancy if she would have had the problems she did--conjecture, we know. Any thoughts? ************************************************************* *********************************************************** I think you are both right on the money! Sandrock, CNM Creighton Model Fertility Care System Nurse-Midwife/Practitioner Intern my online bookstore... http://familyfriendlybooksetc.spreadtheword.com __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 26, 2006 Report Share Posted January 26, 2006 What are your thoughts about the following: Dr. Hilger's norms were established at his lab. Can results obtained at other labs be reliably compared to the norms established at one lab? I knno nothing about this. I'm just curious. Paige ly " We can do no great things, only small things with great love. " Mother Re: Help with patient --------------------------------- -----Original Message----- From: " D. Poehailos, MD " To the list, Should I start supplementation now while awaiting results? ***************************************************** Speaking as someone who lost a baby while waiting for the progesterone results (it took over two weeks to get results, and I was already spotting when we drew the level- this was before I knew much about the Creighton Model!!), I would most definitely start her on the Progesterone- 200mg IM in Sesame Oil. As said, it won't hurt. There is a huge difference in absorbtion between the IM and the PO, and a small difference between the IM and the vag. The IM is superior. Now, I would also ask about her cycles prior to conceiving, just to get an idea of what they were like (another baby conceived with a short Post-peak/luteal phase?). *************************************************************** *************************************************************** If her level comes out ok on the nomogram in Hilgers' book, or do we just then do a wait and see and check frequently. ************************************************************* **************************************************************** If the level is normal, I would give her the choice. Check every month, or wait to see if she has any symptoms (Spotting, cramping, extreme mood swings, etc.), then check. ********************************************************* ********************************************************* She and I cannot help but wonder if she had stayed on the progesterone in the first pregnancy if she would have had the problems she did--conjecture, we know. Any thoughts? ************************************************************* *********************************************************** I think you are both right on the money! Sandrock, CNM Creighton Model Fertility Care System Nurse-Midwife/Practitioner Intern my online bookstore... http://familyfriendlybooksetc.spreadtheword.com __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 26, 2006 Report Share Posted January 26, 2006 Hilger’s norms are different levels from what another lab calls “normal”, so you would want to compare the actual result number to his level of “normal” and not use the lab’s scale of “normal”. You can also have draws sent to Hilger’s lab for processing. Re: Help with patient --------------------------------- -----Original Message----- From: " D. Poehailos, MD " To the list, Should I start supplementation now while awaiting results? ***************************************************** Speaking as someone who lost a baby while waiting for the progesterone results (it took over two weeks to get results, and I was already spotting when we drew the level- this was before I knew much about the Creighton Model!!), I would most definitely start her on the Progesterone- 200mg IM in Sesame Oil. As said, it won't hurt. There is a huge difference in absorbtion between the IM and the PO, and a small difference between the IM and the vag. The IM is superior. Now, I would also ask about her cycles prior to conceiving, just to get an idea of what they were like (another baby conceived with a short Post-peak/luteal phase?). *************************************************************** *************************************************************** If her level comes out ok on the nomogram in Hilgers' book, or do we just then do a wait and see and check frequently. ************************************************************* **************************************************************** If the level is normal, I would give her the choice. Check every month, or wait to see if she has any symptoms (Spotting, cramping, extreme mood swings, etc.), then check. ********************************************************* ********************************************************* She and I cannot help but wonder if she had stayed on the progesterone in the first pregnancy if she would have had the problems she did--conjecture, we know. Any thoughts? ************************************************************* *********************************************************** I think you are both right on the money! Sandrock, CNM Creighton Model Fertility Care System Nurse-Midwife/Practitioner Intern my online bookstore... http://familyfriendlybooksetc.spreadtheword.com __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 26, 2006 Report Share Posted January 26, 2006 His norms can be used if the same testing process is used. There are a few different tests for Progesterone level. His National Hormone Lab # is: . His Med Tech, Jan Alpine, can tell you which test their lab uses. Your local hospital lab can then tell you if it's the same. , MD Shenandoah Valley FPR Front Royal, VA Re: Help with patient --------------------------------- -----Original Message----- From: " D. Poehailos, MD " To the list, Should I start supplementation now while awaiting results? ***************************************************** Speaking as someone who lost a baby while waiting for the progesterone results (it took over two weeks to get results, and I was already spotting when we drew the level- this was before I knew much about the Creighton Model!!), I would most definitely start her on the Progesterone- 200mg IM in Sesame Oil. As said, it won't hurt. There is a huge difference in absorbtion between the IM and the PO, and a small difference between the IM and the vag. The IM is superior. Now, I would also ask about her cycles prior to conceiving, just to get an idea of what they were like (another baby conceived with a short Post-peak/luteal phase?). *************************************************************** *************************************************************** If her level comes out ok on the nomogram in Hilgers' book, or do we just then do a wait and see and check frequently. ************************************************************* **************************************************************** If the level is normal, I would give her the choice. Check every month, or wait to see if she has any symptoms (Spotting, cramping, extreme mood swings, etc.), then check. ********************************************************* ********************************************************* She and I cannot help but wonder if she had stayed on the progesterone in the first pregnancy if she would have had the problems she did--conjecture, we know. Any thoughts? ************************************************************* *********************************************************** I think you are both right on the money! Sandrock, CNM Creighton Model Fertility Care System Nurse-Midwife/Practitioner Intern my online bookstore... http://familyfriendlybooksetc.spreadtheword.com __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 28, 2006 Report Share Posted March 28, 2006 , If she is not actively trying to conceive, you can cycle her on bioidentical estradiol and progesterone. The Vivelle patch .1mg.every 3-4 days and Prometrium 200 mg. qhs 10-12 days out of the month would produce hormone levels that are physiologic for a young woman. It can take many months or even a couple years to reverse hypopituitarism, so if she wants to get pregnant in two years she should start gaining weight and changing her exercise habits to something like yoga now. Micronutrients like Optivite and flax oil can help ovarian function. Some of these very thin exercise-addicted women are very refractory to changing their habits and are not in touch with reality. You should tell her that it is much harder to get pregnant unless her BMI is 21-25. In some instances you will not be able to induce ovulation with drugs, or only with great difficulty, expense, and risk. D -- In nfpprofessionals , " D. Poehailos, MD " wrote: > > To all doctors and such, > > I have a patient on whom I just received past records today and I need some > advice. > > Patient is 26yo G0. She was on the birth control pill for 9 years prior to > coming off, and has been amenorrheic for now about 1 year. Her medical > history--regular cycles before the Pill, she has a BMI of 16.1 (always has, > though she states her body fat is now lower than years ago b/c she exercises > more even though she is staying at steady weight. She exercises about 5-6 > hours of hard cardio a week.) Vigorously denies eating disorders. > > Lab eval at her prior doctor--CBC, TSH, Prolactin all ok. FSH 8.6, LH 5.6. > They've diagnosed her with hypothalamic hypopituitarism, secondary to her > excessive exercise and low body fat. They wanted to put her back on BCP to > prevent osteoporosis, she refuses. She isn't desiring pregnancy now, but > hopes to in a year or two, and is worried if she's anovulatory. > > 1) Has anything else been missed? > > 2) As far as protecting bones, what form of estrogen is most bioequivalent, > and a schedule? I'm comfortable with progesterone replacement now, but > haven't replaced estrogen in a woman of this age group before. > > 3) What else should I be doing? I did tell her today that I think she will > need to back off the workouts at such point as she is desiring > pregnancy...but I'm unclear if that's the whole picture. > > Thanks for any advice! > > Poehailos > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 29, 2006 Report Share Posted March 29, 2006 I agree with here – some of these women don’t understand there is such a thing as being TOO thin. Their desire to obsessively exercise almost seems stemmed from a psychological issue – such as a mother who always worried about her daughter being too fat (even though she wasn’t), or a boyfriend/husband who pushes the rail-thin look. She may be resistant to gaining a little weight because she’s addicted to the scale. Re: Help with patient , If she is not actively trying to conceive, you can cycle her on bioidentical estradiol and progesterone. The Vivelle patch .1mg.every 3-4 days and Prometrium 200 mg. qhs 10-12 days out of the month would produce hormone levels that are physiologic for a young woman. It can take many months or even a couple years to reverse hypopituitarism, so if she wants to get pregnant in two years she should start gaining weight and changing her exercise habits to something like yoga now. Micronutrients like Optivite and flax oil can help ovarian function. Some of these very thin exercise-addicted women are very refractory to changing their habits and are not in touch with reality. You should tell her that it is much harder to get pregnant unless her BMI is 21-25. In some instances you will not be able to induce ovulation with drugs, or only with great difficulty, expense, and risk. D -- In nfpprofessionals , " D. Poehailos, MD " wrote: > > To all doctors and such, > > I have a patient on whom I just received past records today and I need some > advice. > > Patient is 26yo G0. She was on the birth control pill for 9 years prior to > coming off, and has been amenorrheic for now about 1 year. Her medical > history--regular cycles before the Pill, she has a BMI of 16.1 (always has, > though she states her body fat is now lower than years ago b/c she exercises > more even though she is staying at steady weight. She exercises about 5-6 > hours of hard cardio a week.) Vigorously denies eating disorders. > > Lab eval at her prior doctor--CBC, TSH, Prolactin all ok. FSH 8.6, LH 5.6. > They've diagnosed her with hypothalamic hypopituitarism, secondary to her > excessive exercise and low body fat. They wanted to put her back on BCP to > prevent osteoporosis, she refuses. She isn't desiring pregnancy now, but > hopes to in a year or two, and is worried if she's anovulatory. > > 1) Has anything else been missed? > > 2) As far as protecting bones, what form of estrogen is most bioequivalent, > and a schedule? I'm comfortable with progesterone replacement now, but > haven't replaced estrogen in a woman of this age group before. > > 3) What else should I be doing? I did tell her today that I think she will > need to back off the workouts at such point as she is desiring > pregnancy...but I'm unclear if that's the whole picture. > > Thanks for any advice! > > Poehailos > Quote Link to comment Share on other sites More sharing options...
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