Advances in Women's Health

Advances in WOMEN’S HEALTH

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Advances in Women’s Health Editorial 4

Parul Sarwal, MD

President’s Message 5

Giles Whalen, MD

Innovations in Education and Training to Improve Perinatal Mental Health 5

Martha Zimmermann, PhD, Anna R. Whelan, MD, FACOG, Tiffany A. Moore Simas, MD, MPH, MEd, FACOG and Nancy Byatt, DO, MS, MBA, DFAPA, FACLP

Cold Sandwiches 8

Megha Dogra, MD

The Black Maternal Health Crisis, Black Women Are Not Broken 9

Cherise Hamblin, MD and Ahnyia Sanders, MS

Women’s Health: An Alternative Perspective 10

June R. O’Connor, MD

Misinformation and Manipulation: Exposing Crisis Pregnancy Centers 12

Zarah Rosen, MD

Promoting the Health, Inclusion, and Belonging of Sexual and Gender Minorities in the Clinical Space 13

Olivia Buckle, BA

Pharmacological Advancements for Women’s Reproductive Health Transitions 15

Mary Fischer, PhD, WHNP-BC, MSCP, Audrey O’Neill, RN, David Runyan, FNP-BC, NRP and Teri Aronowitz, PhD, FNP-BC, FAAN

wdms editorial board

Lisa Beittel, MBA

Sonia Chimenti, MD

Anthony L. Esposito, MD

Lloyd Fisher, MD

Larry Garber, MD

2023 Women in Medicine Breakfast 17

Childbirth, Pain, and Women’s Movement(s) 18

B. Dale Magee, MD Curator

New Innovations to Increase Contraception Access in Massachusetts 21

Katharine Nault, PharmD, MBA, BCCCP and Aimee Dawson, PharmD

Curbside with Dr. Baker 23

Christopher Baker MD, UMass radiologist/contributing cartoonist to Cartoonstock.com

In Memoriam

Dr. Robert Dennis Blute Jr. 24

Wayne B. Glazier, MD

Bhalchandra Parulkar, MD

Dr. Neil Scannell 24

Nandana Kansra, MD

George M. Abraham, MD, MPH, MACP, FIDSA, FRCP (Lon.)

Kathy L. Chrismer, MD 25

Brenda M. McHugh, MD

Gerrilu Bruun, RN 25

Paula Madison, RN

References

For a complete listing of references from the articles in this issue, click or tap here.

MD, SVH, Medicine Resident

Olivia Buckle, Student Representative

wdms officers

President Giles Whalen, MD

Vice President Alwyn Rapose, MD

Secretary Michelle Hadley, DO

Treasurer B. Dale Magee, MD

wdms administration

Martha Wright, MBA, Executive Director

Rebecca Kowaloff, DO

Susan Krantz, MD

Julianne Lauring, MD

Anna Morin, PharmD

Nancy Morris, PhD, NP

Thoru Pederson, PhD

Joel Popkin, MD

Alwyn Rapose, MD

Parul Sarwal, MD

Akil Sherif, MD, SVH, Cardiology Fellow

Parul Sarwal, MD

When we first decided to do an issue on Women’s Health, there were certain apprehensions. It’s 2024 – have we still not reached the point where women’s health has been adequately integrated into broader health discussions? Would an issue talking about the health of women now undermine the cause of gender equality? Given that women are no longer a gender minority, does this thematic focus on women’s health risk not being inclusive enough? Conversely, have we as a society overcorrected for inclusivity and need to also address Men’s Health? Or does the eponymous best-selling magazine have that side covered?

As the articles started to arrive, the initial skepticism turned out to be speculative. It became clear how women’s health continues to be a nuanced domain and why we still need to talk about it.

Despite it being 2024, problems as significant as perinatal mental health are only now starting to get the attention that they deserve. It is thus our honor to congratulate the Lifeline for Moms research team at UMass Chan Medical School— headed by Dr. Nancy Byatt, alongside Drs. Wendy Davis and Christopher Sheldrick, the team recently secured a $21-million grant from the Patient-Centered Outcomes Research Institute to investigate mental health equity in perinatal care.

Despite it being 2024, there are populations consistently lacking the social determinants of health and experiencing worse health outcomes compared to those with access to them. In this issue of Worcester Medicine, Dr. June O’Connor of Women’s Health of Central Massachusetts highlights how our local community at St. Anne’s Free Medical Program has championed the complex medico-social needs of uninsured and underinsured women in Worcester. In a powerful piece of narrative medicine, Dr. Megha Dogra, hospitalist at St. Vincent Hospital, pens a compelling story of a single mother and her struggle with sustenance. Dr. Cherise Hamblin and Ahnyia Sanders, medical director and program coordinator at the UMass Memorial Doula Program respectively, highlight the importance of acknowledging racism to promote culturally sensitive birthing practices. But is “women’s health” synonymous to obstetrics and gynecology (Ob/Gyn)? Olivia Buckle, a third-year medical student at UMass Chan Medical School, dispels this notion to acknowledge the varied identities of patients in the field of Ob/Gyn, aiming to bridge gaps in healthcare for gender minorities and provide queer-inclusive care.

Despite it being 2024, the legal terrain surrounding basic reproductive rights and access to abortion services has become more treacherous than in the past decades. In this issue, Dr. Zarah Rosen, resident physician in Ob/Gyn at UMass Chan Medical School, exposes crisis pregnancy centers (CPCs)— unregulated, faith-based nonprofits deceiving individuals seeking abortion care in the guise of clinics. Dr. Rosen uncovers how, in reality, CPCs are dedicated to persuading individuals against choosing abortion, often compiling databases used to support the criminalization of those seeking or obtaining abortion services.

Despite it being 2024, no, we have not reached a stage where women’s health is an instinctive part of mainstream health discourse. Notwithstanding how prevalent these issues are, pelvic floor dysfunction, women’s sexual dysfunction, and arousal disorders remain taboo. The good news is that the burgeoning field of FemTech is reshaping women’s health and wellness with numerous innovative initiatives. The FDA-approved Milli is the first all-in-one expanding vaginal dilator designed to address vaginismus and related dyspareunia without the discomfort and inconvenience of having to swap differently sized devices. Menstrual tracking apps are allowing users to monitor their cycles, predict fertile windows, and track symptoms with precision, providing personalized insights into reproductive health. Smart technology is offering pelvic floor trainers, breast pumps, and Kegel exercise trackers to support pelvic health and postpartum recovery. At-home hormone testing kits are enabling women to understand fertility and reproductive health, aiding informed decisionmaking about family planning and fertility treatments. Telemedicine platforms are now providing convenient access to birth control, emergency contraception, and STI testing and treatment, addressing gaps in reproductive healthcare access across the United States. On February 21, 2024, First Lady Jill Biden unveiled $100 million in federal funding as a part of the White House Initiative on Women’s Health Research. This investment targets groundbreaking initiatives by women’s health researchers and startups lacking private backing.

Women’s health continues to be a work in progress that requires our attention. This edition of Worcester Medicine invites you to explore the ongoing efforts and contributions of Central Massachusetts’ medical community towards addressing these issues. From innovative research to community outreach initiatives, learn how our healthcare professionals are engaged in shaping the future of women’s health and striving towards a more equitable and inclusive healthcare landscape. +

Dear Colleagues,

President’s Message

Giles Whalen, MD

As 2024 rolls out, I’m pleased to let you know we are earnestly working on the 2024-2025 Calendar of Events and Slate of Officers. Our television program, Health Matters, continues to move forward, with airtime twice per month. With that, we look forward to interviewing new members by introducing a regularly scheduled Noontime Lecture Series where we collaborate and learn from one another. We would love to hear your suggestions for topics and if you wish to be interviewed, please contact the WDMS office at 508-753-1579.

In this issue of Worcester Medicine our esteemed colleagues share their thoughts and expertise on “Advances in Women’s Health”. I’d like to welcome our new Editor-in-Chief, Dr. Parul Sarwal. An emerging leader in internal medicine, she brings a fresh perspective extending beyond the traditional boundaries of healthcare with an extensive background in magazine production and design. Dr. Sarwal is a hospitalist at St. Vincent Hospital.

Dr. Susan George recently delivered the 228th WDMS Oration on “The Evolution of Learning and Teaching in Medicine”. It was a thought-provoking and informative discourse, attesting to Dr. George’s commitment to advancing the landscape of medical education.

The remaining events for our 2023-2024 calendar include:

• Annual Business Meeting (4/10/2024)

• MMS/HOD proceedings (April – May, 2024)

• Workshop on Finances (Sponsored by our Medical Student Committee) (5/8/2024)

• Meet the Author – The Good Night by Dr. Sunita Puri (5/9/2024)

As our membership continues to grow, we hope to see you at our upcoming programs. +

Giles Whalen, MD President, WDMS

Innovations in Education and Training to Improve Perinatal Mental Health

Martha Zimmermann, PhD

Anna R. Whelan, MD, FACOG

Tiffany A. Moore Simas, MD, MPH, MEd, FACOG

Nancy Byatt, DO, MS, MBA, DFAPA, FACLP

At her 18-week obstetric visit, Kai expresses that she feels sad and has difficulty with daily tasks. Her obstetric provider recommends that she call her insurance company for therapy, but when she does, she is faced with a four-month wait. As her symptoms worsen 24 weeks into her pregnancy, she requests medication. Her obstetric clinician,not trained in depression care, refers Kai to a psychiatrist with a five-month wait. Kai never receives treatment for depression during pregnancy. Unfortunately, experiences like this often occur in obstetric settings across the country.

One in five individuals will experience a mood or anxiety disorder during or in the year after pregnancy (the perinatal period). Mental health and substance use disorders (SUD) are the leading cause of maternal mortality in the U.S. [1]. While we have treatment that improves perinatal mood and anxiety disorders, including therapy and medication, perinatal mental health conditions are underdiagnosed and undertreated. Pregnant and postpartum individuals often face barriers to accessing care, such as long wait times to see a mental health professional. Perinatal individuals from marginalized groups, such as Black/African American, Hispanic/ Latina/o/e/x, American Indian or Alaska Native, or Native Hawaiian or other Pacific Islander are even less likely to receive adequate care [2].

Researchers at the Lifeline for Families Center at UMass Chan Medical School are working on innovative solutions to combat this lack of resources and inequities in care. By taking a “population-level” approach, the team is considering how interventions can have the greatest public health impact. Recognizing that there are not enough mental health professionals to meet the need, the team focuses on how obstetric care professionals can address perinatal mental health in the settings where they practice.

Drs. Nancy Byatt and Tiffany Moore Simas have made significant progress towards this goal. Dr. Moore Simas led the perinatal mental health conditions patient safety bundle published by the Alliance on Innovation in Maternal Health (AIM) and the clinical practice guidelines published by the American College of Obstetricians and Gynecologists (ACOG) [3,4]. The new bundle and guidelines set the standard that addressing mental health is part of obstetric care. To help obstetric clinicians meet this standard, Drs. Byatt and Moore Simas led the development of a set of resources:1) Addressing Perinatal Mental Health Conditions in Obstetric Settings E-module, 2) Perinatal Mental Health Tool Kit, and 3) Guide for Integrating Mental Health Care into Obstetric Practice. These tools are being disseminated by ACOG, reaching more than 70,000 obstetric professionals nationwide. They will be used regionally through the Perinatal-Neonatal Quality Improvement Network of Massachusetts as

Advances in Women’s Health

Innovations in Education and Training to Improve Perinatal Mental Health

Dr. Moore Simas collaboratively leads AIM patient safety bundle integration across MA birthing hospitals and obstetric practices starting summer 2024.

In addition to these advances, Dr. Byatt was the founding medical director, and Dr. Moore Simas the obstetric engagement director, of the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms. Funded by the Massachusetts Department of Mental Health, MCPAP for Moms empowers obstetric professionals to address mental health and SUD through training, provider consultation, one-time face-to-face psychiatric consultation, resources, and referrals. Obstetric professionals can call the MCPAP for Moms’ consultation line to request consultation regarding screening, diagnosis, treatment of perinatal mental health and SUD.

MCPAP for Moms is the flagship model for the Perinatal Psychiatry Access Program that has been adopted in 28 states across the U.S. The program is associated with improvements in symptoms of depression and nearly double the mental health treatment rates found in previous studies [5]. Since the program’s inception almost a decade ago, program staff and researchers have worked together to improve the program and expand its offerings. In partnership with Dr. Wendy Davis from Postpartum Support International and other key collaborators, Dr. Byatt was recently awarded a $21-million grant from the Patient-Centered Outcomes Research Institute (PCORI) to build on this model by comparing the impact of a health care model to the health carecommunity partnership model on patient outcomes. The study will include training Perinatal Psychiatry Access Programs across the country to implement identified models of care even after the study is complete. Provider training will include case-based interactive sessions focused on anti-racism, traumainformed care, and screening and referrals for social and structural determinants of health, or the conditions in which people work and live. The goal of trauma-informed care is to address the impact of trauma through clinical interactions and through organizational policies.

The team has increasingly focused on programs that can prevent perinatal mood and anxiety disorders before they cause harm. Dr. Anna Whelan and Dr. Martha Zimmermann are junior investigators leading studies to improve well-being in the perinatal period by adapting evidence-based interventions that have helped non-pregnant people. Dr. Whelan is developing an intervention to reduce weight stigma, which

Continued

contributes to higher rates of perinatal mood and anxiety disorders among perinatal individuals in larger bodies. Dr. Zimmermann is developing a digital intervention to reduce risk for perinatal anxiety disorders.

With the support of programs like MCPAP for Moms, obstetric providers now have tools to provide depression care. If Kai sought care now, she would fill out a short questionnaire that asks about her mood that would let her provider know she is experiencing symptoms of depression. Her obstetric clinician would consult with MCPAP for Moms for a therapy referral and to prescribe medication if it was indicated. Her symptoms of depression would be more likely to improve, and the adverse consequences avoided. Continued progress in this area is needed to ensure every pregnant and postpartum person has access to high quality, culturally responsive, and trauma-informed care. +

Martha Zimmermann, Ph.D.

Assistant Professor

UMass Chan Medical School

Lifeline for Families Center & Lifeline for Moms Program

Implementation Science and Practice Advances Research Center (iSPARC)

Department of Psychiatry

e-mail: martha.zimmermann1@umassmed.edu

Dr. Anna Whelan MD, FACOG

Assistant Professor

Department of Obstetrics & Gynecology

UMass Chan Medical School

Lifeline for Families Center & Lifeline for Moms Program

e-mail: Anna.Whelan@umassmemorial.org

Tiffany A. Moore Simas, MD, MPH, MEd

Donna M. and Robert J. Manning Chair in Obstetrics and Gynecology

Chair, Department of Obstetrics & Gynecology

Professor, Obstetrics & Gynecology, Pediatrics, Psychiatry, and Population & Quantitative Health Sciences

Medical Director, Lifeline for Moms

Obstetric Engagement Liaison, MCPAP for Moms

e-mail: Tiffany.MooreSimas@umassmemorial.org

Nancy Byatt, DO, MS, MBA, DFAPA, FACLP

Executive Director, Lifeline for Families Center & Lifeline for Moms Program

Professor with Tenure of Psychiatry, Obstetrics & Gynecology and Population & Quantitative Health Sciences

Medical Director of Research and Evaluation, MCPAP for Moms

e-mail: Nancy.Byatt@umassmemorial.org

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ICold Sandwiches

Megha Dogra, MD

t is just another fall morning. I am greeted by a gush of cold air as I step out of my centrally heated apartment for work. I have been waiting for fall. The orange, yellow, hints of red and rust in the trees are a welcome change. The leaves make a crunching sound as I make my way to my car. I drive to the hospital.

My new patient today is Riley Lane. Riley was found in a van, covered in her urine and soot. She lay there for hours until Danny found her and called grandpa to help. Danny is 8, by years of birth. He was forced to grow far beyond his age. He would cook, clean, get himself ready for school and walk himself to the school bus stop every day. In the evening he would come home, scavenge the fridge for leftovers, and make dinner. My first question to him was what does he cook? What can an 8-year-old cook? Can an 8-year-old be trusted near a burning stove? He answered “cold sandwiches” which reassured me. Danny was blue-eyed, pale-haired, maybe a little overweight, much unlike his mother. His mother had also grown far beyond her years. On first glimpse I assumed nothing short of 60. The chart said 45. I was 35 when I stood in front of her. I imagined if I would look like her in 10 years. What if my daughter had the life of Danny in 10 years? Can she be trusted near a burning stove?

Riley had black teeth, not the tattooed kind, but the kind that aren’t taken care of, the kind that belong to someone who has to choose between paying bills or paying for dental insurance. Her skin was freckled and told stories of the countless hours she must have spent out in the sun. Skin so thin that you could see through the bends and hills in her bones. The hospital gown could fit two of her kind, or maybe three. A picture of the scene where she was found flashed in front of my eyes. In the back of a school van. I see Danny peeking in, calling for her in a calm voice. He is not screaming, he is not scared, he has seen worse. He has the stoic demeanor of a soldier. He stands still and calls her name. He doesn’t dare to go in. This is not the mother he knows. This one smells of sickness. But does he know how sickness smells? How much is an 8-year-old supposed to know?

Danny and his grandpa are here. Grandpa is well dressed and has a back brace for an accessory. Danny’s crocs are a bright shade of green, the ninja turtle green and have crevices which make them look like jaws. The crocs and his pajamas contrast with the situation Riley might be in. We still don’t know what happened to her. If only she could talk. She mumbles and screams when touched. I hope Danny would know and understand his mother’s mumbling. Alas, it is a mumble for him too. Riley can’t move. Not even when pushed or prodded. Danny must give me answers today. There’s no one else who knows Riley better. I hesitate before framing my words. He’s just an 8-year-old kid. What if I slip and say a word he shouldn’t know. How much is an 8-year-old supposed to know? Danny makes cold sandwiches. I feel reassured. I assume he is safe standing in the kitchen every day, morning and evening, looking inside the refrigerator, figuring out what to cook. What to cook remains a struggle in my kitchen even now. What is an 8-year-old supposed to know about cooking? He wants to be a chef, he says. He loves to cook. He has said that many times now. So much so that I am forced to ponder if he has something to hide.

How do you ask an 8-year-old if there’s a chance his mother could be pregnant? I start with any sight of needles at home. Danny elaborates that the hallway smells of weed. He holds his breath every time he walks by, fearing that he might inhale some of the “bad air”. I believe him when he says he hasn’t seen needles at home. There’s no mention of a father. There’s no mention of friends. I struggle to find words.

It is day one in the hospital. The pregnancy test prohibits me from giving her radiation. We start with an MRI of the brain and the pelvis. All the organs inside the impoverished frame look normal. The blood and the urine say everything is “within normal limits”, mocking the body I see. Riley doesn’t move, doesn’t flinch, doesn’t talk. She has mastered staring at the known and unknown alike. Danny takes out from his bag a strawberry yogurt and a whoopie pie, her favorite foods. She swishes the yogurt inside her mouth, as if she has forgotten to swallow.

In the 19th century a strange disease emerged among the sailors. Ships full of men would turn into ghosts. The ghosts would be skin and bones, lifeless, they laid still, they couldn’t talk, couldn’t move until death would free them. The disease would affect just the lower ranks, the ones who took to sailing to survive the lowlife, the ones who survived on rice and potatoes. The rich on the ground rarely became a part of it. A doctor then staged an experiment. The low lives on a ship were given fruits and vegetables and they seemed to escape the infestation. That’s how thiamine was discovered.

Riley could talk after the magic vitamin infusion. She remembered how to swallow. Unaware who I was, how long she had been there, how she ended up there, but she remembered Danny. I jokingly inquired if Danny was a good cook. She chuckled, “he tries”.

On the days that ensued, she underwent an EMG, a muscle biopsy, scans of the spine and many other tests. The vitamin infusions brought back her chuckles, her independence to walk to the bathroom, a smile on Danny’s face, and her life as a single, struggling mother. Riley stays in my mind as the face of a humbling vitamin. If only malnourishment was as revered as any other disease, we would prevent childhoods like Danny’s. +

Megha Dogra, MD

Internal Medicine Hospitalist

St. Vincent Hospital, Worcester, MA

drmeghadogra@gmail.com

TThe Black Maternal Health Crisis, Black Women Are

Not Broken

Cherise Hamblin, MD

Ahnyia Sanders, MS

he United States has the highest maternal mortality rate of industrialized nations. In 2020, the U.S. reported 23.8 deaths per 100,000 live births compared to Italy with a low of 2.7 and Canada at 8.4 deaths per 100,000 live births [1]. In addition to poor maternal outcomes, the U.S. has disparate outcomes amongst races. In 2020, the non-Hispanic Black maternal mortality rate (MMR) was 55.3 and in non-Hispanic White birthing persons it was 19.1 [2]. Racial maternal health disparities widened during COVID-19, as the MMR among non-Hispanic Black birthing persons increased 32.6% from 2018 to 2021 [3]. Within the same time frame, the MMR for non-Hispanic White birthing persons rose 11.7% [3].

In the state of Massachusetts, severe maternal morbidity (SMM) almost doubled from 2011 to 2020 at a rate of 52.3 to 100.4 deaths per

10,000 deliveries, with non-Hispanic Black birthing people dying at a rate of 2.5-fold of their non-Hispanic White counterparts [4]. In Massachusetts, as with many states attempting to address maternity care and disparate outcomes, there are many legislative, community, and private foundation initiatives to support efforts to address severe maternal morbidity.

In December of 2023, MassHealth announced that doula care would be a covered benefit. With this resolution, Massachusetts became the 10th state to implement doula coverage for birthing persons with Medicaid. The express purpose of MassHealth’s doula services program is to eliminate health inequities and promote positive outcomes and experiences for all birthing families. A doula is a non-medical support person who provides physical, emotional, and informational support to birthing people [5]. Doula care is associated with lower cesarean section rates and decreased preterm birth rates and other complications [6]. For many families, the out-of-pocket expense of doula care, which can run between $1,0003,000 in addition to preparing for a baby, is prohibitive.

In the early 1800s, birth was attended uniformly by women without degrees. Though women were barred from a formal education, they passed down knowledge and experiences from neighbors and through mother to daughter relationships [7] .“Granny midwives” were enslaved Black women who delivered babies on their plantations and in the surrounding communities. After emancipation, granny midwives continued to work with Black and White women in the rural South. As medicine and hospitals formalized, and birth became medicalized, the tides changed from almost all births in the country being at home to only 40% of births occurring at home by 1940 [8]. Granny midwives were forced out of the perinatal workforce through regulation and legislation, despite no evidence of superior outcomes.

Source: Johnson-Agbakwu CE. The Impact of Racism and the Sociopolitical Climate on the Birth Outcomes of Migrant Women, Mothers, and Birthing People in the United States. Medical Care. 2022.

https://doi.org/10.1097/MLR.0000000000001780

The Black Maternal Health Crisis, Black Women Are Not Broken Continued

How did Black women go from being the most experienced and well-trained hands, serving at home births, to being the people group with the worst obstetric outcomes? How is it that today only 7% of midwives [9] and 10.7% of ObGyns [10] are Black? Racism is the tie that binds.

Racial health disparities, as well as the lack of diversity in medicine are a result of racism. However, Black women are not broken, and the media should not continually plant seeds of fear in the minds of birthing persons with gruesome statistics. Instead, racism should be recognized at various levels –whether individual, interpersonal, community, or societal levels – as the root cause for racial health disparities to take an important step toward building a more equitable health landscape. We should focus our efforts on positive Black birthing experiences and showcase how having a positive culturally adept birth can affirm Black joy, culture, resilience, and strength so our country can mimic those standards of care. When we acknowledge that racism is pervasive in society, as well as in medicine, we can make targeted solutions that address the root causes and yield results. +

Cherise Hamblin, MD

Assistant Professor, Obstetrics & Gynecology Medical Director, UMass Memorial Doula Program Director, URiM Community Workforce Development and Capacity Building Collaborative in Health Equity UMass Chan Medical School

Ahnyia Sanders, MS UMass Memorial Doula Program Coordinator

WWomen’s Health: An Alternative Perspective

June R. O’Connor, MD

omen’s health has become a popular topic over the past year as a result of changing sociopolitical climates which have highlighted this historically underrepresented healthcare sector. However, recent efforts to place importance on the overall wellbeing of this underserved demographic are commonly built on the perspective of the American healthcare system. To truly have an understanding that allows for progress in women’s health, we must take a more global approach; there is a great difference in the term “women’s health” when it comes to women belonging to underserved or marginalized populations in the developing world.

To have an all-encompassing perspective of women’s health requires an understanding of what women belonging to our world’s most underserved populations are experiencing when seeking medical care, an experience not all physicians are routinely exposed to, especially within the United States. Because of this “blind spot” in our collective approach to women’s health, the women who need compassionate health care the most are often overlooked. Locally, the St. Anne’s Free Medical Program is diligently working to correct this in the Worcester region. This group is a shining example of hard-working and dedicated health care providers that go above and beyond the standard to ensure equal health care to those in need. They are committed to serving the under or uninsured patients of the Worcester community with compassion and diligently addressing their often complex social and medical needs, as these patients often arrive with stories that reach into the core of your soul - heartbreaking tales of great traveling, loss of children and families, domestic violence, and perseverance which are otherwise unknown to our community. These patients shoulder the burden of desperation, isolation, and hardship in their everyday lives.

Unlike many patients within the American health care system, women from underserved or uninsured populations have no expectations of medical care. Their inability to receive care makes them victim to withstanding physical conditions that would be intolerable to many of us. This includes undiagnosed ailments that have progressed to critical stages – ailments that would have been detected at an earlier stage with standard health care insurance. I cared for one pregnant patient who traveled alone from Honduras, leaving her family and friends, with no knowledge of English with her hopes relying only on a letter from an unknown sponsor. Another patient was diagnosed with infertility due to premature ovarian failure, with no resources available to her. For patients with stories such as these, receiving necessary medical care is only the beginning of their healing – they require not only a provider’s medical knowledge to address the health care disparities which they have been subjected to, but also human compassion.

In addition to the inequality in women’s healthcare in our own community, I have also experienced a more global perspective on healthcare inequity during my medical missions to the Dominican Republic. After multiple medical missions, I – along with several of my dedicated and talented colleagues – have been able to explore this side of women’s health while serving the impoverished patients of this country. Here, we cared for the underserved female population of the Dominican Republic, as well as the Haitian immigrants occupying the bateyes. “Bateyes” are the villages interspersed in the vast acreage of sugarcane

fields where migrant workers from Haiti live and work in harsh conditions; the residents are housed in rudimentary huts without running water, plumbing, or electricity. The women occupying these bateyes face obvious barriers to healthcare but are further burdened with a high prevalence of uterine myomata which make them prone to heavy menstrual bleeding. This can be extremely difficult to manage due to their limited access to health care and disposable hygiene products, as well as the lack of a waste removal system.

Unfortunately, this issue is not localized to the bateyes; globally, many women in developing nations are burdened with similar issues surrounding their menstrual cycles. In some nations, girls are made to sit in “menstrual huts” for the days each month that they have their menses, isolating them from friends and family while also placing them at the disadvantage of missing school and other activities. The solution to these conditions is multi-faceted, but there are organizations such as “Days for Girls” which are dedicated to correcting these clear inequities. “Days for Girls” and their volunteers sew reusable hygiene kits for girls in developing countries, enabling them to remain in school and their daily activities. Their efforts go a long way for the regular occurrence of menses

in school age girls, but there is still much to be done for the women who suffer from more severe gynecological health concerns.

Another memorable patient was a young woman in her early twenties, who came to us with a large benign ovarian tumor which made her appear to be approximately 20 weeks pregnant; the tumor’s size was exaggerated even further by her otherwise bone-thin frame. Despite being benign, the tumor’s ramifications on this patient’s life were significant and spanned from not being able to fit into the fashionable tight jeans, to being ostracized from her community because she appeared pregnant and was not married. To remove the cyst took less than an hour of our time and, with minimal effort on our part, her life was transformed.

In our quest to provide for women in our community and abroad, it is important to keep an all-encompassing perspective on “women’s health” that allows for the voices of the underserved to be heard. To treat a woman who otherwise would not have access to healthcare goes beyond the act of a physician assisting a patient. It is the act of one human extending a hand to another, and a true demonstration of human compassion. It is important to realize that we all have the ability to improve the lives of others with what we may consider the smallest and insignificant of actions. To change someone’s life for the better is powerful and deeply fulfilling; it adds value to our own lives.

June R. O’Connor, MD

Women’s Health of Central Massachusetts

june.oconnor@umassmemorial.org

AMisinformation and Manipulation: Exposing Crisis Pregnancy Centers

Zarah Rosen, MD

s the faint line of the pregnancy test darkens, you remember the billboard you drive by daily, “Pregnant? Scared? Need help?” You know that you want an abortion, but don’t have a primary care doctor, and haven’t established care with a local provider. You’re unsure of the cost of abortion care and whether insurance will cover it. Online, the top result reads, “FREE Testing, Support, Abortion Counseling”. You call the number and a friendly voice helps you make an appointment. At the clinic, you’re brought to an exam room and counseled on options for parenting and adoption by a woman in a white coat. Asking about abortion leads her to share pamphlets outlining its risks and providing additional information on parenting. You realize that at this clinic, abortion isn’t an option. This is because you are at a “crisis pregnancy center”.

“

ultrasounds by unlicensed staff can lead to inaccurate or misleading results. Recognizing the timesensitive nature of abortion care, these ultrasounds are employed to deceive individuals about how far along they are in their pregnancy. Delays from such practices limit abortion choices or make the procedure entirely inaccessible. Unregulated ultrasounds also lead to significant medical misses of abnormal pregnancy diagnoses. This incident occurred just last year in Worcester when a CPC’s assurance of a normal pregnancy later required emergency surgery to address a life-threatening ruptured ectopic pregnancy. CPC tactics singularly focus on misleading and manipulating to dissuade people from choosing abortion. Their anti-abortion goal should not be allowed to surpass ensuring the well-being and safety of those making reproductive healthcare decisions.

The lack of privacy regulations in the increasingly hostile anti-abortion legal landscape makes it easy and frightening to imagine this network of databases being utilized as evidence in the criminalization of seeking and obtaining abortion care.

Crisis pregnancy centers (CPCs) pose as resource clinics for pregnant individuals, but in actuality are facilities run by anti-abortion groups with an agenda to prevent access to comprehensive reproductive care, including abortion and contraception. The situation described is not an uncommon occurrence; it mirrors the experiences of individuals who inadvertently turn to CPCs for assistance.

Throughout the United States, there thrives a network of more than 2,750 CPCs. In Massachusetts alone, CPCs outnumber reproductive healthcare providers offering comprehensive counseling on pregnancy intention options, including abortion care, by more than 2:1. This statistic is even more staggering when in the context of a state where abortion care remains legal up to 24 weeks.

CPCs mislead those seeking abortion care into mistaking a CPC for an intended clinic by using tactics such as analogous names, logos, and intentional proximity. Consider, in Worcester, Problem Pregnancy’s location across the street from Planned Parenthood. Despite deliberate attempts to give the impression of a legitimate medical clinic, presenting staff in scrubs and white coats, the use of exam rooms, and offering ultrasounds, these centers are unregulated, faith-based nonprofits exempt from regulatory and legal oversight which govern healthcare facilities.

The majority of centers fail to offer even basic reproductive healthcare such as pap smears or birth control counseling. The use of non-diagnostic

Regardless of terminology, including ‘crisis pregnancy center’ or ‘women’s help/care/counseling/ resource/medical clinic’, these individual centers are affiliated with and supported by a sophisticated and well-funded network of anti-choice parent organizations. Unregulated donations from anti-abortion advocacy groups including Heartbeat International and Care Net are not the only source of financial support. Public funding to these centers includes sales from “Choose Life” specialty license plates, and in at least 10 states, the funneling of federally-funded Temporary Assistance to Needy Families (TANF) grants. These funds are diverted from their intended support of vulnerable families to organizations preventing vulnerable pregnant people from receiving comprehensive and safe healthcare.

The absence of operations and funding oversight of the CPC network sharply contrasts the countless restrictions and increasing barriers imposed on abortion providers. The lack of privacy regulations in the increasingly hostile anti-abortion legal landscape makes it easy and frightening to imagine this network of databases being utilized as evidence in the

criminalization of seeking and obtaining abortion care.

Many factors contribute to an individual’s reproductive health choices - including interpersonal relationships, financial obligations, pregnancy, and maternal health conditions. Navigating a fraught political landscape and overcoming the increasing barriers to access abortion care, it’s hard to think of a more complex and difficult healthcare decision. Whether or not you entered the correct clinic should never be an additional obstacle.

Despite well-coordinated efforts to conceal motives and dominate search engine results, there are ways to distinguish CPCs from comprehensive health clinics. Identifying their own misinformation can be used as a tool to recognize fraudulent clinics, for example advertising abortion “reversal” treatment, a fabricated treatment lacking evidence of safety or effectiveness. Additionally, promoting false claims regarding exaggerated risks of abortion procedures and links between abortion and breast cancer, infertility, and mental illness. There is widely accepted consensus that abortion is a safe medical intervention. Childbirth is significantly more dangerous than abortion, with the risk of maternal death in childbirth 14 times higher than with an abortion [1,3]. The American College of Obstetricians and Gynecologists (ACOG) and American Cancer Society unequivocally state that there is no association between abortion and risk of breast cancer or any type of cancer [4,2]. ACOG and the National Health Service confirm no link between abortions and infertility, in fact, people can become pregnant immediately after an abortion [3,5]. In another blatant distortion of facts, evidence supports that the experience of being denied an abortion is linked to negative mental health impacts including anxiety and depression [3,6].

CPCs are a public health threat. We can mitigate their danger by advocating for legislation mandating regulation and counteracting misinformation by promoting resources that identify known CPCs as well as legitimate reproductive health providers [7,8]. It is crucial that individuals understand their options and are informed of resources available, enabling them to make decisions free from interference or distortion by political ideologies. CPCs, or if we refer to them as what they are, Anti-Abortion Centers, cannot continue to covertly operate to undermine safe, equitable healthcare. It is the responsibility of healthcare providers to recognize potential harms and be guided toward comprehensive reproductive care in the community. +

Zarah Rosen, MD, Resident Physician in Obstetrics and Gynecology at UMass Chan Medical School

Promoting the Health, Inclusion, and Belonging of Sexual and Gender Minorities in the Clinical Space

Olivia Buckle, BA

Amagazine issue on the state of women’s health would be remiss in not acknowledging the spectrum of identities of patients who receive care under the banner of obstetrics and gynecology.

Adults who identify as a sexual or gender minority (SGM) make up roughly 7% of the United States population, according to data from the NIH’s All of Us Research Program. If this is extrapolated to the city of Worcester, which has an adult population of 166,800 people, then as many as 11,675 Worcester adults identify as a sexual or gender minority (US Census Bureau). This number represents a significant portion of potential patients in the Worcester area.

Now that we have established the need for queer-inclusive care in Worcester, it is important to recognize the problem. We know that individuals who identify as members of the LGBTQIA+ community have worse reported health outcomes in many realms compared to the general population. We also know that a large part of these worse outcomes is driven by a lack of access to safe, affirming healthcare and a deep-seeded mistrust of the medical community.

Like all medical specialties, the field of obstetrics and gynecology provides care to patients who identify as SGM, or those excluded by heteronormative and/or cis gender labels. Unlike other specialties, however, obstetrics and gynecology (OB/Gyn) is a specialty uniquely positioned in its historical mandate of providing care to a patient population marginalized on the basis of sex. For many readers and health institutions, ‘women’s health’ undoubtedly is nearly synonymous to ‘OB/ Gyn’. Following this logic, both the general public and institutional policy often assume that a patient who receives care in an OB/Gyn clinical setting identifies as a woman. I encourage you to challenge this assumption.

As a future care provider with a clinical interest in LGBTQIA+ health and gender affirming care, I began my undergraduate medical training with a desire to further my knowledge and understanding of how best to serve SGM patients. I identified obstetrics and gynecology as a potential area of vulnerability for this patient population, given its heavily gendered nature. Much to my chagrin, I discovered that the curriculum in LGBTQIA+ health was sparse. Apart from a few phenomenal lectures by Dr. Yasmin Carter, Assistant Professor of Translational Anatomy and the Director of DRIVE (Diversity, Representation and Inclusion for Value in Education), SGM populations were largely absent. The vast majority of educational opportunities involving the care of SGM patients were opt-in experiences which thus only reached the handful of self-selected students who typically possessed a pre-existing interest in the area.

In an effort to learn more, I worked with Dr. Carter and Dr. Tara Kumaraswami, Assistant Professor of Obstetrics and Gynecology, to develop a project analyzing the inclusivity of UMass Memorial’s OB/ Gyn clinical space. Although the care of SGM patients—especially that of transgender and gender expansive (T/GE) youth—currently serves as a major topic of public discourse, the research continues to lag behind.

Advances in Women’s Health

Promoting the Health, Inclusion, and Belonging of Sexual and Gender Minorities in the Clinical Space Continued

Outside of HIV testing and health disparities linked to minority stress research, a literature search revealed that little has been published on how SGM patients experience health care. In particular, there is a dearth of research on the systematic inclusion of SGM patients in the clinical space or how health care providers should alter their clinical environment and practice in order to best promote the health, well-being, and comfort of LGBTQIA+ patients and families.

What does exist are a few guidelines outlining the major tenets of inclusivity promotion in the physical clinic environment, developed by leading experts in the field of LGBTQIA+ health such as The Fenway Institute and the Center of Excellence for Transgender Health of UCSF. Such tenets include, but are not limited to: involving community stakeholders in the development of any intervention; identifying a space champion for the cause; updating clinic signage, intake forms, consent forms, and any other patient facing documents or platforms to be inclusive of all SGM identities; collecting sexual orientation and gender identity (SOGI) data on all patients; referring to patients by their pronouns and preferred names; ensuring labels for lab specimens have correct names and pronouns; regular inclusivity training for staff, faculty, learners, and anyone else interacting with patients; posting a non-discrimination policy and mission statement in public view; investing in artwork and informational posters that are inclusive of the spectrum of patient identities; avoiding exclusive use of gendered color palettes for wall colors, patient gowns, and medical equipment, and any other fixtures of the clinic space. In short, there exist many ways in which we as providers can support all of our patients and make them feel welcome in any clinical environment, regardless of gender identity, presentation, or sexual orientation.

The next step, of course, is action. After selecting the Community Women’s Care OB/Gyn resident clinic and the Levine Obstetrics and Gynecology space as our pilot sites, our group—led by Dr. Kumaraswami and made up predominantly of clinic staff, faculty, and residents—has begun the work of improving the clinical space. So far, we have designed new gender neutral restroom signage, collaborated with local artists to begin the process of updating the artwork in the clinical space, and developed an inclusivity statement written by the OB/Gyn residents to be posted in the clinical spaces. Future work includes, but is not limited to, continuing the process of improving staff training and updating intake forms, consents, and any other patient-facing documents. +

A special thank you to Dr. Yasmin Carter, Dr. Tara Kumaraswami, Dr. Jules Trobaugh, Dr. Luu Ireland, Dr. Zarah Rosen, Dr. Brittney Gaudet, Christy Bassett, Carol Tudhope, Gwendolyn Bultron, and Shannon Lyons. This work would not be possible without you.

Olivia Buckle, BA, is a third-year medical student at UMass Chan Medical School and the student representative to the Editorial Board. Olivia.buckle@umassmed.edu

Pharmacological Advancements for Women’s Reproductive Health Transitions

Mary Fischer, PhD, WHNP-BC, MSCP

Audrey O’Neill, RN

David Runyan, FNP-BC, NRP

Teri Aronowitz, PhD, FNP-BC, FAAN

Women experience major reproductive health transitions across their lifespan including menarche, childbearing, and menopause [1]. Although these transitional phases and the accompanying hormonal changes are considered normal [1], for some women these transitions can lead to disruptive symptoms and challenging health considerations [2,3]. Two new pharmacological treatments for women experiencing difficult reproductive health transitions have recently been approved by the FDA and are now available. To effectively support women through reproductive transitions, health care providers must be knowledgeable about these new pharmacological options. As members of the health care team, nurses play a pivotal role in implementing the plan of care when new medications are prescribed for women experiencing challenging reproductive health transitions [4].

One of the new medications is Zuranolone, the first oral medication for treating postpartum depression (PPD) [5]. PPD, one of the most prevalent mental health complications of childbirth, affects up to 1 in 7 women [3]; however, it often goes untreated. Although PPD most often presents within the first few weeks to months after delivery, it can occur anytime within a year after birth or even during pregnancy [3]. There are multiple risks for PPD including psychological, obstetric, hormonal, biological, and social factors [6]. The stigmatization of mental health conditions is a significant barrier to obtaining needed treatment: many mothers may experience shame and fear of judgment which can delay or even prevent them from seeking help. When PPD is not adequately screened for and treated, it can lead to suicide, which is the leading cause of death for women with PPD [7]. Additionally, PPD affects the child’s health, altering emotional and intellectual development [8]. Effective and timely treatment is essential and may often include a pharmacological agent.

Zuranolone is a positive allosteric modulator of gamma-aminobutyric acid (GABA), the primary inhibitory neurotransmitter in the brain. Enhancing the activity of GABA is known to create a calming effect, as GABA controls the hyperactive neurons linked with anxiety and fear [6]. Zuranolone is unique in its rapid onset, thus patients have the potential to feel better in a matter of days rather than weeks. In the case of PPD, where time is of the essence for mother-child bonding and the mother’s mental and physical health, a rapid onset medication is favorable [6].

Nurses working with postpartum women have the opportunity to appropriately screen for and identify those who may be experiencing PPD. Many women are concerned about starting a new medication while postpartum, especially because of safety concerns for their newborn,

and may look to nurses for confirmation that this medication is a good option for them. Nurses can help women with PPD consider drug therapy for treatment by making them aware of it as an option and educating them about the potential benefits to both mother and child. Education will include instructions on how to take the medication (for 14 days only, in the evening with a high fat food), strategies to support adherence to drug therapy, not driving for 12 hours after each dose, and review of potential side effects and drug interactions (Zuranolone is metabolized by CYP450) [9]. Shared decision-making is important for lactating women as there is limited data about medication safety during breastfeeding [10]. Another nursing imperative is providing counseling regarding the need for contraception while taking this medication due to potential fetal harm [11]. By providing education and supporting patients with both pharmacological decision-making and destigmatization of maternal mood disorders, nurses are instrumental in providing high quality care for patients experiencing PPD.

Another reproductive health transition is menopause. The menopause transition can be prolonged and challenging, with an average duration of ten years [12,13]. The most prevalent symptoms during the menopause transition are vasomotor symptoms (VMS) which affect over 80% of women [12,13]. VMS can be debilitating, leading to diminished sleep quality, changes in mood, along with decreased quality of life, interpersonal relationships, libido, job satisfaction, and workplace productivity; thus, negatively impacting both physical and psychosocial well-being [15]. Hormone therapy with estrogen +/progesterone is the gold standard for treating VMS, however not all women are candidates for hormone therapy. Unfortunately, older non-hormonal or nonpharmacological options are less effective [16,17].

A recently approved selective neurokinin 3 receptor (NK3R) antagonist, Fezolinetant, offers a novel nonhormonal approach to the treatment of VMS. VMS are believed to occur as a result of hypersecretion of neurotransmitters from the KNDy (kisspeptin/ nuerokininB/dynorphin) neurons. Fezolinetant blocks the activation of the KNDy neurons, resulting in a decrease in neurotransmitter secretion and thus fewer VMS [14,17].

Here again nurses can be instrumental in identifying potential candidates for this non-hormonal option and providing education to support decisionmaking. In addition to providing education regarding dosing instructions (e.g., setting reminders to take pills on time and swallowing pills intact), nurses should also conduct a thorough health and medication history to assess for conditions and drug interactions that

Pharmacological Advancements for Women’s Reproductive Health Transitions Continued

could lead to higher concentrations of Fezolinetant and necessitate dose reductions. Furthermore, providing instructions about the need for blood work in the first nine months (due to the potential for transient elevations in liver enzymes) and monitoring those levels is a key nursing responsibility [18].

In the past, there has been a lack of focus on women’s health studies for decades due to discrimination in funding [19]. However, now that promising pharmacological treatment options are available for women suffering from PPD or VMS, women’s health care providers are equipped with a more comprehensive arsenal to effectively manage complications during childbearing and menopausal transitions. Nurses are in a unique position to support women during these reproductive life transitions. Early recognition is crucial to managing PPD effectively and decreasing the symptom burden of VMS. For women experiencing PPD or troublesome VMS, being able to discuss treatment options will lead to individualized plans of care that best meet their treatment goals. By assessing individuals experiencing distressing symptoms, counseling them about symptom management options, and monitoring response to treatment, nurses are key members of the women’s health care team. +

Mary Fischer PhD MSN WHNP-BC MSCP Assistant Professor

Tan Chingfen Graduate School of Nursing

UMass Chan Medical School mary.fischer@umassmed.edu

Audrey O’Neill, RN PMHNP-DNP Candidate in the Tan Chingfen Graduate School of Nursing

UMass Chan Medical School. audrey.oneill@umassmed.edu

David Runyan, FNP-BC, RN, NRP DNP Candidate in the Tan Chingfen Graduate School of Nursing

UMass Chan Medical School. David.Runyan@umassmed.edu.

Teri Aronowitz, PhD, APRN, FNP-BC, FAAN Professor & Associate Dean of Research & Innovation

Tan Chingfen Graduate School of Nursing

UMass Chan Medical School. terese.aronowitz@umassmed.edu

Worcester District Medical Society

Medical Student Workshop on Finances

May 8, 2024, 5:30 pm

Faculty Conference Room, University Campus, UMass

Keynote Speakers:

Gayle Galletta, MD

Jennifer English, Director of Financial Aid

Gayle Galletta, MD

Ms. Jennifer English

Topics for discussion:

• Loan repayment

• Public Student Loan Forgiveness

• SAVE Plan: The Saving on a Valuable Education (SAVE) Plan Offers Lower

Monthly Loan Payments | Federal Student Aid

• Life and Disability Insurances

• Retirement Accounts

• Emergency Funds

• Budgeting

2023 Women in Medicine Breakfast

Keynote Speaker Dr. Tara Kumaraswami and Dr. Lynda Young, Chair, WDMS Women’s Caucus

The Dobbs Ruling- Its Impact on How We Practice Medicine in Massachusetts

AChildbirth, Pain, and

Yahweh asked the woman, “What is it that you have done?”

The woman replied, “The serpent tempted me, and I ate.”

Yahweh said to the woman, “I will multiply your sorrows in childbearing. You shall give birth to your children in suffering...”

Genesis 3:13,16

pparently, some women decided to get a second opinion. Just over three months after William Morton introduced ether for anesthesia at Massachusetts General Hospital in Boston in 1846, obstetrician James Young Simpson administered it to a woman in labor in Edinburgh, Scotland. And, barely a few months after that, on April 7, 1847, Fanny Appleton Longfellow (Henry’s wife), in Cambridge, gave birth using ether with the assistance of Nathan Keep, who had experience using it in dentistry.

Despite the terror that many women felt regarding the prospect of labor, the controversy about using anesthesia persisted. Some felt that it represented a violation of God’s will. Many physicians expressed concerns regarding safety and “interrupting a natural process”. When, in 1853, Queen Victoria gave birth to her eighth child using chloroform (which had become more popular in England) the acceptability of using anesthesia was given the visibility that it needed. By 1900, approximately 50% of physicianattended births used ether or chloroform. Relief was limited, however, to the delivery itself, and labor pains prior to delivery had to be dealt with by the patient.

In 1902, von Steinbuchel of Gratz, Germany introduced the combination of scopolamine and morphine to produce analgesia and amnesia during labor and delivery, using the newly developed hypodermic syringe. To protect their amnesic state, the women needed to be kept in a darkened, quiet room and watched carefully to assure that they did not fall out of bed. Dubbed “Twilight Sleep” the technique spread quickly in Europe, but in America, doctors again felt that the safety issue was not settled and were reluctant to adopt the procedure.

Following the publication of a two-part series in McClure’s Magazine in 1914 and 1915, Twilight Sleep Associations formed in the US. Rallies were held, pictures of healthy babies delivered under Twilight Sleep were displayed and leaders declared that “modern science has abolished the primal sentence of the scriptures upon womankind”. After a burst of enthusiasm in the era before 1920, the use declined as reports of depressed infants and mothers began to emerge. Still, Twilight Sleep was considered an option for the next half century.

Beginning in the 1950s, publications by Fernand Lamaze in France and Grantly DickRead in the US sought to introduce techniques of education, coaching, and breathing to better prepare women for labor and mitigate the severity of pain. After a woman from New York was delivered by Lamaze in France she sought the same approach here and, unable to find a doctor able to help her, wrote an article in the Women’s Home Journal. The Lamaze movement was launched, and the American Society for Psychoprophylaxis was formed.

This movement became even stronger in the early 1970s as the women’s liberation movement sought to assert more control over women’s health care. The first edition of Our Bodies, Ourselves by the Boston Women’s Health Collective noted that drugs should only be used in labor for a real medical emergency and cautioned that the use of drugs could “deprive a mother of one of the most joyful of human experiences”.

At the time, regional anesthesia, such as an epidural, was available but was discouraged by the Collective except under unusual circumstances. They noted that it was not always available, was costly, and might prolong labor.

As experience with epidurals increased, their safety was established, and they became more available (though still expensive). Patients’ viewpoints changed and today approximately 80% of deliveries are with epidural anesthesia. Queen Victoria would likely approve… +

For questions about this column or with ideas for future history activities, please contact dalemagee@gmail.com

Enjoy history, art, and music at Mechanics Hall. Our great hall and other event spaces are the perfect place to host extraordinary events and attend inspiring programs and concerts.

View our event calendar for information on upcoming programs and concerts at mechanicshall.org/tickets/

Celebrate

Please join us as we honor the lives of Black Americans and their impact on American history through the Portraits Project.

We are adding three new portraits of 19th century Black Americans to the Great Hall Gallery. Your donations to the Project allow us to create a community space that uplifts and honors these brave Americans.

DONATE TODAY USING THE QR CODE. 321 Main Street, Worcester, MA 01608 | www.mechanicshall.org

Master Singersof Worcester CaraBrindisi

Music Worcester: WyntonMarsalis&Jazz atLincolnCenter

Music Worcester: DukeEllington SacredConcert

Holiday Pops Concert

WDMS Annual Business Meeting and Awards Ceremony

April 10, 2024, 5:30 pm, Beechwood Hotel

Presentation and voting on the 2024-2025 State of Officers and Elected Officials, and Bylaws

Keynote Speaker: Richard Baron, MD

Protecting the Legitimacy of Medical Expertise: Combating Misinformation in Medicine

Celebrating Members’ Milestones:

25 Year Anniversary: Ajay K. Batra, MD

50 Year Anniversary: William R. Cohen, MD and William G. Lavelle, MD

Kathryn Edmiston, MD

2024 the MMS/WDMS Community Clinician of the Year Award

Interested in attending this event? Click or tap here.

Advances in OTC Birth Control

New Innovations to Increase Contraception Access in Massachusetts

Katharine Nault, PharmD, MBA, BCCCP

Aimee Dawson, PharmD

FD&C Yellow No. 5 allergy should not take OPill. [5].

Norgestrel (OPill), a progestin-only contraceptive pill (POP or “mini-pill”), was granted over-the-counter (OTC) status in 2023 by the Food and Drug Administration (FDA). [1]. Pharmacy and online sales are planned for early 2024. [1]. There are numerous advantages to OTC contraception, but two concerns were noted during the approval process:

1. Unknown effect of obesity on real-world efficacy: The FDA cited a lack of studies investigating the efficacy of norgestrel in the last 20 years, a time frame in which obesity rates have drastically increased. [2]. Pharmacokinetic evidence demonstrates a link between increased body mass and decreased concentration of progestins, theoretically leading to contraceptive failure. [2]. Although there is a theoretical concern, the U.S. Medical Eligibility Criteria for Contraceptive Use (USMEC) currently lists obesity as a category 1 for POPs, meaning there are no restrictions for use and patients with obesity can use without precautions. [3].

2. Appropriate Use: Non-adherence can result in an immediate return to fertility and contraceptive failure.[2]. Patients need to understand the critical administration timing of norgestrel, as it must be taken within three hours of the same time every day.[2]. If a patient is more than three hours late taking a dose, back-up contraception, such as a condom, is required for 48 hours. [2]. Efficacy data with POPs are cited as 99% with “perfect use,”, yet only 91% with “typical use,” highlighting the dramatic effect that non-adherence has on efficacy.[4]. Encouragingly, OTC label comprehension study patients were able to follow appropriate use directions from the label on 97% of days.[5].

Compared to other types of contraception POPs are not commonly used in the U.S., causing a significant paucity of current real-world efficacy data.[3]. Post-marketing reporting will be critical to determine if these two concerns alter efficacy rates once available OTC.

POPs are considered relatively safe. Side effects of norgestrel are similar to other POPs including spotting or irregular bleeding, headaches, nausea, cramps, and bloating.[1]. There are contraindications that patients will need to identify from the OTC labeling. Contraindications include breast cancer history, liver disease, and potential drug interactions that decrease progestin efficacy, including seizure medications and St. John’s Wort.[5]. Although results met standards, in a label comprehension study 6 out of 205 subjects with a history of breast cancer erroneously identified the drug as safe for them. [3]. Users should also note that OPill is safe for patients with migraines but requires provider evaluation if migraine severity increases due to an increased stroke risk. [5]. Patients with

There are other recommendations not included in the OTC label. Data indicates that oral contraceptives may deplete folate and other B vitamins, so patients, particularly those at higher risk of nutrient deficiencies like adolescents or those on a vegan diet, may consider use of a quality multivitamin or B-complex vitamin. [6]. As OPill users have the potential to become pregnant due to the lower efficacy rates with typical use, it is advisable to take folic acid.

The limitations with OTC norgestrel should be a reminder that clinicians need to have age-appropriate family planning discussions with patients at each visit. As OPill will soon be available online, patients may purchase this drug without ever speaking to a provider about its efficacy, safety, limitations, or appropriate use.

Advances in Digital Health for Contraception

The Natural Cycles app was FDA approved as contraception in 2018. [7]. This new technology harnesses an “old-school” method, basal body temperature for natural family planning, to provide non-pharmacologic contraception from your phone. Daily temperatures are automatically synced from an Oura ring or Apple watch or can be manually logged with a basal thermometer. The app displays a green indicator when unprotected intercourse would result in a low likelihood of pregnancy. The app displays a red indicator when the user is fertile and must practice abstinence or use a barrier method such as condoms to avoid pregnancy. [8]. Natural Cycles provides 93.5% efficacy with ‘typical use’ and 98.2% efficacy with perfect use, indicating similar efficacy to a contraceptive pill. [7]. The cost of the monthly app is relatively low, but users should consider the additional costs of an Oura ring or Apple Watch to get the full benefit of this technology.

Advances in Pharmacist-Prescribed Contraception

In Fall 2023, Massachusetts approved pharmacist-prescribed birth control. [8]. This authorizes pharmacists to prescribe and dispense contraceptive pills and patches. [8]. To prescribe, the law requires pharmacists to complete an approved training and utilize a patient screening tool based on the USMEC. [8]. Pharmacists must provide counseling and may dispense up to a 12-month supply. [8]. Per regulations, patients are not required to schedule an appointment, allowing for immediate access to prescription contraception. [8]. In MA, contraception must be covered by most insurances at no-cost to a patient, making

New Innovations to Increase Contraception Access in Massachusetts Continued

this service free for most patients. Although the law was designed to be immediately implemented, it is not yet available in most pharmacies. Pharmacies are not required to participate, so patients will need to inquire if their pharmacy will be offering this service. +

Katharine Nault, PharmD, MBA, BCCCP

Assistant Professor of Pharmacy Practice

School of Pharmacy – Worcester/Manchester Massachusetts College of Pharmacy and Health Sciences katharine.nault@mcphs.edu

Aimee Dawson, PharmD

Associate Professor and Vice Chair of the Department of Pharmacy Practice

School of Pharmacy – Worcester/Manchester Massachusetts College of Pharmacy and Health Sciences aimee.dawson@mcphs.edu

Curbside with Dr. Baker

Christopher Baker MD, UMass radiologist/contributing cartoonist to Cartoonstock.com

Dr. Robert Dennis Blute Jr. August 26, 1948 to November 5, 2023

WDMS member since: August 28, 1980

With the deepest of sadness, we note the passing of a true pillar of the Worcester medical community, Dr. Robert Blute, Jr., “Bob” as he was known to his colleagues, was a wonderful physician, husband, dad, brother, son, relative, and friend. Bob grew up in Shrewsbury and graduated from St. John’s High School. He graduated from Tufts University Medical School and always planned to follow in his dad’s footsteps and train as a urologist. Bob trained at Beth Israel Hospital in general surgery and then went on to his urology training at Brigham & Women’s Hospital. Following completion of his urology residency he joined his dad, Dr. Robert Blute, Sr., in his practice. Bob brought innovative skill to his surgical practice and was an impeccable and innovative surgeon. Bob was the urologist who urologists would call on for advice in dealing with complex cases. Bob was instrumental in keeping the Urology Residency Program at UMass Medical Center alive, becoming section chief after the then chief moved on. In that capacity he mentored many physicians.

Residents, students, and colleagues in the UMass urology program drew from his energy. He epitomized the Energizer Bunny. There was a time when he booked and completed multiple radical open prostatectomies in a single day and still had time to catch a flight and participate in an international urology conference. He would find time between cases to run over from St Vincent to Memorial or UMass Hospital and perform urgent surgery and then return for his next case. Bob had an excellent clinical sense and was never heard to say no to the most challenging cases. As new practices including laparoscopic and robotic techniques emerged, he mastered them and insisted the residents learn them as well. He was the consummate teacher learning from residents and willing to teach all. Most importantly his patients loved him and would often wait hours for an appointment. As his health failed, he continued to charm patients and colleagues with his memorable stories and shared his family pictures as he was so proud! His workplace was a second home to him. His larger-than-life presence will be particularly missed in the corridors of St Vincent Hospital, but his legacy will live on particularly in the medical community and all he touched.

Wayne B. Glazier, MD

Bhalchandra Parulkar, MD

Dr. Neil Scannell

December 6, 1973 to December 6, 2023 WDMS member since: March 28, 1999

Dr. Neil Scannell, 50, died suddenly on December 6 at his home in Worcester. He leaves his parents; Paul W. and Maureen (Lucey) Scannell of Leicester; his brother, Steven D. Scannell and his wife Mary of Holland; his sister, Megan M. Scannell of Southbridge; aunts, Pat Grady of Leicester, Lynne Thurber, and her husband Gerald of Worcester; uncle, Edward Lucey and his wife Nancy of Auburn, and nieces, nephew, and cousins. He is predeceased by his brother Sgt. John D. Scannell in 2010.

Neil was born in Worcester and completed his schooling as valedictorian of Leicester High School. His yearbook pictures named him as an “Individual Most Likely to Succeed”.

Neil did not just succeed, he excelled in every aspect of life and impacted entire communities with his personality. Neil initially studied marine biology at Worcester Polytechnic Institute in Worcester and quickly realized his passion was healthcare. He went on to earn his Doctor in Osteopathy degree from the University of New England, College of Medicine in Biddeford, Maine. Neil completed his internal medicine training at Saint Vincent Hospital.

In 2005, Neil started as one of the first hospitalists in a dedicated hospitalist program at SVH at a time when hospital medicine was still in its preliminary stages of inception. His remarkable work ethic, his empathic care of his patients, and his warm collegiality made him one of the most beloved figures on the ‘wards’ at SVH. Neil came early and stayed late, often rounding after hours to make sure his patients were well tucked in. Additionally, if anyone needed a day off or called out sick, Neil would unhesitatingly volunteer to work any shift to accommodate their request.

Neil was an astute diagnostician and a comprehensive caregiver. He would personally reach out to other members of the healthcare team to discuss the care of his patients – rather than simply requesting a consultation in the chart. He was brilliant yet humble. He moved seamlessly between teaching students and playing a valuable role in key committees in the Department of Medicine. He was a leading proponent of medical informatics and was instrumental in the Meditech/CPOE (Computerized Provider Order Entry) rollout at SVH in 2016.

Neil emphasized interdisciplinary care, networking effectively with case management, social workers, and ancillary services to make sure not just the medical aspects but also the social determinants of the patients’ treatment were addressed, providing them with comprehensive care.

Neil was awarded Physician of the Year in 2022 for his outstanding contributions and unwavering commitment to SVH. After 20 years of working at SVH, Neil joined Fairlawn Rehabilitation Center in 2023 and, within months, became an invaluable team member.

Outside work, Neil remained young at heart and he created beautiful memories over the years with his family at Disney World. He was deeply protective of his family and a role model to his younger siblings. Neil was a history buff and made time, in his off hours, to visit the rich historical landmarks around Massachusetts. He was an avid basketball and soccer player and followed the Boston sports teams closely. He had an impeccable sense of humor, making the most intense workdays enjoyable. He teased me mercilessly if I had less patients than

him – ‘slacker” was a word we used for each other if our census was less than 24 patients each when we were hospitalists together.

Neil was a comfortable conversationalist and he made time to reach out to his colleagues, those who were shy or new to the hospital. Even though Neil was well read his most valuable skill was his respectful listening of the other person.

Neil was a trailblazer, an iconic physician, and an exceptional human being. He was emblematic as someone who put everyone before himself. He dedicated his entire life to making Saint Vincent a better place for his patients and his colleagues.

As tributes to Neil pour in and we try to make sense of this untimely loss, his greatest legacy will be his impact on the community. A story by his colleague, Dr. Kevin Martin, pulmonologist at SVH, comes to mind - Dr. Martin was checking out at a grocery store after work and had forgotten to remove his hospital ID. The cashier noted the ID and asked, “I see you work at Saint Vincent Hospital; do you know Dr. Scannell?” The cashier went on to describe the tremendous impact that Neil had made on his family through the care that he had provided.

A scholarship has been set up in honor of Dr. Scannell; donations made payable to the Saint Vincent Hospital Education and Research Fund. Please mail your check to Dr. George Abraham, Department of Medicine, 123 Summer Street, Worcester, MA 01608.

Nandana Kansra, MD

George M. Abraham, MD, MPH, MACP, FIDSA, FRCP (Lon.)

Kathy L. Chrismer, MD July 15, 1956 to December 16, 2023

Dr. Kathy L. Chrismer, 67, of Paxton, passed away on December 16, 2023. She was a close and cherished colleague of mine. We started practicing at Fallon Clinic in July 1988. She was beloved by staff, patients and their families. She continued to practice at Fallon Clinic/Reliant Medical Group for nearly 20 years until joining a private practice in Holden. Her practice style was characterized by kindness, efficiency, and clinical acumen.

Kathy graduated from Nottingham High School, Syracuse, New York where she was part of the jazz and symphonic bands, playing saxophone. She studied biochemistry at Smith College and went on to earn her medical degree at the University of Rochester. She completed her pediatric residency at Strong Memorial Hospital.

She leaves her life partner, Steve Crowe, her brother and sister, their spouses and beloved nieces and nephews. She loved the outdoors and was an avid hiker and skier. She was a great animal lover having had horses, rabbits, and always at least one dog in her life. At each stage of her life she made close and lasting friendships and I am pleased to have been one of them. Her joie de vivre was contagious.

Brenda

M. McHugh, MD Pediatrician

Gerrilu Bruun, RN February 26, 1942 to January 5, 2024 Alliance Member, Extraordinaire

Gerrilu H. Bruun, devoted wife, mother and grandmother, died on January 5, 2024, after a brief illness, surrounded by members of her loving family. She was born February 26, 1942, in Geneva, NY. She completed her educational training at the Genesee Hospital School of Nursing in Rochester, NY, where she met her future husband, Dr. Svend W. Bruun, who was studying medicine at the University of Rochester School of Medicine and Dentistry. They married on August 21, 1965.

They eventually relocated to Massachusetts, settling in Lunenburg in 1972 while Dr. Bruun established his medical practice in Fitchburg. Gerrilu remained active in the medical community through decades of engagement with the Massachusetts Medical Society Alliance (MMSA) at both the district and state levels, where she advocated for a variety of public health initiatives. She was a willing and selfless volunteer representing the Alliance at health fairs in schools and at Kidsfest, Wachusett Mountain and the UMass Teddy Bear Clinic at the Greendale Mall. Because of Gerrilu’s dedication to educate and raise awareness about seat belts, infant/child car seats, and bicycle helmets, countless lives were saved and injuries prevented. Together with the Alliance, and other private and public organizations, these efforts resulted in legislation being passed. At the state level, Gerrilu believed in the importance of MMS committees and served as Alliance Liaison to Public Health, Communication, and Membership Committees.

She returned to the workforce for the last 10 years of her husband’s medical practice in Fitchburg, serving as his office nurse until his retirement. The couple moved to Hubbardston in 2016, where Gerrilu was a loving, skilled, and tireless caregiver to her husband.

Forever in our hearts, Gerrilu will be remembered as a dedicated and engaged leader and as an inspiration of what being a part of the Alliance community is all about.

Paula Madison, RN Worcester District Medical Society Alliance (WDMSA) Board Member

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