Oral retinoids can harm unborn babies. But many women taking them for acne may not be using contraception
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Oral retinoids are a type of medicine used to treat severe acne. They’re sold under the brand name Roaccutane, among others.
While oral retinoids are very effective, they can have harmful effects if taken during pregnancy. These medicines can cause miscarriages and major congenital abnormalities (harm to unborn babies) including in the brain, heart and face. At least 30% of children exposed to oral retinoids in pregnancy have severe congenital abnormalities.
Neurodevelopmental problems (in learning, reading, social skills, memory and attention) are also common.
Because of these risks, the Australasian College of Dermatologists advises oral retinoids should not be prescribed a month before or during pregnancy under any circumstances. Dermatologists are instructed to make sure a woman isn’t pregnant before starting this treatment, and discuss the risks with women of childbearing age.
But despite this, and warnings on the medicines’ packaging, pregnancies exposed to oral retinoids continue to be reported in Australia and around the world.
In a study published this month, we wanted to find out what proportion of Australian women of reproductive age were taking oral retinoids, and how many of these women were using contraception.
Our results suggest a high proportion of women are not using effective contraception while on these drugs, indicating Australia needs a strategy to reduce the risk oral retinoids pose to unborn babies.
Contraception options
Using birth control to avoid pregnancy during oral retinoid treatment is essential for women who are sexually active. Some contraception methods, however, are more reliable than others.
Long-acting-reversible contraceptives include intrauterine devices (IUDs) inserted into the womb (such as Mirena, Kyleena, or copper devices) and implants under the skin (such as Implanon). These “set and forget” methods are more than 99% effective.
The effectiveness of oral contraceptive pills among “perfect” users (following the directions, with no missed or late pills) is similarly more than 99%. But in typical users, this can fall as low as 91%.
Condoms, when used as the sole method of contraception, have higher failure rates. Their effectiveness can be as low as 82% in typical users.
Oral retinoid use over time
For our study, we analysed medicine dispensing data among women aged 15–44 from Australia’s Pharmaceutical Benefit Scheme (PBS) between 2013 and 2021.
We found the dispensing rate for oral retinoids doubled from one in every 71 women in 2013, to one in every 36 in 2021. The increase occurred across all ages but was most notable in young women.
Most women were not dispensed contraception at the same time they were using the oral retinoids. To be sure we weren’t missing any contraception that was supplied before the oral retinoids, we looked back in the data. For example, for an IUD that lasts five years, we looked back five years before the oral retinoid prescription.
Our analysis showed only one in four women provided oral retinoids were dispensed contraception simultaneously. This was even lower for 15- to 19-year-olds, where only about one in eight women who filled a prescription for oral retinoids were dispensed contraception.
A recent study found 43% of Australian year 10 and 69% of year 12 students are sexually active, so we can’t assume this younger age group largely had no need for contraception.
One limitation of our study is that it may underestimate contraception coverage, because not all contraceptive options are listed on the PBS. Those options not listed include male and female sterilisation, contraceptive rings, condoms, copper IUDs, and certain oral contraceptive pills.
But even if we presume some of the women in our study were using forms of contraception not listed on the PBS, we’re still left with a significant portion without evidence of contraception.
What are the solutions?
Other countries such as the United States and countries in Europe have pregnancy prevention programs for women taking oral retinoids. These programs include contraception requirements, risk acknowledgement forms and regular pregnancy tests. Despite these programs, unintended pregnancies among women using oral retinoids still occur in these countries.
But Australia has no official strategy for preventing pregnancies exposed to oral retinoids. Currently oral retinoids are prescribed by dermatologists, and most contraception is prescribed by GPs. Women therefore need to see two different doctors, which adds costs and burden.
Rather than a single fix, there are likely to be multiple solutions to this problem. Some dermatologists may not feel confident discussing sex or contraception with patients, so educating dermatologists about contraception is important. Education for women is equally important.
A clinical pathway is needed for reproductive-aged women to obtain both oral retinoids and effective contraception. Options may include GPs prescribing both medications, or dermatologists only prescribing oral retinoids when there’s a contraception plan already in place.
Some women may initially not be sexually active, but change their sexual behaviour while taking oral retinoids, so constant reminders and education are likely to be required.
Further, contraception access needs to be improved in Australia. Teenagers and young women in particular face barriers to accessing contraception, including costs, stigma and lack of knowledge.
Many doctors and women are doing the right thing. But every woman should have an effective contraception plan in place well before starting oral retinoids. Only if this happens can we reduce unintended pregnancies among women taking these medicines, and thereby reduce the risk of harm to unborn babies.
Dr Laura Gerhardy from NSW Health contributed to this article.
Antonia Shand, Research Fellow, Obstetrician, University of Sydney and Natasha Nassar, Professor of Paediatric and Perinatal Epidemiology and Chair in Translational Childhood Medicine, University of Sydney
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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How To Know When You’re Healing Emotionally
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The healing process can be humbling but rewarding, leading to deep fulfillment and inner peace. Discomfort in healing can be part of growth and self-integration. Because of that, progress sometimes looks and/or feels like progress… And sometimes it doesn’t. Here’s how to recognize it, though:
Small but important parts of a bigger process
Nine signs indicating you are healing:
- Allowing emotions: you acknowledge and process both negative and positive emotions instead of suppressing them.
- Improved boundaries: you improve at expressing and maintaining boundaries, overcoming fear of rejection, guilt, and shame.
- Acceptance of past: you accept difficult past experiences and their impact, reducing their hold over you.
- Less reactivity: you become less reactive and more thoughtful in responses, practicing emotional self-regulation.
- Non-linear healing: you understand that healing involves ups and downs and isn’t a straightforward journey.
- Stepping out of your comfort zone: you start taking brave steps that previously induced fear or anxiety.
- Handling disappointments: you accept setbacks and respond to them healthily, without losing motivation.
- Inner peace: you develop a sense of wholeness, and forgiveness for yourself and others, reducing self-sabotage.
- Welcoming support: you become more open to seeking and accepting help, moving beyond pride and shame.
In short: healing (especially the very first part: accepting that something needs healing) can be uncomfortable but lead to much better places in life. It’s okay if healing is slow; everyone’s journey is different, and doing your best is enough.
For more on each of these, enjoy:
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Why You Can’t Just “Get Over” Trauma
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You’re Not Forgetful: How To Remember Everything
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Elizabeth Filips, medical student busy learning a lot of information, explains how in today’s video:
Active processing
An important thing to keep in mind is that forgetting is an active process, not passive as once believed. It has its own neurotransmitters and pathways, and as such, to improve memory, it’s essential to understand and manage forgetting.
So, how does forgetting occur? Memories are stored with cues or tags, which help retrieve information. However, overloading cues with too much information can cause “transient forgetting”—that is to say, the information is still in there somewhere; you just don’t have the filing system required to retrieve the data. This is the kind of thing that you will try hard to remember at some point in the day when you need it, fail, and then wake up at 3am with an “Aha!” because your brain finally found what you were looking for. So, to avoid that, use unique and strong cues to help improve recall (mnemonics are good for this, as are conceptual anchors).
While memory does not appear to actually be finite, there is some practical truth in the “finite storage” model insofar as learning new information can overwrite previous knowledge, iff your brain mistakes it for an update rather than addition. So for that reason, it’s good to periodically go over old information—in psychology this is called rehearsal, which may conjure theatrical images, but it can be as simple as mentally repeating a phone number, a mnemonic, or visually remembering a route one used to take to go somewhere.
Self-perception affects memory performance. Negative beliefs about one’s memory can worsen performance (so don’t say “I have a bad memory”, even to yourself, and in contrast, find more positive affirmations to make about your memory), and mental health in general plays a significant role in memory. For example, if you have ever had an extended period of depression, then chances are good you have some huge gaps in your memory for that time in your life.
A lot of what we learned in school was wrong—especially what we learned about learning. Traditional (vertical) learning is harder to retain, whereas horizontal learning (connecting topics through shared characteristics) creates stronger, interconnected memories. In short, your memories should tell contextual stories, not be isolated points of data.
Embarking on a new course of study? Yes? (If not, then why not? Pick something!)
It may be difficult at first, but experts memorize things more quickly due to built-up intuition in their field. For example a chess master can glance at a chess board for about 5 seconds and memorize the position—but only if the position is one that could reasonably arise in a game; if the pieces are just placed at random, then their memorization ability plummets to that of the average person, because their expertise has been nullified.
What this means in practical terms: building a “skeleton” framework before learning can enhance memorization through logical connections. For this reason, if embarking on a serious course of study, getting a good initial overview when you start is critical, so that you have a context for the rest of what you learn to go into. For example, let’s say you want to learn a language; if you first quickly do a very basic bare-bones course, such as from Duolingo or similar, then even though you’ll have a very small vocabulary and a modest grasp of grammar and make many mistakes and have a lot of holes in your knowledge, you now have somewhere to “fit” every new word or idea you learn. Same goes for other fields of study; for example, a doctor can be told about a new drug and remember everything about it immediately, because they understand the systems it interacts with, understand how it does what it does, and can compare it mentally to similar drugs, and they thus have a “place” in that overall system for the drug information to reside. But for someone who knows nothing about medicine, it’s just a lot of big words with no meaning. So: framework first, details later.
For more on all this, enjoy:
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You might also like to read:
How To Boost Your Memory Immediately (Without Supplements)
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What’s Your Ikigai?
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Ikigai: A Closer Look
We’ve mentioned ikigai from time to time, usually when discussing the characteristics associated with Blue Zone centenarians, for example as number 5 of…
It’s about finding one’s “purpose”. Not merely a function, but what actually drives you in life. And, if Japanese studies can be extrapolated to the rest of the world, it has a significant and large impact on mortality (other factors being controlled for); not having a sense of ikigai is associated with an approximately 47%* increase in 7-year mortality risk in the categories of cardiovascular disease and external cause mortality:
Sense of life worth living (ikigai) and mortality in Japan: Ohsaki Study
*we did a lot of averaging and fuzzy math to get this figure; the link will show you the full stats though!
In case that huge (n=43,391) study didn’t convince you, here’s another comparably-sized (n=43,117) one that found similarly, albeit framing the numbers the other way around, i.e. a comparable decrease in mortality risk for having a sense of ikigai:
This study was even longer (12 years rather than 7), so the fact that it found pretty much the same results the 7-year study we cited just before is quite compelling evidence. Again, multivariate hazard ratios were adjusted for age, BMI, drinking and smoking status, physical activity, sleep duration, education, occupation, marital status, perceived mental stress, and medical history—so all these things were effectively controlled for statistically.
Three kinds of ikigai
There are three principal kinds of ikigai:
- Social ikigai: for example, a caring role in the family or community, volunteer work, teaching
- Asocial ikigai: for example, a solitary practice of self-discipline, spirituality, or study without any particular intent to teach others
- Antisocial ikigai: for example, a strong desire to outlive an enemy, or to harm a person or group that one hates
You may be thinking: wait, aren’t those last things bad?
And… Maybe! But ikigai is not a matter of morality or even about “warm fuzzy feelings”. The fact is, having a sense of purpose increases longevity regardless of moral implications or niceness.
Nevertheless, for obvious reasons there is a lot more focus on the first two categories (social and asocial), and of those, especially the first category (social), because on a social level, “we all do well when we all do well”.
We exemplified them above, but they can be defined:
- Social: working for the betterment of society
- Asocial: working for the betterment of oneself
Of course, for many people, the same ikigai may cover both of those—often somebody who excels at something for its own sake and/but shares it with others to enrich their lives also, for example a teacher, an artist, a scientist, etc.
For it to cover both, however, requires that both parts of it are genuinely part of their feeling of ikigai, and not merely unintended consequences.
For example, a piano teacher who loves music in general and the piano in particular, and would gladly spend every waking moment studying/practising/performing, but hates having to teach it, but needs to pay the bills so teaches it anyway, cannot be said to be living any kind of social ikigai there, just asocial. And in fact, if teaching the piano is causing them to not have the time or energy to pursue it for its own sake, they might not even be living any ikigai at all.
One other thing to watch out for
There is one last stumbling block, which is that while we can find ikigai, we can also lose it! Examples of this may include:
- A professional whose job is their ikigai, until they face mandatory retirement or are otherwise unable to continue their work (perhaps due to disability, for example)
- A parent whose full-time-parent role is their ikigai, until their children leave for school, university, life in general
- A married person whose “devoted spouse” role is their ikigai, until their partner dies
For this reason, people of any age can have a “crisis of identity” that’s actually more of a “crisis of purpose”.
There are two ways of handling this:
- Have a back-up ikigai ready! For example, if your profession is your ikigai, maybe you have a hobby waiting in the wings, that you can smoothly jump ship to upon retirement.
- Embrace the fluidity of life! Sometimes, things don’t happen the way we expect. Sometimes life’s surprises can trip us up; sometimes they can leave us a sobbing wreck. But so long as life continues, there is an opportunity to pick ourselves up and decide where to go from that point. Note that this is not fatalism, by the way, it doesn’t have to be “this bad thing happened so that we could find this good thing, so really it was a good thing all along”. Rather, it can equally readily be “well, we absolutely did not want that bad thing to happen, but since it did, now we shall take it this way from here”.
For more on developing/maintaining psychological resilience in the face of life’s less welcome adversities, see:
Psychological Resilience Training
…and:
Putting The Abs Into Absurdity ← do not underestimate the power of this one
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Dietary Changes for Artery Health
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It’s Q&A Day at 10almonds!
Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small
❝How does your diet change clean out your arteries of the bad cholesterol?❞
There’s good news and bad news here, and they can both be delivered with a one-word reply:
Slowly.
Or rather: what’s being cleaned out is mostly not the LDL (bad) cholesterol, but rather, the result of that.
When our diet is bad for cardiovascular health, our arteries get fatty deposits on their walls. Cholesterol gets stuck here too, but that’s not the main physical problem.
Our body’s natural defenses come into action and try to clean it up, but they (for example macrophages, a kind of white blood cell that consumes invaders and then dies, before being recycled by the next part of the system) often get stuck and become part of the buildup (called atheroma), which can lead to atherosclerosis and (if calcium levels are high) hardening of the arteries, which is the worst end of this.
This can then require medical attention, precisely because the body can’t remove it very well—especially if you are still maintaining a heart-unhealthy diet, thus continuing to add to the mess.
However, if it is not too bad yet, yes, a dietary change alone will reverse this process. Without new material being added to the arterial walls, the body’s continual process of rejuvenation will eventually fix it, given time (free from things making it worse) and resources.
In fact, your arteries can be one of the quickest places for your body to make something better or worse, because the blood is the means by which the body moves most things (good or bad) around the body.
All the more reason to take extra care of it, since everything else depends on it!
You might also like our previous main feature:
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Statins: His & Hers?
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The Hidden Complexities of Statins and Cardiovascular Disease (CVD)
This is Dr. Barbara Roberts. She’s a cardiologist and the Director of the Women’s Cardiac Center at one of the Brown University Medical School teaching hospitals. She’s an Associate Clinical Professor of Medicine and takes care of patients, teaches medical students, and does clinical research. She specializes in gender-specific aspects of heart disease, and in heart disease prevention.
We previously reviewed Dr. Barbara Roberts’ excellent book “The Truth About Statins: Risks and Alternatives to Cholesterol-Lowering Drugs”. It prompted some requests to do a main feature about Statins, so we’re doing it today. It’s under the auspices of “Expert Insights” as we’ll be drawing almost entirely from Dr. Roberts’ work.
So, what are the risks of statins?
According to Dr. Roberts, one of the biggest risks is not just drug side-effects or anything like that, but rather, what they simply won’t treat. This is because statins will lower LDL (bad) cholesterol levels, without necessarily treating the underlying cause.
Imagine you got Covid, and it’s one of the earlier strains that’s more likely deadly than “merely” debilitating.
You’re coughing and your throat feels like you gargled glass.
Your doctor gives you a miracle cough medicine that stops your coughing and makes your throat feel much better.
(Then a few weeks later, you die, because this did absolutely nothing for the underlying problem)
You see the problem?
Are there problematic side-effects too, though?
There can be. But of course, all drugs can have side effects! So that’s not necessarily news, but what’s relevant here is the kind of track these side-effects can lead one down.
For example, Dr. Roberts cites a case in which a woman’s LDL levels were high and she was prescribed simvastatin (Zocor), 20mg/day. Here’s what happened, in sequence:
- She started getting panic attacks. So, her doctor prescribed her sertraline (Zoloft) (a very common SSRI antidepressant) and when that didn’t fix it, paroxetine (Paxil). This didn’t work either… because the problem was not actually her mental health. The panic attacks got worse…
- Then, while exercising, she started noticing progressive arm and leg weakness. Her doctor finally took her off the simvastatin, and temporarily switched to ezetimibe (Zetia), a less powerful nonstatin drug that blocks cholesterol absorption, which change eased her arm and leg problem.
- As the Zetia was a stopgap measure, the doctor put her on atorvastatin (Lipitor). Now she got episodes of severe chest pressure, and a skyrocketing heart rate. She also got tremors and lost her body temperature regulation.
- So the doctor stopped the atorvastatin and tried rosovastatin (Crestor), on which she now suffered exhaustion (we’re not surprised, by this point) and muscle pains in her arms and chest.
- So the doctor stopped the rosovastatin and tried lovastatin (Mevacor), and now she had the same symptoms as before, plus light-headedness.
- So the doctor stopped the lovastatin and tried fluvastatin (Lescol). Same thing happened.
- So he stopped the fluvastatin and tried pravastatin (Pravachol), without improvement.
- So finally he took her off all these statins because the high LDL was less deleterious to her life than all these things.
- She did her own research, and went back to the doctor to ask for cholestyramine (Questran), which is a bile acid sequestrent and nothing to do with statins. She also asked for a long-acting niacin. In high doses, niacin (one of the B-vitamins) raises HDL (good) cholesterol, lowers LDL, and lowers tryglycerides.
- Her own non-statin self-prescription (with her doctor’s signature) worked, and she went back to her life, her work, and took up running.
Quite a treatment journey! Want to know more about the option that actually worked?
Read: Bile Acid Resins or Sequestrants
What are the gender differences you/she mentioned?
A lot of this is still pending more research—basically it’s a similar problem in heart disease to one we’ve previously talked about with regard to diabetes. Diabetes disproportionately affects black people, while diabetes research disproportionately focuses on white people.
In this case, most heart disease research has focused on men, with women often not merely going unresearched, but also often undiagnosed and untreated until it’s too late. And the treatments, if prescribed? Assumed to be the same as for men.
Dr. Roberts tells of how medicine is taught:
❝When I was in medical school, my professors took the “bikini approach” to women’s health: women’s health meant breasts and reproductive organs. Otherwise the prototypical patient was presented as a man.❞
There has been some research done with statins and women, though! Just, still not a lot. But we do know for example that some statins can be especially useful for treating women’s atherosclerosis—with a 50% success rate, rather than 31% for men.
For lowering LDL, it can work but is generally not so hot in women.
Fun fact:
In men:
- High total cholesterol
- High non-HDL cholesterol
- High LDL cholesterol
- Low HDL cholesterol
…are all significantly associated with an increased risk of death from CVD.
In women:
…levels of LDL cholesterol even more than 190 were associated with only a small, statistically insignificant increased risk of dying from CVD.
So…
The fact that women derive less benefit from a medicine that mainly lowers LDL cholesterol, may be because elevated LDL cholesterol is less harmful to women than it is to men.
And also: Treatment and Response to Statins: Gender-related Differences
And for that matter: Women Versus Men: Is There Equal Benefit and Safety from Statins?*
Definitely a case where Betteridge’s Law of Headlines applies!
What should women do to avoid dying of CVD, then?
First, quick reminder of our general disclaimer: we can’t give medical advice and nothing here comprises such. However… One particularly relevant thing we found illuminating in Dr. Roberts’ work was this observation:
The metabolic syndrome is diagnosed if you have three (or more) out of five of the following:
- Abdominal obesity (waist >35″ if a woman or >40″ if a man)
- Fasting blood sugars of 100mg/dl or more
- Fasting triglycerides of 150mg/dl or more
- Blood pressure of 130/85 or higher
- HDL <50 if a woman or <40 if a man
And yet… because these things can be addressed with exercise and a healthy diet, which neither pharmaceutical companies nor insurance companies have a particular stake in, there’s a lot of focus instead on LDL levels (since there are a flock of statins that can be sold be lower them)… Which, Dr. Roberts says, is not nearly as critical for women.
So women end up getting prescribed statins that cause panic attacks and all those things we mentioned earlier… To lower our LDL, which isn’t nearly as big a factor as the other things.
In summary:
Statins do have their place, especially for men. They can, however, mask underlying problems that need treatment—which becomes counterproductive.
When it comes to women, statins are—in broad terms—statistically not as good. They are a little more likely to be helpful specifically in cases of atherosclerosis, whereby they have a 50/50 chance of helping.
For women in particular, it may be worthwhile looking into alternative non-statin drugs, and, for everyone: diet and exercise.
Further reading: How Can I Safely Come Off Statins?
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Heal & Reenergize Your Brain With Optimized Sleep Cycles
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Sometimes 8 hours sleep can result in grogginess while 6 hours can result in waking up fresh as a daisy, so what gives? Dr. Tracey Marks explains, in this short video.
Getting more than Zs in
Sleep involves 90-minute cycles, usually in 4 stages:
- Stage 1: (drowsy state): brief muscle jerks; lasts a few minutes.
- Stage 2: (light sleep): sleep spindles for memory consolidation; 50% of total sleep.
- Stage 3 (deep sleep): tissue repair, immune support, brain toxin removal via the glymphatic system.
- Stage 4 (REM sleep): emotional processing, creativity, problem-solving, and dreaming.
Some things can disrupt some or all of those. To give a few common examples:
- Alcohol: impairs REM sleep.
- Caffeine: hinders deep sleep even if consumed hours before bed.
- Screentime: delays sleep onset due to blue light (but not by much); the greater problem is that it can also disrupt REM sleep due to mental stimulation.
To optimize things, Dr. Marks recommends:
- 90-minute rule: plan sleep to align with full cycles (e.g: 22:30 to 06:00 = 7½ hours, which is 5x 90-minute cycles).
- Smart alarms: use sleep-tracking apps with built-in alarm, to wake you up during light sleep phases.
- Strategic naps: keep naps to 20 minutes or a full 90-minute cycle.
- Pink noise: improves deep sleep.
- Meal timing: avoid eating within 3 hours of bedtime.
- Natural light: get morning light exposure in the morning to strengthen circadian rhythm.
For more on all of this, enjoy:
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You might also like to read:
Calculate (And Enjoy) The Perfect Night’s Sleep
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