Opinion

Lauren is a 45-year-old corporate lawyer who managed to excel in every aspect of her life, including parenting her three children while working full-time as a corporate lawyer. A math major at Harvard, she loves data.

Suffice it to say, given that I was treating her for a thyroid condition rather than diabetes, I was a little surprised when she requested I prescribe her a FreeStyle Libre (Abbott) monitor. She explained she was struggling to lose 10 pounds, and she thought continuous glucose monitoring (CGM) would help her determine which foods were impeding her weight loss journey. 

While I didn’t see much downside to acquiescing, I felt she had probably been spending too much time on Reddit. What information could CGM give someone without diabetes that couldn’t be gleaned from a food label? Nevertheless, Lauren filled the prescription and began her foray into this relatively uncharted world. When she returned for a follow-up visit several months later, I was shocked to see that she had lost her intended weight. With my tail between my legs, I decided to review the theories and science behind the use of CGM in patients without insulin resistance. 

Although it’s not rocket science, CGM can help patients through a “carrot and stick” approach to dieting. Lean proteins, nonstarchy vegetables, and monounsaturated fats such as nuts and avocado all support weight loss and tend to keep blood glucose levels stable. In contrast, foods known to cause weight gain (eg, sugary foods, refined starches, and processed foods) cause sugar spikes in real time. Similarly, large portion sizes are more likely to result in sugar spikes, and pairing proteins with carbohydrates minimizes blood glucose excursions. 

Though all of this is basic common sense, the constant feedback from a CGM device holds patients accountable for their food choices and helps with behavioral change. And because blood glucose is influenced by myriad factors including stress, genetics and metabolism, CGM can also potentially help create personal guidance for food choices. 

In addition, CGM can reveal the effect of poor sleep and stress on blood glucose levels, thereby encouraging healthier lifestyle choices. The data collected also may provide information on how different modalities of physical activity affect blood glucose levels. A recent study compared the effect of high-intensity interval training (HIIT) and continuous moderate-intensity exercise on postmeal blood glucose in overweight individuals without diabetes. CGM revealed that HIIT is more advantageous for preventing postmeal spikes. 

Although CGM appears to be a sophisticated form of cognitive-behavioral therapy, I do worry that the incessant stream of information can lead to worsening anxiety, obsessive compulsive behaviors, or restrictive eating tendencies. Still, thanks to Lauren, I now believe that real-time CGM may lead to behavior modification in food selection and physical activity. 
 

Dr. Messer, Clinical Assistant Professor, Mount Sinai School of Medicine; Associate Professor, Hofstra School of Medicine, New York, NY, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Lauren is a 45-year-old corporate lawyer who managed to excel in every aspect of her life, including parenting her three children while working full-time as a corporate lawyer. A math major at Harvard, she loves data.

Suffice it to say, given that I was treating her for a thyroid condition rather than diabetes, I was a little surprised when she requested I prescribe her a FreeStyle Libre (Abbott) monitor. She explained she was struggling to lose 10 pounds, and she thought continuous glucose monitoring (CGM) would help her determine which foods were impeding her weight loss journey. 

While I didn’t see much downside to acquiescing, I felt she had probably been spending too much time on Reddit. What information could CGM give someone without diabetes that couldn’t be gleaned from a food label? Nevertheless, Lauren filled the prescription and began her foray into this relatively uncharted world. When she returned for a follow-up visit several months later, I was shocked to see that she had lost her intended weight. With my tail between my legs, I decided to review the theories and science behind the use of CGM in patients without insulin resistance. 

Although it’s not rocket science, CGM can help patients through a “carrot and stick” approach to dieting. Lean proteins, nonstarchy vegetables, and monounsaturated fats such as nuts and avocado all support weight loss and tend to keep blood glucose levels stable. In contrast, foods known to cause weight gain (eg, sugary foods, refined starches, and processed foods) cause sugar spikes in real time. Similarly, large portion sizes are more likely to result in sugar spikes, and pairing proteins with carbohydrates minimizes blood glucose excursions. 

Though all of this is basic common sense, the constant feedback from a CGM device holds patients accountable for their food choices and helps with behavioral change. And because blood glucose is influenced by myriad factors including stress, genetics and metabolism, CGM can also potentially help create personal guidance for food choices. 

In addition, CGM can reveal the effect of poor sleep and stress on blood glucose levels, thereby encouraging healthier lifestyle choices. The data collected also may provide information on how different modalities of physical activity affect blood glucose levels. A recent study compared the effect of high-intensity interval training (HIIT) and continuous moderate-intensity exercise on postmeal blood glucose in overweight individuals without diabetes. CGM revealed that HIIT is more advantageous for preventing postmeal spikes. 

Although CGM appears to be a sophisticated form of cognitive-behavioral therapy, I do worry that the incessant stream of information can lead to worsening anxiety, obsessive compulsive behaviors, or restrictive eating tendencies. Still, thanks to Lauren, I now believe that real-time CGM may lead to behavior modification in food selection and physical activity. 
 

Dr. Messer, Clinical Assistant Professor, Mount Sinai School of Medicine; Associate Professor, Hofstra School of Medicine, New York, NY, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Lauren is a 45-year-old corporate lawyer who managed to excel in every aspect of her life, including parenting her three children while working full-time as a corporate lawyer. A math major at Harvard, she loves data.

Suffice it to say, given that I was treating her for a thyroid condition rather than diabetes, I was a little surprised when she requested I prescribe her a FreeStyle Libre (Abbott) monitor. She explained she was struggling to lose 10 pounds, and she thought continuous glucose monitoring (CGM) would help her determine which foods were impeding her weight loss journey. 

While I didn’t see much downside to acquiescing, I felt she had probably been spending too much time on Reddit. What information could CGM give someone without diabetes that couldn’t be gleaned from a food label? Nevertheless, Lauren filled the prescription and began her foray into this relatively uncharted world. When she returned for a follow-up visit several months later, I was shocked to see that she had lost her intended weight. With my tail between my legs, I decided to review the theories and science behind the use of CGM in patients without insulin resistance. 

Although it’s not rocket science, CGM can help patients through a “carrot and stick” approach to dieting. Lean proteins, nonstarchy vegetables, and monounsaturated fats such as nuts and avocado all support weight loss and tend to keep blood glucose levels stable. In contrast, foods known to cause weight gain (eg, sugary foods, refined starches, and processed foods) cause sugar spikes in real time. Similarly, large portion sizes are more likely to result in sugar spikes, and pairing proteins with carbohydrates minimizes blood glucose excursions. 

Though all of this is basic common sense, the constant feedback from a CGM device holds patients accountable for their food choices and helps with behavioral change. And because blood glucose is influenced by myriad factors including stress, genetics and metabolism, CGM can also potentially help create personal guidance for food choices. 

In addition, CGM can reveal the effect of poor sleep and stress on blood glucose levels, thereby encouraging healthier lifestyle choices. The data collected also may provide information on how different modalities of physical activity affect blood glucose levels. A recent study compared the effect of high-intensity interval training (HIIT) and continuous moderate-intensity exercise on postmeal blood glucose in overweight individuals without diabetes. CGM revealed that HIIT is more advantageous for preventing postmeal spikes. 

Although CGM appears to be a sophisticated form of cognitive-behavioral therapy, I do worry that the incessant stream of information can lead to worsening anxiety, obsessive compulsive behaviors, or restrictive eating tendencies. Still, thanks to Lauren, I now believe that real-time CGM may lead to behavior modification in food selection and physical activity. 
 

Dr. Messer, Clinical Assistant Professor, Mount Sinai School of Medicine; Associate Professor, Hofstra School of Medicine, New York, NY, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Human papillomavirus (HPV) is one of the most common sexually transmitted infections and persistent infection with high-risk strains is the leading cause of cervical cancer. Fortunately, vaccines are available to prevent many HPV-related diseases, but they haven’t fully eliminated the risks. Cervical cancer screening remains essential for early detection and prevention.

The US Preventive Services Task Force (USPSTF) currently recommends regular cervical cancer screenings for women aged 21-65. These screenings can include a Pap test every 3 years, a combination of HPV testing and Pap smear every 5 years, or high-risk HPV testing alone every 5 years, depending on age and individual risk factors.

Although these guidelines are currently under review, routine screenings have been instrumental in reducing cervical cancer rates. However, many patients still face barriers that prevent them from accessing these services. Common challenges include discomfort with pelvic exams, lack of time, and limited access to healthcare services. In recent years, advancements in home-based diagnostic testing have opened new avenues for preventative care.

Home HPV testing is one such advancement, offering an alternative to traditional in-office screening methods. While the US Food and Drug Administration (FDA) has not yet approved home HPV testing, self-collection in clinical settings is available and gaining traction. Primary care physicians can integrate this self-collection method into their practices, helping to close the screening gap, especially for underserved populations.

If approved, home HPV testing could be a game-changer for patients who have difficulty attending in-person visits. Geographical barriers, transportation issues, and personal discomfort with in-office exams can prevent patients from receiving the care they need. Home testing eliminates many of these hurdles, enabling patients to perform the test in the comfort of their own homes at a time that works for them. This flexibility is particularly beneficial for rural and underserved populations, where access to healthcare is limited.

Similarly, in-office self-collection offers a comfortable alternative for those who find traditional pelvic exams uncomfortable or distressing. Self-administered HPV tests allow patients to take control of their cervical cancer screening, fostering empowerment and personal responsibility for their health. By reducing the discomfort and inconvenience of traditional screening, self-collection can improve adherence to screening guidelines, leading to earlier detection and prevention of cervical cancer.

Primary care physicians may soon offer both in-office and at-home testing options, tailoring the approach to each patient’s unique needs. Virtual appointments provide an excellent opportunity to educate patients about the importance of cervical cancer screening and offer guidance on using home HPV testing kits. This personalized care ensures patients feel supported even without in-person visits. If home testing becomes FDA approved, patients could receive test kits by mail, perform the test, and send it back to the lab for analysis. For those with positive results, primary care physicians can ensure timely follow-up, including Pap smears or colposcopies, to further evaluate cervical health.

Although home HPV testing offers many benefits, there are valid concerns about accuracy and follow-up care. Studies show that self-collected samples for HPV testing are highly accurate, with sensitivity and specificity comparable with clinician-collected samples, echoing the success of self-swabbing for other sexually transmitted infections.

It is crucial, however, that patients receive clear instructions on proper sample collection to maintain this accuracy. Follow-up care is another essential aspect of the screening process. While many HPV infections resolve on their own, high-risk strains require closer monitoring to prevent progression to cervical cancer. Primary care physicians must establish clear protocols for notifying patients of their results and ensuring appropriate follow-up appointments.

Additionally, there may be concerns about the cost and insurance coverage of home HPV tests. However, home testing could prove more cost-effective than multiple in-office visits, especially when factoring in travel expenses and missed work. Physicians should work to make home testing accessible to all patients, including those in low-income and rural communities.

Should these options become more widely available, it will be important to communicate that this does not fully eliminate the need for pelvic exams. As primary care physicians, we will still need to advise patients that they should bring up concerns of vaginal bleeding, vaginal discharge, and other symptoms. Pelvic exams will still be necessary for diagnosis when symptoms are present. Home HPV tests also will not replace in-office clinician collected exams for those who do not feel comfortable with self-collection.

Home and in-office self-collection for HPV testing are promising tools for improving cervical cancer screening rates and patient satisfaction. By offering a convenient, private, and accessible option, primary care physicians can help more patients stay on track with their preventive care and reduce their risk of cervical cancer. As this technology continues to evolve, embracing both in-office and home HPV testing will be essential to ensuring all patients benefit from these innovations.
 

Dr. Wheat is Vice Chair of Diversity, Equity, and Inclusion, Department of Family and Community Medicine and Associate Professor, Family and Community Medicine Feinberg School of Medicine, Northwestern University, Chicago. She serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].

References

Daponte N et al. HPV-Based Self-Sampling in Cervical Cancer Screening: An Updated Review of the Current Evidence in the Literature. Cancers (Basel). 2023 Mar 8;15(6):1669.

Di Gennaro G et al. Does self-sampling for human papilloma virus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials. Front Public Health. 2022 Dec 8;10:1003461.

US Preventive Services Task Force. Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(7):674-686.

Human papillomavirus (HPV) is one of the most common sexually transmitted infections and persistent infection with high-risk strains is the leading cause of cervical cancer. Fortunately, vaccines are available to prevent many HPV-related diseases, but they haven’t fully eliminated the risks. Cervical cancer screening remains essential for early detection and prevention.

The US Preventive Services Task Force (USPSTF) currently recommends regular cervical cancer screenings for women aged 21-65. These screenings can include a Pap test every 3 years, a combination of HPV testing and Pap smear every 5 years, or high-risk HPV testing alone every 5 years, depending on age and individual risk factors.

Although these guidelines are currently under review, routine screenings have been instrumental in reducing cervical cancer rates. However, many patients still face barriers that prevent them from accessing these services. Common challenges include discomfort with pelvic exams, lack of time, and limited access to healthcare services. In recent years, advancements in home-based diagnostic testing have opened new avenues for preventative care.

Home HPV testing is one such advancement, offering an alternative to traditional in-office screening methods. While the US Food and Drug Administration (FDA) has not yet approved home HPV testing, self-collection in clinical settings is available and gaining traction. Primary care physicians can integrate this self-collection method into their practices, helping to close the screening gap, especially for underserved populations.

If approved, home HPV testing could be a game-changer for patients who have difficulty attending in-person visits. Geographical barriers, transportation issues, and personal discomfort with in-office exams can prevent patients from receiving the care they need. Home testing eliminates many of these hurdles, enabling patients to perform the test in the comfort of their own homes at a time that works for them. This flexibility is particularly beneficial for rural and underserved populations, where access to healthcare is limited.

Similarly, in-office self-collection offers a comfortable alternative for those who find traditional pelvic exams uncomfortable or distressing. Self-administered HPV tests allow patients to take control of their cervical cancer screening, fostering empowerment and personal responsibility for their health. By reducing the discomfort and inconvenience of traditional screening, self-collection can improve adherence to screening guidelines, leading to earlier detection and prevention of cervical cancer.

Primary care physicians may soon offer both in-office and at-home testing options, tailoring the approach to each patient’s unique needs. Virtual appointments provide an excellent opportunity to educate patients about the importance of cervical cancer screening and offer guidance on using home HPV testing kits. This personalized care ensures patients feel supported even without in-person visits. If home testing becomes FDA approved, patients could receive test kits by mail, perform the test, and send it back to the lab for analysis. For those with positive results, primary care physicians can ensure timely follow-up, including Pap smears or colposcopies, to further evaluate cervical health.

Although home HPV testing offers many benefits, there are valid concerns about accuracy and follow-up care. Studies show that self-collected samples for HPV testing are highly accurate, with sensitivity and specificity comparable with clinician-collected samples, echoing the success of self-swabbing for other sexually transmitted infections.

It is crucial, however, that patients receive clear instructions on proper sample collection to maintain this accuracy. Follow-up care is another essential aspect of the screening process. While many HPV infections resolve on their own, high-risk strains require closer monitoring to prevent progression to cervical cancer. Primary care physicians must establish clear protocols for notifying patients of their results and ensuring appropriate follow-up appointments.

Additionally, there may be concerns about the cost and insurance coverage of home HPV tests. However, home testing could prove more cost-effective than multiple in-office visits, especially when factoring in travel expenses and missed work. Physicians should work to make home testing accessible to all patients, including those in low-income and rural communities.

Should these options become more widely available, it will be important to communicate that this does not fully eliminate the need for pelvic exams. As primary care physicians, we will still need to advise patients that they should bring up concerns of vaginal bleeding, vaginal discharge, and other symptoms. Pelvic exams will still be necessary for diagnosis when symptoms are present. Home HPV tests also will not replace in-office clinician collected exams for those who do not feel comfortable with self-collection.

Home and in-office self-collection for HPV testing are promising tools for improving cervical cancer screening rates and patient satisfaction. By offering a convenient, private, and accessible option, primary care physicians can help more patients stay on track with their preventive care and reduce their risk of cervical cancer. As this technology continues to evolve, embracing both in-office and home HPV testing will be essential to ensuring all patients benefit from these innovations.
 

Dr. Wheat is Vice Chair of Diversity, Equity, and Inclusion, Department of Family and Community Medicine and Associate Professor, Family and Community Medicine Feinberg School of Medicine, Northwestern University, Chicago. She serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].

References

Daponte N et al. HPV-Based Self-Sampling in Cervical Cancer Screening: An Updated Review of the Current Evidence in the Literature. Cancers (Basel). 2023 Mar 8;15(6):1669.

Di Gennaro G et al. Does self-sampling for human papilloma virus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials. Front Public Health. 2022 Dec 8;10:1003461.

US Preventive Services Task Force. Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(7):674-686.

Human papillomavirus (HPV) is one of the most common sexually transmitted infections and persistent infection with high-risk strains is the leading cause of cervical cancer. Fortunately, vaccines are available to prevent many HPV-related diseases, but they haven’t fully eliminated the risks. Cervical cancer screening remains essential for early detection and prevention.

The US Preventive Services Task Force (USPSTF) currently recommends regular cervical cancer screenings for women aged 21-65. These screenings can include a Pap test every 3 years, a combination of HPV testing and Pap smear every 5 years, or high-risk HPV testing alone every 5 years, depending on age and individual risk factors.

Although these guidelines are currently under review, routine screenings have been instrumental in reducing cervical cancer rates. However, many patients still face barriers that prevent them from accessing these services. Common challenges include discomfort with pelvic exams, lack of time, and limited access to healthcare services. In recent years, advancements in home-based diagnostic testing have opened new avenues for preventative care.

Home HPV testing is one such advancement, offering an alternative to traditional in-office screening methods. While the US Food and Drug Administration (FDA) has not yet approved home HPV testing, self-collection in clinical settings is available and gaining traction. Primary care physicians can integrate this self-collection method into their practices, helping to close the screening gap, especially for underserved populations.

If approved, home HPV testing could be a game-changer for patients who have difficulty attending in-person visits. Geographical barriers, transportation issues, and personal discomfort with in-office exams can prevent patients from receiving the care they need. Home testing eliminates many of these hurdles, enabling patients to perform the test in the comfort of their own homes at a time that works for them. This flexibility is particularly beneficial for rural and underserved populations, where access to healthcare is limited.

Similarly, in-office self-collection offers a comfortable alternative for those who find traditional pelvic exams uncomfortable or distressing. Self-administered HPV tests allow patients to take control of their cervical cancer screening, fostering empowerment and personal responsibility for their health. By reducing the discomfort and inconvenience of traditional screening, self-collection can improve adherence to screening guidelines, leading to earlier detection and prevention of cervical cancer.

Primary care physicians may soon offer both in-office and at-home testing options, tailoring the approach to each patient’s unique needs. Virtual appointments provide an excellent opportunity to educate patients about the importance of cervical cancer screening and offer guidance on using home HPV testing kits. This personalized care ensures patients feel supported even without in-person visits. If home testing becomes FDA approved, patients could receive test kits by mail, perform the test, and send it back to the lab for analysis. For those with positive results, primary care physicians can ensure timely follow-up, including Pap smears or colposcopies, to further evaluate cervical health.

Although home HPV testing offers many benefits, there are valid concerns about accuracy and follow-up care. Studies show that self-collected samples for HPV testing are highly accurate, with sensitivity and specificity comparable with clinician-collected samples, echoing the success of self-swabbing for other sexually transmitted infections.

It is crucial, however, that patients receive clear instructions on proper sample collection to maintain this accuracy. Follow-up care is another essential aspect of the screening process. While many HPV infections resolve on their own, high-risk strains require closer monitoring to prevent progression to cervical cancer. Primary care physicians must establish clear protocols for notifying patients of their results and ensuring appropriate follow-up appointments.

Additionally, there may be concerns about the cost and insurance coverage of home HPV tests. However, home testing could prove more cost-effective than multiple in-office visits, especially when factoring in travel expenses and missed work. Physicians should work to make home testing accessible to all patients, including those in low-income and rural communities.

Should these options become more widely available, it will be important to communicate that this does not fully eliminate the need for pelvic exams. As primary care physicians, we will still need to advise patients that they should bring up concerns of vaginal bleeding, vaginal discharge, and other symptoms. Pelvic exams will still be necessary for diagnosis when symptoms are present. Home HPV tests also will not replace in-office clinician collected exams for those who do not feel comfortable with self-collection.

Home and in-office self-collection for HPV testing are promising tools for improving cervical cancer screening rates and patient satisfaction. By offering a convenient, private, and accessible option, primary care physicians can help more patients stay on track with their preventive care and reduce their risk of cervical cancer. As this technology continues to evolve, embracing both in-office and home HPV testing will be essential to ensuring all patients benefit from these innovations.
 

Dr. Wheat is Vice Chair of Diversity, Equity, and Inclusion, Department of Family and Community Medicine and Associate Professor, Family and Community Medicine Feinberg School of Medicine, Northwestern University, Chicago. She serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].

References

Daponte N et al. HPV-Based Self-Sampling in Cervical Cancer Screening: An Updated Review of the Current Evidence in the Literature. Cancers (Basel). 2023 Mar 8;15(6):1669.

Di Gennaro G et al. Does self-sampling for human papilloma virus testing have the potential to increase cervical cancer screening? An updated meta-analysis of observational studies and randomized clinical trials. Front Public Health. 2022 Dec 8;10:1003461.

US Preventive Services Task Force. Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(7):674-686.

When prescribing glucagon-like peptide 1 (GLP-1) medications, many physicians prefer tirzepatide over the more well-known semaglutide due to its superior efficacy in weight loss and A1c reduction. Studies indicated that tirzepatide can lead to greater weight loss than semaglutide.

Factors like insurance coverage, drug availability, and side effects also influence physicians’ choices, with some patients benefiting from the broader dosing options that tirzepatide offers.

In this Q&A, Medscape Medical News explored how physicians can make the best decisions with their patients when choosing between GLP-1 medications tirzepatide and semaglutide for the treatment for type 2 diabetes and obesity.

We spoke to physicians who specialize in medical weight loss on things to consider when choosing between these two medications, such as patient profiles, drug access and availability, and financial considerations. We also discussed the side effect profiles of the medications based on current data in the literature.
 

Medscape Medical News: How are you deciding which of the two drugs to prescribe?

Caroline Messer, MD, endocrinologist at Lenox Hill Hospital, Northwell, New York City: To some degree, it’s based on insurance. But in general, I’m pushing most patients toward tirzepatide just because the data show that there’s more weight loss and more A1c reduction on tirzepatide. But the research shows that there are more side effects. But I think every practicing clinician who uses these medications knows that there are actually fewer side effects despite what the trial showed.

Sue Decotiis, MD, weight loss doctor, New York City: I think that many doctors that are prescribing these drugs are not really weight loss specialists. It’s just like one of many drugs that they prescribe. And semaglutide (Ozempic) is more well known. I think it’s because they don’t really know that it’s not as good as the other drugs. There are still massive shortages of these drugs. So that’s another reason why a doctor may choose one drug over another. Also, if a patient’s reliant on insurance to cover it, they may go with whatever the insurance company is willing to cover.

Kathleen Dungan, MD, professor of internal medicine, Division of Endocrinology, Diabetes and Metabolism, The Ohio State University Wexner Medical Center and College of Medicine: Some patients may have preferences with the delivery device. In the past year, in particular, availability of these drugs was limited and varied from time to time and geographically, and therefore, patients needed to substitute one drug for another in order to maintain treatment.

Maria Teresa Anton, MD, endocrinologist and educator, Pritikin Longevity Center, Miami: While I do not prescribe these medications, I do focus on integrating them into a comprehensive lifestyle program that empowers patients to make sustainable changes. By fostering an environment of education and support, we enhance their well-being and promote long-term health outcomes. In my practice, I’ve found that the most successful outcomes occur when these medications are combined with a comprehensive approach, including dietary changes, physical activity, and behavioral support.
 

Medscape Medical News: How do you make the decision of tirzepatide vs semaglutide?

Messer: There’s no guideline per se. Sometimes when I don’t want a patient to lose too much weight, I might consider Ozempic or Wegovy if you know they only have 5 lb to lose. If diabetes, then I might go for the Ozempic instead, just because the weight loss is so drastic with tirzepatide with any kind of appetite.

Decotiis: If somebody has a lot of weight to lose and they’re highly insulin resistant, as most people are when they start these drugs, I really prefer tirzepatide ... because I think patients are going to lose more weight, they’re going to lose more fat. I also see that patients have less side effects because before tirzepatide came out, I was prescribing mostly semaglutide, and there were a lot of side effects. But semaglutide is fine. I mean, it’s a good drug. Maybe it’s better for people that don’t have as much weight to lose. So I don’t have to worry about them hitting that wall after a certain period of time. But it’s a good drug. I mean, I certainly still use it.
 

Medscape Medical News: What of the data and the literature on the differences in the outcomes and the side effect profile?

Messer: In terms of outcomes, the weight loss is almost double [with tirzepatide]. It depends what trial you’re looking at, but we tend to see like about 15% of your body weight you lose with the semaglutide and 25%-30% with the tirzepatide. The big difference, I suppose…is semaglutide now has a cardiovascular indication and the tirzepatide doesn’t, but I’m very confident that tirzepatide is going to get the same indication.

Decotiis: When that first Lilly study came out in June of 2022, it really blew everybody away. I mean, some patients lost up to 25% of their weight on tirzepatide, whereas on Ozempic, it was really like 15%. Now, in my practice, I really monitor everyone with a body composition scale. I’m not just looking at somebody’s weight or body mass index, I am looking at how much body fat they have, how much muscle mass they have, how much water they have, and how much bone they have.

The golden rule here is make sure the patient loses fat, and you want to make sure they’re not losing muscle or too much water. The patient really needs to be adequately hydrated. So what I’m saying is a lot of people who have lost weight have not reached the promised land because they haven’t lost enough body fat to get them into that healthy zone. But once they reduce the body fat to a certain percentage, let’s say for a woman about 20%, or a man in the low teens, they’re less likely to regain that weight because they haven’t really lost fat. And that’s how we gain health.
 

A version of this article first appeared on Medscape.com.

When prescribing glucagon-like peptide 1 (GLP-1) medications, many physicians prefer tirzepatide over the more well-known semaglutide due to its superior efficacy in weight loss and A1c reduction. Studies indicated that tirzepatide can lead to greater weight loss than semaglutide.

Factors like insurance coverage, drug availability, and side effects also influence physicians’ choices, with some patients benefiting from the broader dosing options that tirzepatide offers.

In this Q&A, Medscape Medical News explored how physicians can make the best decisions with their patients when choosing between GLP-1 medications tirzepatide and semaglutide for the treatment for type 2 diabetes and obesity.

We spoke to physicians who specialize in medical weight loss on things to consider when choosing between these two medications, such as patient profiles, drug access and availability, and financial considerations. We also discussed the side effect profiles of the medications based on current data in the literature.
 

Medscape Medical News: How are you deciding which of the two drugs to prescribe?

Caroline Messer, MD, endocrinologist at Lenox Hill Hospital, Northwell, New York City: To some degree, it’s based on insurance. But in general, I’m pushing most patients toward tirzepatide just because the data show that there’s more weight loss and more A1c reduction on tirzepatide. But the research shows that there are more side effects. But I think every practicing clinician who uses these medications knows that there are actually fewer side effects despite what the trial showed.

Sue Decotiis, MD, weight loss doctor, New York City: I think that many doctors that are prescribing these drugs are not really weight loss specialists. It’s just like one of many drugs that they prescribe. And semaglutide (Ozempic) is more well known. I think it’s because they don’t really know that it’s not as good as the other drugs. There are still massive shortages of these drugs. So that’s another reason why a doctor may choose one drug over another. Also, if a patient’s reliant on insurance to cover it, they may go with whatever the insurance company is willing to cover.

Kathleen Dungan, MD, professor of internal medicine, Division of Endocrinology, Diabetes and Metabolism, The Ohio State University Wexner Medical Center and College of Medicine: Some patients may have preferences with the delivery device. In the past year, in particular, availability of these drugs was limited and varied from time to time and geographically, and therefore, patients needed to substitute one drug for another in order to maintain treatment.

Maria Teresa Anton, MD, endocrinologist and educator, Pritikin Longevity Center, Miami: While I do not prescribe these medications, I do focus on integrating them into a comprehensive lifestyle program that empowers patients to make sustainable changes. By fostering an environment of education and support, we enhance their well-being and promote long-term health outcomes. In my practice, I’ve found that the most successful outcomes occur when these medications are combined with a comprehensive approach, including dietary changes, physical activity, and behavioral support.
 

Medscape Medical News: How do you make the decision of tirzepatide vs semaglutide?

Messer: There’s no guideline per se. Sometimes when I don’t want a patient to lose too much weight, I might consider Ozempic or Wegovy if you know they only have 5 lb to lose. If diabetes, then I might go for the Ozempic instead, just because the weight loss is so drastic with tirzepatide with any kind of appetite.

Decotiis: If somebody has a lot of weight to lose and they’re highly insulin resistant, as most people are when they start these drugs, I really prefer tirzepatide ... because I think patients are going to lose more weight, they’re going to lose more fat. I also see that patients have less side effects because before tirzepatide came out, I was prescribing mostly semaglutide, and there were a lot of side effects. But semaglutide is fine. I mean, it’s a good drug. Maybe it’s better for people that don’t have as much weight to lose. So I don’t have to worry about them hitting that wall after a certain period of time. But it’s a good drug. I mean, I certainly still use it.
 

Medscape Medical News: What of the data and the literature on the differences in the outcomes and the side effect profile?

Messer: In terms of outcomes, the weight loss is almost double [with tirzepatide]. It depends what trial you’re looking at, but we tend to see like about 15% of your body weight you lose with the semaglutide and 25%-30% with the tirzepatide. The big difference, I suppose…is semaglutide now has a cardiovascular indication and the tirzepatide doesn’t, but I’m very confident that tirzepatide is going to get the same indication.

Decotiis: When that first Lilly study came out in June of 2022, it really blew everybody away. I mean, some patients lost up to 25% of their weight on tirzepatide, whereas on Ozempic, it was really like 15%. Now, in my practice, I really monitor everyone with a body composition scale. I’m not just looking at somebody’s weight or body mass index, I am looking at how much body fat they have, how much muscle mass they have, how much water they have, and how much bone they have.

The golden rule here is make sure the patient loses fat, and you want to make sure they’re not losing muscle or too much water. The patient really needs to be adequately hydrated. So what I’m saying is a lot of people who have lost weight have not reached the promised land because they haven’t lost enough body fat to get them into that healthy zone. But once they reduce the body fat to a certain percentage, let’s say for a woman about 20%, or a man in the low teens, they’re less likely to regain that weight because they haven’t really lost fat. And that’s how we gain health.
 

A version of this article first appeared on Medscape.com.

When prescribing glucagon-like peptide 1 (GLP-1) medications, many physicians prefer tirzepatide over the more well-known semaglutide due to its superior efficacy in weight loss and A1c reduction. Studies indicated that tirzepatide can lead to greater weight loss than semaglutide.

Factors like insurance coverage, drug availability, and side effects also influence physicians’ choices, with some patients benefiting from the broader dosing options that tirzepatide offers.

In this Q&A, Medscape Medical News explored how physicians can make the best decisions with their patients when choosing between GLP-1 medications tirzepatide and semaglutide for the treatment for type 2 diabetes and obesity.

We spoke to physicians who specialize in medical weight loss on things to consider when choosing between these two medications, such as patient profiles, drug access and availability, and financial considerations. We also discussed the side effect profiles of the medications based on current data in the literature.
 

Medscape Medical News: How are you deciding which of the two drugs to prescribe?

Caroline Messer, MD, endocrinologist at Lenox Hill Hospital, Northwell, New York City: To some degree, it’s based on insurance. But in general, I’m pushing most patients toward tirzepatide just because the data show that there’s more weight loss and more A1c reduction on tirzepatide. But the research shows that there are more side effects. But I think every practicing clinician who uses these medications knows that there are actually fewer side effects despite what the trial showed.

Sue Decotiis, MD, weight loss doctor, New York City: I think that many doctors that are prescribing these drugs are not really weight loss specialists. It’s just like one of many drugs that they prescribe. And semaglutide (Ozempic) is more well known. I think it’s because they don’t really know that it’s not as good as the other drugs. There are still massive shortages of these drugs. So that’s another reason why a doctor may choose one drug over another. Also, if a patient’s reliant on insurance to cover it, they may go with whatever the insurance company is willing to cover.

Kathleen Dungan, MD, professor of internal medicine, Division of Endocrinology, Diabetes and Metabolism, The Ohio State University Wexner Medical Center and College of Medicine: Some patients may have preferences with the delivery device. In the past year, in particular, availability of these drugs was limited and varied from time to time and geographically, and therefore, patients needed to substitute one drug for another in order to maintain treatment.

Maria Teresa Anton, MD, endocrinologist and educator, Pritikin Longevity Center, Miami: While I do not prescribe these medications, I do focus on integrating them into a comprehensive lifestyle program that empowers patients to make sustainable changes. By fostering an environment of education and support, we enhance their well-being and promote long-term health outcomes. In my practice, I’ve found that the most successful outcomes occur when these medications are combined with a comprehensive approach, including dietary changes, physical activity, and behavioral support.
 

Medscape Medical News: How do you make the decision of tirzepatide vs semaglutide?

Messer: There’s no guideline per se. Sometimes when I don’t want a patient to lose too much weight, I might consider Ozempic or Wegovy if you know they only have 5 lb to lose. If diabetes, then I might go for the Ozempic instead, just because the weight loss is so drastic with tirzepatide with any kind of appetite.

Decotiis: If somebody has a lot of weight to lose and they’re highly insulin resistant, as most people are when they start these drugs, I really prefer tirzepatide ... because I think patients are going to lose more weight, they’re going to lose more fat. I also see that patients have less side effects because before tirzepatide came out, I was prescribing mostly semaglutide, and there were a lot of side effects. But semaglutide is fine. I mean, it’s a good drug. Maybe it’s better for people that don’t have as much weight to lose. So I don’t have to worry about them hitting that wall after a certain period of time. But it’s a good drug. I mean, I certainly still use it.
 

Medscape Medical News: What of the data and the literature on the differences in the outcomes and the side effect profile?

Messer: In terms of outcomes, the weight loss is almost double [with tirzepatide]. It depends what trial you’re looking at, but we tend to see like about 15% of your body weight you lose with the semaglutide and 25%-30% with the tirzepatide. The big difference, I suppose…is semaglutide now has a cardiovascular indication and the tirzepatide doesn’t, but I’m very confident that tirzepatide is going to get the same indication.

Decotiis: When that first Lilly study came out in June of 2022, it really blew everybody away. I mean, some patients lost up to 25% of their weight on tirzepatide, whereas on Ozempic, it was really like 15%. Now, in my practice, I really monitor everyone with a body composition scale. I’m not just looking at somebody’s weight or body mass index, I am looking at how much body fat they have, how much muscle mass they have, how much water they have, and how much bone they have.

The golden rule here is make sure the patient loses fat, and you want to make sure they’re not losing muscle or too much water. The patient really needs to be adequately hydrated. So what I’m saying is a lot of people who have lost weight have not reached the promised land because they haven’t lost enough body fat to get them into that healthy zone. But once they reduce the body fat to a certain percentage, let’s say for a woman about 20%, or a man in the low teens, they’re less likely to regain that weight because they haven’t really lost fat. And that’s how we gain health.
 

A version of this article first appeared on Medscape.com.

Sarah, a new mom who’s thrilled about her 3-month-old baby, is struggling with her sex life. Her once vibrant physical relationship with her partner has dwindled, and she’s dealing with painful intercourse and a notable drop in desire.

Pregnancy and childbirth are transformative experiences that affect every facet of a person’s life, including their sexual well-being. Despite this fact, clinicians frequently ignore sexual well-being, beyond contraception, in prenatal and postpartum care. In peripartum care, anticipatory guidance is recognized to be crucial to the well-being of new parents and their babies. Why should sexual well-being get the shaft? 
 

Why Talk About Sex?

Sex is a fundamental aspect of many people’s lives and relationships and can significantly affect overall well-being. Despite cultural narratives that often exclude the sexual function and pleasure aspect of sexual health from peripartum discussions, many new parents face sexual challenges that can worsen their physical and emotional health.

While up to 88% of new parents report problems with sexual well-being, less than 30% report receiving anticipatory guidance about sexual function changes. One study found only 15% of postpartum women reported discussing sexual concerns with their medical providers. And, when new parents receive more information about sexual health, they tend to report improved sexual well-being. Clearly, a gap needs bridging.

Sexual health doesn’t just affect individual well-being; it intertwines with relationship satisfaction. Attending to satisfaction in one’s relationship may be an important component of child health as well. 

Declines in the frequency of sexual engagement and desire are common after childbirth. Changes in arousal, orgasm, and sexual pleasure, often accompanied by pain, are also reported by many women. Some birthing parents report changes to the sensation of their genitals that are thought to be related to stretch of the pudendal nerve during parturition. Most experience resolution of these concerns within the first year after childbirth, although some women report persistent problems, including up to 33% with persistent sexual pain.

Many factors can contribute to postpartum sexual issues, including hormonal changes, body image concerns, and mental health conditions. Breastfeeding, for instance, can lead to vaginal dryness and reduced sexual arousal due to hormonal shifts. Body image issues and mood disorders like depression and anxiety can also adversely affect sexual function. Women with postpartum depression are more likely to experience sexual concerns, and the relationship between sexual difficulties and depression can be bidirectional.
 

Empowerment and Expectations

One commonly cited recommendation is to wait until 6 weeks postpartum before resuming penetrative intercourse after a normal vaginal delivery. However, this guideline lacks robust scientific backing. Many people might feel ready for sexual intercourse much sooner or, conversely, might not feel comfortable at the 6-week mark. As clinicians, we must empower our patients to trust their own bodies and make decisions based on their comfort and readiness.

The 6-week advice can sometimes unintentionally convey to women that they are not experts on their own bodies, or that any kind of sex is risky. Acknowledging the recovery timeline for every person is unique and various forms of sexual expression are safe can help foster a healthier approach to resuming sexual activities. In one study of postpartum sexual behavior, in the first 6 weeks after delivery, the most common kinds of sexual play included giving oral sex to a partner and solo sex. Between 80% and 90% have resumed vaginal-receiving sexual play (including intercourse) by 3 months. 

While recognizing that changes to sexual experience occur, we need to reinforce that gradual recovery is expected. And if women express distress about a sexual change, or if those changes persist, primary care providers should be prepared to help them with their concerns. 

Parents need to know experiencing pain is not something they should “just deal with” or ignore. Attempting to repeatedly endure sexual pain can cause new issues, such as high-tone dysfunction of the pelvic floor or an understandable decrease in willingness or receptiveness to sexual play of any kind. Encouraging open communication about these issues can help couples navigate these changes more smoothly.

Partners, especially new fathers, also experience sexual and emotional challenges. They can feel blindsided by the changes in their relationship and might struggle with feelings of jealousy or inadequacy. Understanding partners also face difficulties can help in providing a more comprehensive approach to sexual health care.
 

Starting the Conversation

So, how can we initiate these important conversations with new parents? Start by providing permission. As healthcare providers, we need to create an environment where discussing sexual health is normalized and welcomed. Simple, nonjudgmental statements can open the door to these discussions. For example, saying, “Many people notice changes in their sexual desire or pleasure after childbirth. Has anything like this happened to you or your partner?” can encourage patients to share their concerns.

Assessing the importance to patients of sexual problems can help direct the need for intervention. Follow up on these concerns and offer support, whether through counseling, pelvic floor physical therapy, or a referral to a sexual medicine specialist, a sex therapist, or other appropriate resource.

Let’s return to Sarah. In the ideal world, at 3 months postpartum she will already have had a handful of clinical conversations about her sexual well-being with her healthcare team — at prenatal visits, at well-baby visits, and at her postpartum checkups. Several of these conversations included her partner. They both understand the transition to parenthood could be rocky for their sex lives. They’ve set aside time to connect and stay physically close. She’s listened to her body and only engaged in sexual play for which she feels ready. Now, noting that some aspects of sexual play are persistently uncomfortable, she knows it’s time to follow up. Without shame or anxiety, she books an appointment with you, knowing that you understand how important this issue is for her, her partner, and her baby. 

If you’re working with new parents, remember: Open dialogue about sexual health is not just beneficial — it’s essential. Let’s bridge the gap in care by embracing these conversations and offering the support new parents truly need.
 

Dr. Kranz, Clinical Assistant Professor of Obstetrics/Gynecology and Family Medicine, University of Rochester Medical Center, Rochester, New York, has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Sarah, a new mom who’s thrilled about her 3-month-old baby, is struggling with her sex life. Her once vibrant physical relationship with her partner has dwindled, and she’s dealing with painful intercourse and a notable drop in desire.

Pregnancy and childbirth are transformative experiences that affect every facet of a person’s life, including their sexual well-being. Despite this fact, clinicians frequently ignore sexual well-being, beyond contraception, in prenatal and postpartum care. In peripartum care, anticipatory guidance is recognized to be crucial to the well-being of new parents and their babies. Why should sexual well-being get the shaft? 
 

Why Talk About Sex?

Sex is a fundamental aspect of many people’s lives and relationships and can significantly affect overall well-being. Despite cultural narratives that often exclude the sexual function and pleasure aspect of sexual health from peripartum discussions, many new parents face sexual challenges that can worsen their physical and emotional health.

While up to 88% of new parents report problems with sexual well-being, less than 30% report receiving anticipatory guidance about sexual function changes. One study found only 15% of postpartum women reported discussing sexual concerns with their medical providers. And, when new parents receive more information about sexual health, they tend to report improved sexual well-being. Clearly, a gap needs bridging.

Sexual health doesn’t just affect individual well-being; it intertwines with relationship satisfaction. Attending to satisfaction in one’s relationship may be an important component of child health as well. 

Declines in the frequency of sexual engagement and desire are common after childbirth. Changes in arousal, orgasm, and sexual pleasure, often accompanied by pain, are also reported by many women. Some birthing parents report changes to the sensation of their genitals that are thought to be related to stretch of the pudendal nerve during parturition. Most experience resolution of these concerns within the first year after childbirth, although some women report persistent problems, including up to 33% with persistent sexual pain.

Many factors can contribute to postpartum sexual issues, including hormonal changes, body image concerns, and mental health conditions. Breastfeeding, for instance, can lead to vaginal dryness and reduced sexual arousal due to hormonal shifts. Body image issues and mood disorders like depression and anxiety can also adversely affect sexual function. Women with postpartum depression are more likely to experience sexual concerns, and the relationship between sexual difficulties and depression can be bidirectional.
 

Empowerment and Expectations

One commonly cited recommendation is to wait until 6 weeks postpartum before resuming penetrative intercourse after a normal vaginal delivery. However, this guideline lacks robust scientific backing. Many people might feel ready for sexual intercourse much sooner or, conversely, might not feel comfortable at the 6-week mark. As clinicians, we must empower our patients to trust their own bodies and make decisions based on their comfort and readiness.

The 6-week advice can sometimes unintentionally convey to women that they are not experts on their own bodies, or that any kind of sex is risky. Acknowledging the recovery timeline for every person is unique and various forms of sexual expression are safe can help foster a healthier approach to resuming sexual activities. In one study of postpartum sexual behavior, in the first 6 weeks after delivery, the most common kinds of sexual play included giving oral sex to a partner and solo sex. Between 80% and 90% have resumed vaginal-receiving sexual play (including intercourse) by 3 months. 

While recognizing that changes to sexual experience occur, we need to reinforce that gradual recovery is expected. And if women express distress about a sexual change, or if those changes persist, primary care providers should be prepared to help them with their concerns. 

Parents need to know experiencing pain is not something they should “just deal with” or ignore. Attempting to repeatedly endure sexual pain can cause new issues, such as high-tone dysfunction of the pelvic floor or an understandable decrease in willingness or receptiveness to sexual play of any kind. Encouraging open communication about these issues can help couples navigate these changes more smoothly.

Partners, especially new fathers, also experience sexual and emotional challenges. They can feel blindsided by the changes in their relationship and might struggle with feelings of jealousy or inadequacy. Understanding partners also face difficulties can help in providing a more comprehensive approach to sexual health care.
 

Starting the Conversation

So, how can we initiate these important conversations with new parents? Start by providing permission. As healthcare providers, we need to create an environment where discussing sexual health is normalized and welcomed. Simple, nonjudgmental statements can open the door to these discussions. For example, saying, “Many people notice changes in their sexual desire or pleasure after childbirth. Has anything like this happened to you or your partner?” can encourage patients to share their concerns.

Assessing the importance to patients of sexual problems can help direct the need for intervention. Follow up on these concerns and offer support, whether through counseling, pelvic floor physical therapy, or a referral to a sexual medicine specialist, a sex therapist, or other appropriate resource.

Let’s return to Sarah. In the ideal world, at 3 months postpartum she will already have had a handful of clinical conversations about her sexual well-being with her healthcare team — at prenatal visits, at well-baby visits, and at her postpartum checkups. Several of these conversations included her partner. They both understand the transition to parenthood could be rocky for their sex lives. They’ve set aside time to connect and stay physically close. She’s listened to her body and only engaged in sexual play for which she feels ready. Now, noting that some aspects of sexual play are persistently uncomfortable, she knows it’s time to follow up. Without shame or anxiety, she books an appointment with you, knowing that you understand how important this issue is for her, her partner, and her baby. 

If you’re working with new parents, remember: Open dialogue about sexual health is not just beneficial — it’s essential. Let’s bridge the gap in care by embracing these conversations and offering the support new parents truly need.
 

Dr. Kranz, Clinical Assistant Professor of Obstetrics/Gynecology and Family Medicine, University of Rochester Medical Center, Rochester, New York, has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Sarah, a new mom who’s thrilled about her 3-month-old baby, is struggling with her sex life. Her once vibrant physical relationship with her partner has dwindled, and she’s dealing with painful intercourse and a notable drop in desire.

Pregnancy and childbirth are transformative experiences that affect every facet of a person’s life, including their sexual well-being. Despite this fact, clinicians frequently ignore sexual well-being, beyond contraception, in prenatal and postpartum care. In peripartum care, anticipatory guidance is recognized to be crucial to the well-being of new parents and their babies. Why should sexual well-being get the shaft? 
 

Why Talk About Sex?

Sex is a fundamental aspect of many people’s lives and relationships and can significantly affect overall well-being. Despite cultural narratives that often exclude the sexual function and pleasure aspect of sexual health from peripartum discussions, many new parents face sexual challenges that can worsen their physical and emotional health.

While up to 88% of new parents report problems with sexual well-being, less than 30% report receiving anticipatory guidance about sexual function changes. One study found only 15% of postpartum women reported discussing sexual concerns with their medical providers. And, when new parents receive more information about sexual health, they tend to report improved sexual well-being. Clearly, a gap needs bridging.

Sexual health doesn’t just affect individual well-being; it intertwines with relationship satisfaction. Attending to satisfaction in one’s relationship may be an important component of child health as well. 

Declines in the frequency of sexual engagement and desire are common after childbirth. Changes in arousal, orgasm, and sexual pleasure, often accompanied by pain, are also reported by many women. Some birthing parents report changes to the sensation of their genitals that are thought to be related to stretch of the pudendal nerve during parturition. Most experience resolution of these concerns within the first year after childbirth, although some women report persistent problems, including up to 33% with persistent sexual pain.

Many factors can contribute to postpartum sexual issues, including hormonal changes, body image concerns, and mental health conditions. Breastfeeding, for instance, can lead to vaginal dryness and reduced sexual arousal due to hormonal shifts. Body image issues and mood disorders like depression and anxiety can also adversely affect sexual function. Women with postpartum depression are more likely to experience sexual concerns, and the relationship between sexual difficulties and depression can be bidirectional.
 

Empowerment and Expectations

One commonly cited recommendation is to wait until 6 weeks postpartum before resuming penetrative intercourse after a normal vaginal delivery. However, this guideline lacks robust scientific backing. Many people might feel ready for sexual intercourse much sooner or, conversely, might not feel comfortable at the 6-week mark. As clinicians, we must empower our patients to trust their own bodies and make decisions based on their comfort and readiness.

The 6-week advice can sometimes unintentionally convey to women that they are not experts on their own bodies, or that any kind of sex is risky. Acknowledging the recovery timeline for every person is unique and various forms of sexual expression are safe can help foster a healthier approach to resuming sexual activities. In one study of postpartum sexual behavior, in the first 6 weeks after delivery, the most common kinds of sexual play included giving oral sex to a partner and solo sex. Between 80% and 90% have resumed vaginal-receiving sexual play (including intercourse) by 3 months. 

While recognizing that changes to sexual experience occur, we need to reinforce that gradual recovery is expected. And if women express distress about a sexual change, or if those changes persist, primary care providers should be prepared to help them with their concerns. 

Parents need to know experiencing pain is not something they should “just deal with” or ignore. Attempting to repeatedly endure sexual pain can cause new issues, such as high-tone dysfunction of the pelvic floor or an understandable decrease in willingness or receptiveness to sexual play of any kind. Encouraging open communication about these issues can help couples navigate these changes more smoothly.

Partners, especially new fathers, also experience sexual and emotional challenges. They can feel blindsided by the changes in their relationship and might struggle with feelings of jealousy or inadequacy. Understanding partners also face difficulties can help in providing a more comprehensive approach to sexual health care.
 

Starting the Conversation

So, how can we initiate these important conversations with new parents? Start by providing permission. As healthcare providers, we need to create an environment where discussing sexual health is normalized and welcomed. Simple, nonjudgmental statements can open the door to these discussions. For example, saying, “Many people notice changes in their sexual desire or pleasure after childbirth. Has anything like this happened to you or your partner?” can encourage patients to share their concerns.

Assessing the importance to patients of sexual problems can help direct the need for intervention. Follow up on these concerns and offer support, whether through counseling, pelvic floor physical therapy, or a referral to a sexual medicine specialist, a sex therapist, or other appropriate resource.

Let’s return to Sarah. In the ideal world, at 3 months postpartum she will already have had a handful of clinical conversations about her sexual well-being with her healthcare team — at prenatal visits, at well-baby visits, and at her postpartum checkups. Several of these conversations included her partner. They both understand the transition to parenthood could be rocky for their sex lives. They’ve set aside time to connect and stay physically close. She’s listened to her body and only engaged in sexual play for which she feels ready. Now, noting that some aspects of sexual play are persistently uncomfortable, she knows it’s time to follow up. Without shame or anxiety, she books an appointment with you, knowing that you understand how important this issue is for her, her partner, and her baby. 

If you’re working with new parents, remember: Open dialogue about sexual health is not just beneficial — it’s essential. Let’s bridge the gap in care by embracing these conversations and offering the support new parents truly need.
 

Dr. Kranz, Clinical Assistant Professor of Obstetrics/Gynecology and Family Medicine, University of Rochester Medical Center, Rochester, New York, has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Rachel S. Rubin, MD: I’m Dr. Rachel Rubin, a urologist and sexual medicine specialist in the Washington, DC, area. And I am so thrilled because my co-fellow, the brilliant and famous Dr. Ashley Winter, a board-certified urologist and a certified menopause practitioner, who sees patients in our practice from Los Angeles, is joining us today to talk about sex as a vital sign.

Ashley Winter, MD: To have the best sexual function, you need many different systems to work. You need your hormones to be in the right place. You need your blood vessels to dilate when you want them to. You need your nerves to connect to your genitalia to make them responsive. The way people say, “The eyes are the window into the soul” — well, the genitals are the window into the cardiovascular system, the peripheral nervous system, and the hormonal system. It’s so dynamic. Patients can understand how this reflects their health. We just need healthcare providers to hammer home how those things connect.

Rubin: If you’re a primary care doctor seeing a patient and you want to educate them on diabetes or high blood pressure, how can you “ ‘sell it with ‘sex”? How can you use sex to educate them about these important medical conditions?

Winter: I hate using it as a fear tactic, but sometimes you have to. Time and again, I’ve seen men with severe profound erectile dysfunction at a young age, with chronically uncontrolled diabetes.

Diabetes can impair the peripheral nerves, resulting in peripheral neuropathy. The same way that it can affect the fingers and toes, diabetes can affect the penis, even before those other areas. Diabetes can also lead to other conditions such as low testosterone, which also affects the function of the penis.

I’m being brutally honest when I tell patients that diabetes control is critical to having a wonderful sexspan — the duration of your life where you’re able to be sexually active and have great sex and do it in the way that you want.

Chronic conditions such as high cholesterol or hypertension can affect your ability to become erect or aroused whether you have a penis or a vulva, and even your ability to have an orgasm.

Rubin: None of my doctors has ever asked me about these issues. But we have to bring them up with patients because they›re not going to bring them up to us. I always say in the review of systems, we shouldn›t just ask, “Do you have any sexual problems?” (which nobody ever does) and move past the question about men, women or both. We should be asking, “Do you have any issues with libido? Do you want to talk about it? Any issues with erection, arousal, orgasm, or sexual pain?”

When you can talk about those things, you can treat the patient from a whole physiologic perspective. For example, how does their sciatica affect their sexual pain? How does their antidepressant cause a delayed orgasm? How does their low testosterone level affect their energy level, their libido, and their desire? 

We see so much shame and guilt in sexual health, to the extent that patients feel broken. We can help them understand the anatomy and physiology and explain that they aren’t broken. Instead, it’s “You need this medicine for your crippling anxiety, and that’s why your orgasm is delayed, and so can we augment it or add or subtract something to help you with it.”

Winter: In a primary care setting, where we are considering the patient›s overall health, we strive for medication compliance, but a huge part of medication noncompliance is sexual side effects, whether it›s antidepressants, beta-blockers, birth control, or this new world of GLP-1 agonists.

Rubin: I would add breast cancer treatments. Many patients go off their anastrozole or their tamoxifen because of the sexual side effects. 

Winter: This is where we get to the crux of this discussion about sex being a vital sign — something you need to check routinely. We need to become comfortable with it, because then we are unlocking the ability to treat every patient like a whole person, give them better outcomes, improve their compliance, and have a really powerful tool for education.

Rubin: We have a growing toolbox for all genders when it comes to sexual health. We have FDA- approved medications for low libido in women. We use testosterone in men in an evidence-based way to safely improve libido. We use medications to help with the genitourinary syndrome of menopause. Orgasm is a challenging one, but we have devices that can help with those reflexes. And working with people who specialize in sexual pain can be extremely helpful for patients.

Dr. Winter, having practiced in different settings, what would you tell the primary care doctors who don’t want to talk about libido or who minimize sexual complaints because they don’t know how to navigate them?

Winter: I do not envy the challenge of being a primary care provider in the healthcare world we are living in. I think it is the hardest job. The ultimate takeaway is to just normalize the conversation and be able to validate what is happening. Have a few basic tools, and then have referrals. It›s not that you have to have all the time in the world or you have to treat every condition, but you have to start the conversation, be comfortable with it, and then get patients hooked up with the right resources.

Rubin: Every doctor of every kind can connect with patients and try to understand what they care about. What are their goals? What do they want for their families, for their relationships, for their quality of life? And how can we work collaboratively as a team to help them with those things? 

Sex is a huge part of people’s lives. If we don’t ask about it; if we don’t look into it; and if we don’t admit that our physiology, our medications, and our surgeries can affect sexual health and functioning, how can we improve people’s lives? We can do so much as a team when we consider sex as a true vital sign.
 

Dr. Rubin, Assistant Clinical Professor, Department of Urology, Georgetown University, Washington, DC, has disclosed ties with Maternal Medical, Absorption Pharmaceuticals, GlaxoSmithKline, and Endo.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Rachel S. Rubin, MD: I’m Dr. Rachel Rubin, a urologist and sexual medicine specialist in the Washington, DC, area. And I am so thrilled because my co-fellow, the brilliant and famous Dr. Ashley Winter, a board-certified urologist and a certified menopause practitioner, who sees patients in our practice from Los Angeles, is joining us today to talk about sex as a vital sign.

Ashley Winter, MD: To have the best sexual function, you need many different systems to work. You need your hormones to be in the right place. You need your blood vessels to dilate when you want them to. You need your nerves to connect to your genitalia to make them responsive. The way people say, “The eyes are the window into the soul” — well, the genitals are the window into the cardiovascular system, the peripheral nervous system, and the hormonal system. It’s so dynamic. Patients can understand how this reflects their health. We just need healthcare providers to hammer home how those things connect.

Rubin: If you’re a primary care doctor seeing a patient and you want to educate them on diabetes or high blood pressure, how can you “ ‘sell it with ‘sex”? How can you use sex to educate them about these important medical conditions?

Winter: I hate using it as a fear tactic, but sometimes you have to. Time and again, I’ve seen men with severe profound erectile dysfunction at a young age, with chronically uncontrolled diabetes.

Diabetes can impair the peripheral nerves, resulting in peripheral neuropathy. The same way that it can affect the fingers and toes, diabetes can affect the penis, even before those other areas. Diabetes can also lead to other conditions such as low testosterone, which also affects the function of the penis.

I’m being brutally honest when I tell patients that diabetes control is critical to having a wonderful sexspan — the duration of your life where you’re able to be sexually active and have great sex and do it in the way that you want.

Chronic conditions such as high cholesterol or hypertension can affect your ability to become erect or aroused whether you have a penis or a vulva, and even your ability to have an orgasm.

Rubin: None of my doctors has ever asked me about these issues. But we have to bring them up with patients because they›re not going to bring them up to us. I always say in the review of systems, we shouldn›t just ask, “Do you have any sexual problems?” (which nobody ever does) and move past the question about men, women or both. We should be asking, “Do you have any issues with libido? Do you want to talk about it? Any issues with erection, arousal, orgasm, or sexual pain?”

When you can talk about those things, you can treat the patient from a whole physiologic perspective. For example, how does their sciatica affect their sexual pain? How does their antidepressant cause a delayed orgasm? How does their low testosterone level affect their energy level, their libido, and their desire? 

We see so much shame and guilt in sexual health, to the extent that patients feel broken. We can help them understand the anatomy and physiology and explain that they aren’t broken. Instead, it’s “You need this medicine for your crippling anxiety, and that’s why your orgasm is delayed, and so can we augment it or add or subtract something to help you with it.”

Winter: In a primary care setting, where we are considering the patient›s overall health, we strive for medication compliance, but a huge part of medication noncompliance is sexual side effects, whether it›s antidepressants, beta-blockers, birth control, or this new world of GLP-1 agonists.

Rubin: I would add breast cancer treatments. Many patients go off their anastrozole or their tamoxifen because of the sexual side effects. 

Winter: This is where we get to the crux of this discussion about sex being a vital sign — something you need to check routinely. We need to become comfortable with it, because then we are unlocking the ability to treat every patient like a whole person, give them better outcomes, improve their compliance, and have a really powerful tool for education.

Rubin: We have a growing toolbox for all genders when it comes to sexual health. We have FDA- approved medications for low libido in women. We use testosterone in men in an evidence-based way to safely improve libido. We use medications to help with the genitourinary syndrome of menopause. Orgasm is a challenging one, but we have devices that can help with those reflexes. And working with people who specialize in sexual pain can be extremely helpful for patients.

Dr. Winter, having practiced in different settings, what would you tell the primary care doctors who don’t want to talk about libido or who minimize sexual complaints because they don’t know how to navigate them?

Winter: I do not envy the challenge of being a primary care provider in the healthcare world we are living in. I think it is the hardest job. The ultimate takeaway is to just normalize the conversation and be able to validate what is happening. Have a few basic tools, and then have referrals. It›s not that you have to have all the time in the world or you have to treat every condition, but you have to start the conversation, be comfortable with it, and then get patients hooked up with the right resources.

Rubin: Every doctor of every kind can connect with patients and try to understand what they care about. What are their goals? What do they want for their families, for their relationships, for their quality of life? And how can we work collaboratively as a team to help them with those things? 

Sex is a huge part of people’s lives. If we don’t ask about it; if we don’t look into it; and if we don’t admit that our physiology, our medications, and our surgeries can affect sexual health and functioning, how can we improve people’s lives? We can do so much as a team when we consider sex as a true vital sign.
 

Dr. Rubin, Assistant Clinical Professor, Department of Urology, Georgetown University, Washington, DC, has disclosed ties with Maternal Medical, Absorption Pharmaceuticals, GlaxoSmithKline, and Endo.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Rachel S. Rubin, MD: I’m Dr. Rachel Rubin, a urologist and sexual medicine specialist in the Washington, DC, area. And I am so thrilled because my co-fellow, the brilliant and famous Dr. Ashley Winter, a board-certified urologist and a certified menopause practitioner, who sees patients in our practice from Los Angeles, is joining us today to talk about sex as a vital sign.

Ashley Winter, MD: To have the best sexual function, you need many different systems to work. You need your hormones to be in the right place. You need your blood vessels to dilate when you want them to. You need your nerves to connect to your genitalia to make them responsive. The way people say, “The eyes are the window into the soul” — well, the genitals are the window into the cardiovascular system, the peripheral nervous system, and the hormonal system. It’s so dynamic. Patients can understand how this reflects their health. We just need healthcare providers to hammer home how those things connect.

Rubin: If you’re a primary care doctor seeing a patient and you want to educate them on diabetes or high blood pressure, how can you “ ‘sell it with ‘sex”? How can you use sex to educate them about these important medical conditions?

Winter: I hate using it as a fear tactic, but sometimes you have to. Time and again, I’ve seen men with severe profound erectile dysfunction at a young age, with chronically uncontrolled diabetes.

Diabetes can impair the peripheral nerves, resulting in peripheral neuropathy. The same way that it can affect the fingers and toes, diabetes can affect the penis, even before those other areas. Diabetes can also lead to other conditions such as low testosterone, which also affects the function of the penis.

I’m being brutally honest when I tell patients that diabetes control is critical to having a wonderful sexspan — the duration of your life where you’re able to be sexually active and have great sex and do it in the way that you want.

Chronic conditions such as high cholesterol or hypertension can affect your ability to become erect or aroused whether you have a penis or a vulva, and even your ability to have an orgasm.

Rubin: None of my doctors has ever asked me about these issues. But we have to bring them up with patients because they›re not going to bring them up to us. I always say in the review of systems, we shouldn›t just ask, “Do you have any sexual problems?” (which nobody ever does) and move past the question about men, women or both. We should be asking, “Do you have any issues with libido? Do you want to talk about it? Any issues with erection, arousal, orgasm, or sexual pain?”

When you can talk about those things, you can treat the patient from a whole physiologic perspective. For example, how does their sciatica affect their sexual pain? How does their antidepressant cause a delayed orgasm? How does their low testosterone level affect their energy level, their libido, and their desire? 

We see so much shame and guilt in sexual health, to the extent that patients feel broken. We can help them understand the anatomy and physiology and explain that they aren’t broken. Instead, it’s “You need this medicine for your crippling anxiety, and that’s why your orgasm is delayed, and so can we augment it or add or subtract something to help you with it.”

Winter: In a primary care setting, where we are considering the patient›s overall health, we strive for medication compliance, but a huge part of medication noncompliance is sexual side effects, whether it›s antidepressants, beta-blockers, birth control, or this new world of GLP-1 agonists.

Rubin: I would add breast cancer treatments. Many patients go off their anastrozole or their tamoxifen because of the sexual side effects. 

Winter: This is where we get to the crux of this discussion about sex being a vital sign — something you need to check routinely. We need to become comfortable with it, because then we are unlocking the ability to treat every patient like a whole person, give them better outcomes, improve their compliance, and have a really powerful tool for education.

Rubin: We have a growing toolbox for all genders when it comes to sexual health. We have FDA- approved medications for low libido in women. We use testosterone in men in an evidence-based way to safely improve libido. We use medications to help with the genitourinary syndrome of menopause. Orgasm is a challenging one, but we have devices that can help with those reflexes. And working with people who specialize in sexual pain can be extremely helpful for patients.

Dr. Winter, having practiced in different settings, what would you tell the primary care doctors who don’t want to talk about libido or who minimize sexual complaints because they don’t know how to navigate them?

Winter: I do not envy the challenge of being a primary care provider in the healthcare world we are living in. I think it is the hardest job. The ultimate takeaway is to just normalize the conversation and be able to validate what is happening. Have a few basic tools, and then have referrals. It›s not that you have to have all the time in the world or you have to treat every condition, but you have to start the conversation, be comfortable with it, and then get patients hooked up with the right resources.

Rubin: Every doctor of every kind can connect with patients and try to understand what they care about. What are their goals? What do they want for their families, for their relationships, for their quality of life? And how can we work collaboratively as a team to help them with those things? 

Sex is a huge part of people’s lives. If we don’t ask about it; if we don’t look into it; and if we don’t admit that our physiology, our medications, and our surgeries can affect sexual health and functioning, how can we improve people’s lives? We can do so much as a team when we consider sex as a true vital sign.
 

Dr. Rubin, Assistant Clinical Professor, Department of Urology, Georgetown University, Washington, DC, has disclosed ties with Maternal Medical, Absorption Pharmaceuticals, GlaxoSmithKline, and Endo.

A version of this article first appeared on Medscape.com.

Like millions of other modern humans, my daughter and I stood in the backyard recently and watched comet C/2023 A3 (Tsuchinshan–ATLAS) with binoculars. It took a few minutes to locate, but once you see it is unmistakable.

It’s got a long (at least in human terms) orbit, roughly 80,000 years. So what was going on here, on our pale blue dot, the last time it graced our skies?

Well, here in Phoenix, the people were ... not here. Nor were they in Arizona, or North America, or pretty much the entire Western Hemisphere.

In fact, Homo sapiens were confined to Africa. The hardier Neanderthals had successfully moved into Eurasia, but our lineage was just starting to migrate there. There’s some evidence that we numbered maybe 10,000-15,000 at that point. Far more people saw the comet that night in the United States than our entire population count last time it swung by.

But we were moving up in the world. Our ancestors at the time had developed the first forms of jewelry, using seashells. There’s evidence that we’d learned to trade with other, distant, communities. We were using spears to put dinner on the table with less risk to ourselves than clubs posed.

And, in what’s now Kenya, in the same time frame, a pair of grieving parents carefully buried their 3-year-old child, wrapped in a covering and gently placed on a pillow.

Sadly, this isn’t a scene we’re unfamiliar with. Possibly the most famous painting of a physician is “The Doctor” (1891) by Luke Fildes, showing a physician trying to treat a seriously ill child while the parents look on helplessly.

Tate, London 2017

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

Like millions of other modern humans, my daughter and I stood in the backyard recently and watched comet C/2023 A3 (Tsuchinshan–ATLAS) with binoculars. It took a few minutes to locate, but once you see it is unmistakable.

It’s got a long (at least in human terms) orbit, roughly 80,000 years. So what was going on here, on our pale blue dot, the last time it graced our skies?

Well, here in Phoenix, the people were ... not here. Nor were they in Arizona, or North America, or pretty much the entire Western Hemisphere.

In fact, Homo sapiens were confined to Africa. The hardier Neanderthals had successfully moved into Eurasia, but our lineage was just starting to migrate there. There’s some evidence that we numbered maybe 10,000-15,000 at that point. Far more people saw the comet that night in the United States than our entire population count last time it swung by.

But we were moving up in the world. Our ancestors at the time had developed the first forms of jewelry, using seashells. There’s evidence that we’d learned to trade with other, distant, communities. We were using spears to put dinner on the table with less risk to ourselves than clubs posed.

And, in what’s now Kenya, in the same time frame, a pair of grieving parents carefully buried their 3-year-old child, wrapped in a covering and gently placed on a pillow.

Sadly, this isn’t a scene we’re unfamiliar with. Possibly the most famous painting of a physician is “The Doctor” (1891) by Luke Fildes, showing a physician trying to treat a seriously ill child while the parents look on helplessly.

Tate, London 2017

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

Like millions of other modern humans, my daughter and I stood in the backyard recently and watched comet C/2023 A3 (Tsuchinshan–ATLAS) with binoculars. It took a few minutes to locate, but once you see it is unmistakable.

It’s got a long (at least in human terms) orbit, roughly 80,000 years. So what was going on here, on our pale blue dot, the last time it graced our skies?

Well, here in Phoenix, the people were ... not here. Nor were they in Arizona, or North America, or pretty much the entire Western Hemisphere.

In fact, Homo sapiens were confined to Africa. The hardier Neanderthals had successfully moved into Eurasia, but our lineage was just starting to migrate there. There’s some evidence that we numbered maybe 10,000-15,000 at that point. Far more people saw the comet that night in the United States than our entire population count last time it swung by.

But we were moving up in the world. Our ancestors at the time had developed the first forms of jewelry, using seashells. There’s evidence that we’d learned to trade with other, distant, communities. We were using spears to put dinner on the table with less risk to ourselves than clubs posed.

And, in what’s now Kenya, in the same time frame, a pair of grieving parents carefully buried their 3-year-old child, wrapped in a covering and gently placed on a pillow.

Sadly, this isn’t a scene we’re unfamiliar with. Possibly the most famous painting of a physician is “The Doctor” (1891) by Luke Fildes, showing a physician trying to treat a seriously ill child while the parents look on helplessly.

Tate, London 2017

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

A 3-year-old presents to my clinic for evaluation of a possible autism spectrum disorder/difference. He has a history of severe emotional dysregulation, as well as reduced social skills and multiple sensory sensitivities. When I enter the exam room he is watching videos on his mom’s phone, and has some difficulty transitioning to play with toys when I encourage him to do so. He is eventually able to cooperate with my testing, though a bit reluctantly, and scores within the low average range for both language and pre-academic skills. His neurologic exam is within normal limits. He utilizes reasonably well-modulated eye contact paired with some typical use of gestures, and his affect is moderately directed and reactive. He displays typical intonation and prosody of speech, though engages in less spontaneous, imaginative, and reciprocal play than would be expected for his age. His mother reports decreased pretend play at home, minimal interest in toys, and difficulty playing cooperatively with other children.

Upon further history, it becomes apparent that the child spends a majority of his time on electronic devices, and has done so since early toddlerhood. Further dialogue suggests that the family became isolated during the COVID-19 pandemic, and has not yet re-engaged with the community in a meaningful way. The child has had rare opportunity for social interactions with other children, and minimal access to outdoor play. His most severe meltdowns generally involve transitions away from screens, and his overwhelmed parents often resort to use of additional screens to calm him once he is dysregulated.

Oregon Health & Science University (OHSU)

At the end of the visit, through shared decision making, we agree that enrolling the child in a high-quality public preschool will help parents make a concerted effort towards a significant reduction in the hours per day in which the child utilizes electronic devices, while also providing him more exposure to peers. We plan for the child to return in 6 months for a re-evaluation around social-emotional skills, given his current limited exposure to peers and limited “unplugged” play-time.
 

Overutilization of Electronic Devices

As clinicians, we can all see how pervasive the use of electronic devices has become in the lives of the families we care for, as well as in our own lives, and how challenging some aspects of modern parenting have become. The developmental impact of early and excessive use of screens in young children is well documented,¹ but as clinicians it can be tricky to help empower parents to find ways to limit screen time. When parents use screens to comfort and amuse their children during a clinic visit, this situation may serve as an excellent opportunity for a meaningful and respectful conversation around skill deficits which can result from overutilization of electronic devices in young children.

One scenario I often encounter during my patient evaluations as a developmental and behavioral pediatrician is children begging their parents for use of their phone throughout their visits with me. Not infrequently, a child is already on a screen when I enter the exam room, even when there has been a minimal wait time, which often leads to some resistance on behalf of the child as I explain to the family that a significant portion of the visit involves my interactions with the child, testing the child, and observing their child at play. I always provide ample amounts of age-appropriate art supplies, puzzles, fidgets, building toys, and imaginative play items to children during their 30 to 90 minute evaluations, but these are often not appealing to children when they have been very recently engaged with an electronic device. At times I also need to ask caretakers themselves to please disengage from their own electronic devices during the visit so that I can involve them in a detailed discussion about their child.

One challenge with the practice of allowing children access to entertainment on their parent’s smartphones in particular, lies in the fact that these devices are almost always present, meaning there is no natural boundary to inhibit access, in contrast to a television set or stationary computer parked in the family living room. Not dissimilar to candy visible in a parent’s purse, a cell phone becomes a constant temptation for children accustomed to utilizing them at home and public venues, and the incessant begging can wear down already stressed parents.

Children can become conditioned to utilize the distraction of screens to avoid feelings of discomfort or stress, and so can be very persistent and emotional when asking for the use of screens in public settings. Out in the community, I very frequently see young children and toddlers quietly staring at their phones and tablets while at restaurants and stores. While I have empathy for exhausted parents desperate for a moment of quiet, if this type of screen use is the rule rather than the exception for a child, there is risk for missed opportunities for the development of self-regulation skills.

Additionally, I have seen very young children present to my clinic with poor posture and neck pain secondary to chronic smartphone use, and young children who are getting minimal exercise or outdoor time due to excessive screen use, leading to concerns around fine and gross motor skills as well.

While allowing a child to stay occupied with or be soothed by a highly interesting digital experience can create a more calm environment for all, if habitual, this use can come at a cost regarding opportunities for the growth of executive functioning skills, general coping skills, general situational awareness, and experiential learning. Reliance on screens to decrease uncomfortable experiences decreases the opportunity for building distress tolerance, patience, and coping skills.

Of course there are times of extreme distress where a lollipop or bit of screen time might be reasonable to help keep a child safe or further avoid emotional trauma, but in general, other methods of soothing can very often be utilized, and in the long run would serve to increase the child’s general adaptive functioning.
 

A Teachable Moment

When clinicians encounter screens being used by parents to entertain their kids in clinic, it provides a valuable teaching moment around the risks of using screens to keep kids regulated and occupied during life’s less interesting or more anxiety provoking experiences. Having a meaningful conversation about the use of electronic devices with caregivers by clinicians in the exam room can be a delicate dance between providing supportive education while avoiding judgmental tones or verbiage. Normalizing and sympathizing with the difficulty of managing challenging behaviors from children in public spaces can help parents feel less desperate to keep their child quiet at all costs, and thus allow for greater development of coping skills.

Some parents may benefit from learning simple ideas for keeping a child regulated and occupied during times of waiting such as silly songs and dances, verbal games like “I spy,” and clapping routines. For a child with additional sensory or developmental needs, a referral to an occupational therapist to work on emotional regulation by way of specific sensory tools can be helpful. Parent-Child Interaction Therapy for kids ages 2 to 7 can also help build some relational activities and skills that can be utilized during trying situations to help keep a child settled and occupied.

If a child has qualified for Developmental Disability Services (DDS), medical providers can also write “prescriptions’ for sensory calming items which are often covered financially by DDS, such as chewies, weighted vests, stuffed animals, and fidgets. While vilification of all screen time for children is not necessary or helpful, supporting parents as they navigate and implement appropriate boundaries is important for optimizing child development. Encouraging parents to schedule allowed screen time at home in a very predictable and controlled manner is one method to help limit excessive use, as well as it’s utilization as an emotional regulation tool.

For public outings with children with special needs, and in particular in situations where meltdowns are likely to occur, some families find it helpful to dress their children in clothing or accessories that increase community awareness about their child’s condition (such as an autism awareness t-shirt). This effort can also help deflect unhelpful attention or advice from the public. Some parents choose to carry small cards explaining the child’s developmental differences, which can then be easily handed to unsupportive strangers in community settings during trying moments.

Clinicians can work to utilize even quick visits with families as an opportunity to review the American Academy of Pediatrics screen time recommendations with families, and also direct them to the Family Media Plan creation resources. Parenting in the modern era presents many challenges regarding choices around the use of electronic devices with children, and using the exam room experience as a teaching opportunity may be a helpful way to decrease utilization of screens as emotional regulation tools for children, while also providing general education around healthy use of screens.
 

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Oregon.

Reference

1. Takahashi I et al. Screen Time at Age 1 Year and Communication and Problem-Solving Developmental Delays at 2 and 4 years. JAMA Pediatr. 2023 Oct 1;177(10):1039-1046. doi: 10.1001/jamapediatrics.2023.3057.

A 3-year-old presents to my clinic for evaluation of a possible autism spectrum disorder/difference. He has a history of severe emotional dysregulation, as well as reduced social skills and multiple sensory sensitivities. When I enter the exam room he is watching videos on his mom’s phone, and has some difficulty transitioning to play with toys when I encourage him to do so. He is eventually able to cooperate with my testing, though a bit reluctantly, and scores within the low average range for both language and pre-academic skills. His neurologic exam is within normal limits. He utilizes reasonably well-modulated eye contact paired with some typical use of gestures, and his affect is moderately directed and reactive. He displays typical intonation and prosody of speech, though engages in less spontaneous, imaginative, and reciprocal play than would be expected for his age. His mother reports decreased pretend play at home, minimal interest in toys, and difficulty playing cooperatively with other children.

Upon further history, it becomes apparent that the child spends a majority of his time on electronic devices, and has done so since early toddlerhood. Further dialogue suggests that the family became isolated during the COVID-19 pandemic, and has not yet re-engaged with the community in a meaningful way. The child has had rare opportunity for social interactions with other children, and minimal access to outdoor play. His most severe meltdowns generally involve transitions away from screens, and his overwhelmed parents often resort to use of additional screens to calm him once he is dysregulated.

Oregon Health & Science University (OHSU)

At the end of the visit, through shared decision making, we agree that enrolling the child in a high-quality public preschool will help parents make a concerted effort towards a significant reduction in the hours per day in which the child utilizes electronic devices, while also providing him more exposure to peers. We plan for the child to return in 6 months for a re-evaluation around social-emotional skills, given his current limited exposure to peers and limited “unplugged” play-time.
 

Overutilization of Electronic Devices

As clinicians, we can all see how pervasive the use of electronic devices has become in the lives of the families we care for, as well as in our own lives, and how challenging some aspects of modern parenting have become. The developmental impact of early and excessive use of screens in young children is well documented,¹ but as clinicians it can be tricky to help empower parents to find ways to limit screen time. When parents use screens to comfort and amuse their children during a clinic visit, this situation may serve as an excellent opportunity for a meaningful and respectful conversation around skill deficits which can result from overutilization of electronic devices in young children.

One scenario I often encounter during my patient evaluations as a developmental and behavioral pediatrician is children begging their parents for use of their phone throughout their visits with me. Not infrequently, a child is already on a screen when I enter the exam room, even when there has been a minimal wait time, which often leads to some resistance on behalf of the child as I explain to the family that a significant portion of the visit involves my interactions with the child, testing the child, and observing their child at play. I always provide ample amounts of age-appropriate art supplies, puzzles, fidgets, building toys, and imaginative play items to children during their 30 to 90 minute evaluations, but these are often not appealing to children when they have been very recently engaged with an electronic device. At times I also need to ask caretakers themselves to please disengage from their own electronic devices during the visit so that I can involve them in a detailed discussion about their child.

One challenge with the practice of allowing children access to entertainment on their parent’s smartphones in particular, lies in the fact that these devices are almost always present, meaning there is no natural boundary to inhibit access, in contrast to a television set or stationary computer parked in the family living room. Not dissimilar to candy visible in a parent’s purse, a cell phone becomes a constant temptation for children accustomed to utilizing them at home and public venues, and the incessant begging can wear down already stressed parents.

Children can become conditioned to utilize the distraction of screens to avoid feelings of discomfort or stress, and so can be very persistent and emotional when asking for the use of screens in public settings. Out in the community, I very frequently see young children and toddlers quietly staring at their phones and tablets while at restaurants and stores. While I have empathy for exhausted parents desperate for a moment of quiet, if this type of screen use is the rule rather than the exception for a child, there is risk for missed opportunities for the development of self-regulation skills.

Additionally, I have seen very young children present to my clinic with poor posture and neck pain secondary to chronic smartphone use, and young children who are getting minimal exercise or outdoor time due to excessive screen use, leading to concerns around fine and gross motor skills as well.

While allowing a child to stay occupied with or be soothed by a highly interesting digital experience can create a more calm environment for all, if habitual, this use can come at a cost regarding opportunities for the growth of executive functioning skills, general coping skills, general situational awareness, and experiential learning. Reliance on screens to decrease uncomfortable experiences decreases the opportunity for building distress tolerance, patience, and coping skills.

Of course there are times of extreme distress where a lollipop or bit of screen time might be reasonable to help keep a child safe or further avoid emotional trauma, but in general, other methods of soothing can very often be utilized, and in the long run would serve to increase the child’s general adaptive functioning.
 

A Teachable Moment

When clinicians encounter screens being used by parents to entertain their kids in clinic, it provides a valuable teaching moment around the risks of using screens to keep kids regulated and occupied during life’s less interesting or more anxiety provoking experiences. Having a meaningful conversation about the use of electronic devices with caregivers by clinicians in the exam room can be a delicate dance between providing supportive education while avoiding judgmental tones or verbiage. Normalizing and sympathizing with the difficulty of managing challenging behaviors from children in public spaces can help parents feel less desperate to keep their child quiet at all costs, and thus allow for greater development of coping skills.

Some parents may benefit from learning simple ideas for keeping a child regulated and occupied during times of waiting such as silly songs and dances, verbal games like “I spy,” and clapping routines. For a child with additional sensory or developmental needs, a referral to an occupational therapist to work on emotional regulation by way of specific sensory tools can be helpful. Parent-Child Interaction Therapy for kids ages 2 to 7 can also help build some relational activities and skills that can be utilized during trying situations to help keep a child settled and occupied.

If a child has qualified for Developmental Disability Services (DDS), medical providers can also write “prescriptions’ for sensory calming items which are often covered financially by DDS, such as chewies, weighted vests, stuffed animals, and fidgets. While vilification of all screen time for children is not necessary or helpful, supporting parents as they navigate and implement appropriate boundaries is important for optimizing child development. Encouraging parents to schedule allowed screen time at home in a very predictable and controlled manner is one method to help limit excessive use, as well as it’s utilization as an emotional regulation tool.

For public outings with children with special needs, and in particular in situations where meltdowns are likely to occur, some families find it helpful to dress their children in clothing or accessories that increase community awareness about their child’s condition (such as an autism awareness t-shirt). This effort can also help deflect unhelpful attention or advice from the public. Some parents choose to carry small cards explaining the child’s developmental differences, which can then be easily handed to unsupportive strangers in community settings during trying moments.

Clinicians can work to utilize even quick visits with families as an opportunity to review the American Academy of Pediatrics screen time recommendations with families, and also direct them to the Family Media Plan creation resources. Parenting in the modern era presents many challenges regarding choices around the use of electronic devices with children, and using the exam room experience as a teaching opportunity may be a helpful way to decrease utilization of screens as emotional regulation tools for children, while also providing general education around healthy use of screens.
 

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Oregon.

Reference

1. Takahashi I et al. Screen Time at Age 1 Year and Communication and Problem-Solving Developmental Delays at 2 and 4 years. JAMA Pediatr. 2023 Oct 1;177(10):1039-1046. doi: 10.1001/jamapediatrics.2023.3057.

A 3-year-old presents to my clinic for evaluation of a possible autism spectrum disorder/difference. He has a history of severe emotional dysregulation, as well as reduced social skills and multiple sensory sensitivities. When I enter the exam room he is watching videos on his mom’s phone, and has some difficulty transitioning to play with toys when I encourage him to do so. He is eventually able to cooperate with my testing, though a bit reluctantly, and scores within the low average range for both language and pre-academic skills. His neurologic exam is within normal limits. He utilizes reasonably well-modulated eye contact paired with some typical use of gestures, and his affect is moderately directed and reactive. He displays typical intonation and prosody of speech, though engages in less spontaneous, imaginative, and reciprocal play than would be expected for his age. His mother reports decreased pretend play at home, minimal interest in toys, and difficulty playing cooperatively with other children.

Upon further history, it becomes apparent that the child spends a majority of his time on electronic devices, and has done so since early toddlerhood. Further dialogue suggests that the family became isolated during the COVID-19 pandemic, and has not yet re-engaged with the community in a meaningful way. The child has had rare opportunity for social interactions with other children, and minimal access to outdoor play. His most severe meltdowns generally involve transitions away from screens, and his overwhelmed parents often resort to use of additional screens to calm him once he is dysregulated.

Oregon Health & Science University (OHSU)

At the end of the visit, through shared decision making, we agree that enrolling the child in a high-quality public preschool will help parents make a concerted effort towards a significant reduction in the hours per day in which the child utilizes electronic devices, while also providing him more exposure to peers. We plan for the child to return in 6 months for a re-evaluation around social-emotional skills, given his current limited exposure to peers and limited “unplugged” play-time.
 

Overutilization of Electronic Devices

As clinicians, we can all see how pervasive the use of electronic devices has become in the lives of the families we care for, as well as in our own lives, and how challenging some aspects of modern parenting have become. The developmental impact of early and excessive use of screens in young children is well documented,¹ but as clinicians it can be tricky to help empower parents to find ways to limit screen time. When parents use screens to comfort and amuse their children during a clinic visit, this situation may serve as an excellent opportunity for a meaningful and respectful conversation around skill deficits which can result from overutilization of electronic devices in young children.

One scenario I often encounter during my patient evaluations as a developmental and behavioral pediatrician is children begging their parents for use of their phone throughout their visits with me. Not infrequently, a child is already on a screen when I enter the exam room, even when there has been a minimal wait time, which often leads to some resistance on behalf of the child as I explain to the family that a significant portion of the visit involves my interactions with the child, testing the child, and observing their child at play. I always provide ample amounts of age-appropriate art supplies, puzzles, fidgets, building toys, and imaginative play items to children during their 30 to 90 minute evaluations, but these are often not appealing to children when they have been very recently engaged with an electronic device. At times I also need to ask caretakers themselves to please disengage from their own electronic devices during the visit so that I can involve them in a detailed discussion about their child.

One challenge with the practice of allowing children access to entertainment on their parent’s smartphones in particular, lies in the fact that these devices are almost always present, meaning there is no natural boundary to inhibit access, in contrast to a television set or stationary computer parked in the family living room. Not dissimilar to candy visible in a parent’s purse, a cell phone becomes a constant temptation for children accustomed to utilizing them at home and public venues, and the incessant begging can wear down already stressed parents.

Children can become conditioned to utilize the distraction of screens to avoid feelings of discomfort or stress, and so can be very persistent and emotional when asking for the use of screens in public settings. Out in the community, I very frequently see young children and toddlers quietly staring at their phones and tablets while at restaurants and stores. While I have empathy for exhausted parents desperate for a moment of quiet, if this type of screen use is the rule rather than the exception for a child, there is risk for missed opportunities for the development of self-regulation skills.

Additionally, I have seen very young children present to my clinic with poor posture and neck pain secondary to chronic smartphone use, and young children who are getting minimal exercise or outdoor time due to excessive screen use, leading to concerns around fine and gross motor skills as well.

While allowing a child to stay occupied with or be soothed by a highly interesting digital experience can create a more calm environment for all, if habitual, this use can come at a cost regarding opportunities for the growth of executive functioning skills, general coping skills, general situational awareness, and experiential learning. Reliance on screens to decrease uncomfortable experiences decreases the opportunity for building distress tolerance, patience, and coping skills.

Of course there are times of extreme distress where a lollipop or bit of screen time might be reasonable to help keep a child safe or further avoid emotional trauma, but in general, other methods of soothing can very often be utilized, and in the long run would serve to increase the child’s general adaptive functioning.
 

A Teachable Moment

When clinicians encounter screens being used by parents to entertain their kids in clinic, it provides a valuable teaching moment around the risks of using screens to keep kids regulated and occupied during life’s less interesting or more anxiety provoking experiences. Having a meaningful conversation about the use of electronic devices with caregivers by clinicians in the exam room can be a delicate dance between providing supportive education while avoiding judgmental tones or verbiage. Normalizing and sympathizing with the difficulty of managing challenging behaviors from children in public spaces can help parents feel less desperate to keep their child quiet at all costs, and thus allow for greater development of coping skills.

Some parents may benefit from learning simple ideas for keeping a child regulated and occupied during times of waiting such as silly songs and dances, verbal games like “I spy,” and clapping routines. For a child with additional sensory or developmental needs, a referral to an occupational therapist to work on emotional regulation by way of specific sensory tools can be helpful. Parent-Child Interaction Therapy for kids ages 2 to 7 can also help build some relational activities and skills that can be utilized during trying situations to help keep a child settled and occupied.

If a child has qualified for Developmental Disability Services (DDS), medical providers can also write “prescriptions’ for sensory calming items which are often covered financially by DDS, such as chewies, weighted vests, stuffed animals, and fidgets. While vilification of all screen time for children is not necessary or helpful, supporting parents as they navigate and implement appropriate boundaries is important for optimizing child development. Encouraging parents to schedule allowed screen time at home in a very predictable and controlled manner is one method to help limit excessive use, as well as it’s utilization as an emotional regulation tool.

For public outings with children with special needs, and in particular in situations where meltdowns are likely to occur, some families find it helpful to dress their children in clothing or accessories that increase community awareness about their child’s condition (such as an autism awareness t-shirt). This effort can also help deflect unhelpful attention or advice from the public. Some parents choose to carry small cards explaining the child’s developmental differences, which can then be easily handed to unsupportive strangers in community settings during trying moments.

Clinicians can work to utilize even quick visits with families as an opportunity to review the American Academy of Pediatrics screen time recommendations with families, and also direct them to the Family Media Plan creation resources. Parenting in the modern era presents many challenges regarding choices around the use of electronic devices with children, and using the exam room experience as a teaching opportunity may be a helpful way to decrease utilization of screens as emotional regulation tools for children, while also providing general education around healthy use of screens.
 

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Oregon.

Reference

1. Takahashi I et al. Screen Time at Age 1 Year and Communication and Problem-Solving Developmental Delays at 2 and 4 years. JAMA Pediatr. 2023 Oct 1;177(10):1039-1046. doi: 10.1001/jamapediatrics.2023.3057.

Cancer is becoming more common in younger generations. Data show that people under 50 are experiencing higher rates of cancer than any generation before them. As a genetic counselor, I hoped these upward trends in early-onset malignancies would slow with a better understanding of risk factors and prevention strategies. Unfortunately, the opposite is happening. Recent findings from the American Cancer Society reveal that the incidence of at least 17 of 34 cancer types is rising among GenX and Millennials. 

These statistics are alarming. I appreciate how easy it is for patients to get lost in the headlines about cancer, which may shape how they approach their healthcare. Each year, millions of Americans miss critical cancer screenings, with many citing fear of a positive test result as a leading reason. Others believe, despite the statistics, that cancer is not something they need to worry about until they are older. And then, of course, getting screened is not as easy as it should be. 

In my work, I meet with people from both younger and older generations who have either faced cancer themselves or witnessed a loved one experience the disease. One of the most common sentiments I hear from these patients is the desire to catch cancer earlier. My answer is always this: The first and most important step everyone can take is understanding their risk. 

For some, knowing they are at increased risk for cancer means starting screenings earlier — sometimes as early as age 25 — or getting screened with a more sensitive test. 

This proactive approach is the right one. Early detection can dramatically increase survival rates, sometimes by up to eightfold, depending on the type of cancer. It also significantly reduces the burden of total and cancer-specific healthcare costs. While screening may carry some potential risks, clinicians can minimize these risks by adhering to evidence-based guidelines, such as those from the American Cancer Society, and ensuring there is appropriate discussion of treatment options when a diagnosis is made.
 

Normalizing Cancer Risk Assessment and Screening 

A detailed cancer risk assessment and education about signs and symptoms should be part of every preventive care visit, regardless of someone’s age. Further, that cancer risk assessment should lead to clear recommendations and support for taking the next steps. 

This is where care advocacy and patient navigation come in. Care advocacy can improve outcomes at every stage of the cancer journey, from increasing screening rates to improving quality of life for survivors. I’ve seen first-hand how care advocates help patients overcome hurdles like long wait times for appointments they need, making both screening and diagnostic care easier to access. 

Now, with the finalization of a new rule from the Centers for Medicare & Medicaid Services, providers can bill for oncology navigation services that occur under their supervision. This formal recognition of care navigation affirms the value of these services not just clinically but financially as well. It will be through methods like care navigation, targeted outreach, and engaging educational resources — built into and covered by health plans — that patients will feel more in control over their health and have tools to help minimize the effects of cancer on the rest of their lives. 

These services benefit healthcare providers as well. Care navigation supports clinical care teams, from primary care providers to oncologists, by ensuring patients are seen before their cancer progresses to a more advanced stage. And even if patients follow screening recommendations for the rest of their lives and never get a positive result, they’ve still gained something invaluable: peace of mind, knowing they’ve taken an active role in their health. 
 

Fighting Fear With Routine

Treating cancer as a normal part of young people’s healthcare means helping them envision the disease as a condition that can be treated, much like a diagnosis of diabetes or high cholesterol. This mindset shift means quickly following up on a concerning symptom or screening result and reducing the time to start treatment if needed. And with treatment options and success rates for some cancers being better than ever, survivorship support must be built into every treatment plan from the start. Before treatment begins, healthcare providers should make time to talk about sometimes-overlooked key topics, such as reproductive options for people whose fertility may be affected by their cancer treatment, about plans for returning to work during or after treatment, and finding the right mental health support. 

Where we can’t prevent cancer, both primary care providers and oncologists can work together to help patients receive the right diagnosis and treatment as quickly as possible. Knowing insurance coverage has a direct effect on how early cancer is caught, for example, younger people need support in understanding and accessing benefits and resources that may be available through their existing healthcare channels, like some employer-sponsored health plans. Even if getting treated for cancer is inevitable for some, taking immediate action to get screened when it’s appropriate is the best thing we can do to lessen the impact of these rising cancer incidences across the country. At the end of the day, being afraid of cancer doesn’t decrease the chances of getting sick or dying from it. Proactive screening and early detection do. 
 

Brockman, Genetic Counselor, Color Health, Buffalo, New York, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Cancer is becoming more common in younger generations. Data show that people under 50 are experiencing higher rates of cancer than any generation before them. As a genetic counselor, I hoped these upward trends in early-onset malignancies would slow with a better understanding of risk factors and prevention strategies. Unfortunately, the opposite is happening. Recent findings from the American Cancer Society reveal that the incidence of at least 17 of 34 cancer types is rising among GenX and Millennials. 

These statistics are alarming. I appreciate how easy it is for patients to get lost in the headlines about cancer, which may shape how they approach their healthcare. Each year, millions of Americans miss critical cancer screenings, with many citing fear of a positive test result as a leading reason. Others believe, despite the statistics, that cancer is not something they need to worry about until they are older. And then, of course, getting screened is not as easy as it should be. 

In my work, I meet with people from both younger and older generations who have either faced cancer themselves or witnessed a loved one experience the disease. One of the most common sentiments I hear from these patients is the desire to catch cancer earlier. My answer is always this: The first and most important step everyone can take is understanding their risk. 

For some, knowing they are at increased risk for cancer means starting screenings earlier — sometimes as early as age 25 — or getting screened with a more sensitive test. 

This proactive approach is the right one. Early detection can dramatically increase survival rates, sometimes by up to eightfold, depending on the type of cancer. It also significantly reduces the burden of total and cancer-specific healthcare costs. While screening may carry some potential risks, clinicians can minimize these risks by adhering to evidence-based guidelines, such as those from the American Cancer Society, and ensuring there is appropriate discussion of treatment options when a diagnosis is made.
 

Normalizing Cancer Risk Assessment and Screening 

A detailed cancer risk assessment and education about signs and symptoms should be part of every preventive care visit, regardless of someone’s age. Further, that cancer risk assessment should lead to clear recommendations and support for taking the next steps. 

This is where care advocacy and patient navigation come in. Care advocacy can improve outcomes at every stage of the cancer journey, from increasing screening rates to improving quality of life for survivors. I’ve seen first-hand how care advocates help patients overcome hurdles like long wait times for appointments they need, making both screening and diagnostic care easier to access. 

Now, with the finalization of a new rule from the Centers for Medicare & Medicaid Services, providers can bill for oncology navigation services that occur under their supervision. This formal recognition of care navigation affirms the value of these services not just clinically but financially as well. It will be through methods like care navigation, targeted outreach, and engaging educational resources — built into and covered by health plans — that patients will feel more in control over their health and have tools to help minimize the effects of cancer on the rest of their lives. 

These services benefit healthcare providers as well. Care navigation supports clinical care teams, from primary care providers to oncologists, by ensuring patients are seen before their cancer progresses to a more advanced stage. And even if patients follow screening recommendations for the rest of their lives and never get a positive result, they’ve still gained something invaluable: peace of mind, knowing they’ve taken an active role in their health. 
 

Fighting Fear With Routine

Treating cancer as a normal part of young people’s healthcare means helping them envision the disease as a condition that can be treated, much like a diagnosis of diabetes or high cholesterol. This mindset shift means quickly following up on a concerning symptom or screening result and reducing the time to start treatment if needed. And with treatment options and success rates for some cancers being better than ever, survivorship support must be built into every treatment plan from the start. Before treatment begins, healthcare providers should make time to talk about sometimes-overlooked key topics, such as reproductive options for people whose fertility may be affected by their cancer treatment, about plans for returning to work during or after treatment, and finding the right mental health support. 

Where we can’t prevent cancer, both primary care providers and oncologists can work together to help patients receive the right diagnosis and treatment as quickly as possible. Knowing insurance coverage has a direct effect on how early cancer is caught, for example, younger people need support in understanding and accessing benefits and resources that may be available through their existing healthcare channels, like some employer-sponsored health plans. Even if getting treated for cancer is inevitable for some, taking immediate action to get screened when it’s appropriate is the best thing we can do to lessen the impact of these rising cancer incidences across the country. At the end of the day, being afraid of cancer doesn’t decrease the chances of getting sick or dying from it. Proactive screening and early detection do. 
 

Brockman, Genetic Counselor, Color Health, Buffalo, New York, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Cancer is becoming more common in younger generations. Data show that people under 50 are experiencing higher rates of cancer than any generation before them. As a genetic counselor, I hoped these upward trends in early-onset malignancies would slow with a better understanding of risk factors and prevention strategies. Unfortunately, the opposite is happening. Recent findings from the American Cancer Society reveal that the incidence of at least 17 of 34 cancer types is rising among GenX and Millennials. 

These statistics are alarming. I appreciate how easy it is for patients to get lost in the headlines about cancer, which may shape how they approach their healthcare. Each year, millions of Americans miss critical cancer screenings, with many citing fear of a positive test result as a leading reason. Others believe, despite the statistics, that cancer is not something they need to worry about until they are older. And then, of course, getting screened is not as easy as it should be. 

In my work, I meet with people from both younger and older generations who have either faced cancer themselves or witnessed a loved one experience the disease. One of the most common sentiments I hear from these patients is the desire to catch cancer earlier. My answer is always this: The first and most important step everyone can take is understanding their risk. 

For some, knowing they are at increased risk for cancer means starting screenings earlier — sometimes as early as age 25 — or getting screened with a more sensitive test. 

This proactive approach is the right one. Early detection can dramatically increase survival rates, sometimes by up to eightfold, depending on the type of cancer. It also significantly reduces the burden of total and cancer-specific healthcare costs. While screening may carry some potential risks, clinicians can minimize these risks by adhering to evidence-based guidelines, such as those from the American Cancer Society, and ensuring there is appropriate discussion of treatment options when a diagnosis is made.
 

Normalizing Cancer Risk Assessment and Screening 

A detailed cancer risk assessment and education about signs and symptoms should be part of every preventive care visit, regardless of someone’s age. Further, that cancer risk assessment should lead to clear recommendations and support for taking the next steps. 

This is where care advocacy and patient navigation come in. Care advocacy can improve outcomes at every stage of the cancer journey, from increasing screening rates to improving quality of life for survivors. I’ve seen first-hand how care advocates help patients overcome hurdles like long wait times for appointments they need, making both screening and diagnostic care easier to access. 

Now, with the finalization of a new rule from the Centers for Medicare & Medicaid Services, providers can bill for oncology navigation services that occur under their supervision. This formal recognition of care navigation affirms the value of these services not just clinically but financially as well. It will be through methods like care navigation, targeted outreach, and engaging educational resources — built into and covered by health plans — that patients will feel more in control over their health and have tools to help minimize the effects of cancer on the rest of their lives. 

These services benefit healthcare providers as well. Care navigation supports clinical care teams, from primary care providers to oncologists, by ensuring patients are seen before their cancer progresses to a more advanced stage. And even if patients follow screening recommendations for the rest of their lives and never get a positive result, they’ve still gained something invaluable: peace of mind, knowing they’ve taken an active role in their health. 
 

Fighting Fear With Routine

Treating cancer as a normal part of young people’s healthcare means helping them envision the disease as a condition that can be treated, much like a diagnosis of diabetes or high cholesterol. This mindset shift means quickly following up on a concerning symptom or screening result and reducing the time to start treatment if needed. And with treatment options and success rates for some cancers being better than ever, survivorship support must be built into every treatment plan from the start. Before treatment begins, healthcare providers should make time to talk about sometimes-overlooked key topics, such as reproductive options for people whose fertility may be affected by their cancer treatment, about plans for returning to work during or after treatment, and finding the right mental health support. 

Where we can’t prevent cancer, both primary care providers and oncologists can work together to help patients receive the right diagnosis and treatment as quickly as possible. Knowing insurance coverage has a direct effect on how early cancer is caught, for example, younger people need support in understanding and accessing benefits and resources that may be available through their existing healthcare channels, like some employer-sponsored health plans. Even if getting treated for cancer is inevitable for some, taking immediate action to get screened when it’s appropriate is the best thing we can do to lessen the impact of these rising cancer incidences across the country. At the end of the day, being afraid of cancer doesn’t decrease the chances of getting sick or dying from it. Proactive screening and early detection do. 
 

Brockman, Genetic Counselor, Color Health, Buffalo, New York, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 
I've been hearing a lot about apolipoprotein B (apoB) lately. It keeps popping up, but I've not been sure where it fits in or what I should do about it. The new Expert Clinical Consensus from the National Lipid Association now finally gives us clear guidance.  
ApoB is the main protein that is found on all atherogenic lipoproteins. It is found on low-density lipoprotein (LDL) but also on other atherogenic lipoprotein particles. Because it is a part of all atherogenic particles, it predicts cardiovascular (CV) risk more accurately than does LDL cholesterol (LDL-C). 
ApoB and LDL-C tend to run together, but not always. While they are correlated fairly well on a population level, for a given individual they can diverge; and when they do, apoB is the better predictor of future CV outcomes. This divergence occurs frequently, and it can occur even more frequently after treatment with statins. When LDL decreases to reach the LDL threshold for treatment, but apoB remains elevated, there is the potential for misclassification of CV risk and essentially the risk for undertreatment of someone whose CV risk is actually higher than it appears to be if we only look at their LDL-C. The consensus statement says, "Where there is discordance between apoB and LDL-C, risk follows apoB." 
This understanding leads to the places where measurement of apoB may be helpful: 
In patients with borderline atherosclerotic cardiovascular disease risk in whom a shared decision about statin therapy is being determined and the patient prefers not to start a statin, apoB can be useful for further risk stratification. If apoB suggests low risk, then statin therapy could be withheld, and if apoB is high, that would favor starting statin therapy. Certain common conditions, such as obesity and insulin resistance, can lead to smaller cholesterol-depleted LDL particles that result in lower LDL-C, but elevated apoB levels in this circumstance may drive the decision to treat with a statin.  
In patients already treated with statins, but a decision must be made about whether treatment intensification is warranted. If the LDL-C is to goal and apoB is above threshold, treatment intensification may be considered. In patients who are not yet to goal, based on an elevated apoB, the first step is intensification of statin therapy. After that, intensification would be the same as has already been addressed in my review of the 2022 ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering.  
After clarifying the importance of apoB in providing additional discrimination of CV risk, the consensus statement clarifies the treatment thresholds, or goals for treatment, for apoB that correlate with established LDL-C thresholds, as shown in this table: 

This transcript has been edited for clarity. 
I've been hearing a lot about apolipoprotein B (apoB) lately. It keeps popping up, but I've not been sure where it fits in or what I should do about it. The new Expert Clinical Consensus from the National Lipid Association now finally gives us clear guidance.  
ApoB is the main protein that is found on all atherogenic lipoproteins. It is found on low-density lipoprotein (LDL) but also on other atherogenic lipoprotein particles. Because it is a part of all atherogenic particles, it predicts cardiovascular (CV) risk more accurately than does LDL cholesterol (LDL-C). 
ApoB and LDL-C tend to run together, but not always. While they are correlated fairly well on a population level, for a given individual they can diverge; and when they do, apoB is the better predictor of future CV outcomes. This divergence occurs frequently, and it can occur even more frequently after treatment with statins. When LDL decreases to reach the LDL threshold for treatment, but apoB remains elevated, there is the potential for misclassification of CV risk and essentially the risk for undertreatment of someone whose CV risk is actually higher than it appears to be if we only look at their LDL-C. The consensus statement says, "Where there is discordance between apoB and LDL-C, risk follows apoB." 
This understanding leads to the places where measurement of apoB may be helpful: 
In patients with borderline atherosclerotic cardiovascular disease risk in whom a shared decision about statin therapy is being determined and the patient prefers not to start a statin, apoB can be useful for further risk stratification. If apoB suggests low risk, then statin therapy could be withheld, and if apoB is high, that would favor starting statin therapy. Certain common conditions, such as obesity and insulin resistance, can lead to smaller cholesterol-depleted LDL particles that result in lower LDL-C, but elevated apoB levels in this circumstance may drive the decision to treat with a statin.  
In patients already treated with statins, but a decision must be made about whether treatment intensification is warranted. If the LDL-C is to goal and apoB is above threshold, treatment intensification may be considered. In patients who are not yet to goal, based on an elevated apoB, the first step is intensification of statin therapy. After that, intensification would be the same as has already been addressed in my review of the 2022 ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering.  
After clarifying the importance of apoB in providing additional discrimination of CV risk, the consensus statement clarifies the treatment thresholds, or goals for treatment, for apoB that correlate with established LDL-C thresholds, as shown in this table: 

This transcript has been edited for clarity. 
I've been hearing a lot about apolipoprotein B (apoB) lately. It keeps popping up, but I've not been sure where it fits in or what I should do about it. The new Expert Clinical Consensus from the National Lipid Association now finally gives us clear guidance.  
ApoB is the main protein that is found on all atherogenic lipoproteins. It is found on low-density lipoprotein (LDL) but also on other atherogenic lipoprotein particles. Because it is a part of all atherogenic particles, it predicts cardiovascular (CV) risk more accurately than does LDL cholesterol (LDL-C). 
ApoB and LDL-C tend to run together, but not always. While they are correlated fairly well on a population level, for a given individual they can diverge; and when they do, apoB is the better predictor of future CV outcomes. This divergence occurs frequently, and it can occur even more frequently after treatment with statins. When LDL decreases to reach the LDL threshold for treatment, but apoB remains elevated, there is the potential for misclassification of CV risk and essentially the risk for undertreatment of someone whose CV risk is actually higher than it appears to be if we only look at their LDL-C. The consensus statement says, "Where there is discordance between apoB and LDL-C, risk follows apoB." 
This understanding leads to the places where measurement of apoB may be helpful: 
In patients with borderline atherosclerotic cardiovascular disease risk in whom a shared decision about statin therapy is being determined and the patient prefers not to start a statin, apoB can be useful for further risk stratification. If apoB suggests low risk, then statin therapy could be withheld, and if apoB is high, that would favor starting statin therapy. Certain common conditions, such as obesity and insulin resistance, can lead to smaller cholesterol-depleted LDL particles that result in lower LDL-C, but elevated apoB levels in this circumstance may drive the decision to treat with a statin.  
In patients already treated with statins, but a decision must be made about whether treatment intensification is warranted. If the LDL-C is to goal and apoB is above threshold, treatment intensification may be considered. In patients who are not yet to goal, based on an elevated apoB, the first step is intensification of statin therapy. After that, intensification would be the same as has already been addressed in my review of the 2022 ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering.  
After clarifying the importance of apoB in providing additional discrimination of CV risk, the consensus statement clarifies the treatment thresholds, or goals for treatment, for apoB that correlate with established LDL-C thresholds, as shown in this table: 

MOA — Mechanism of action — gets bandied about a lot.

Drug reps love it. Saying your product is a “first-in-class MOA” sounds great as they hand you a glossy brochure. It also features prominently in print ads, usually with pics of smiling people.

It’s a good thing to know, too, both medically and in a cool-science-geeky way. We want to understand what we’re prescribing will do to patients. We want to explain it to them, too.

It certainly helps to know that what we’re doing when treating a disorder using rational polypharmacy.

But at the same time we face the realization that it may not mean as much as we think it should. I don’t have to go back very far in my career to find Food and Drug Administration–approved medications that worked, but we didn’t have a clear reason why. I mean, we had a vague idea on a scientific basis, but we’re still guessing.

This didn’t stop us from using them, which is nothing new. The ancients had learned certain plants reduced pain and fever long before they understood what aspirin (and its MOA) was.

At the same time we’re now using drugs, such as the anti-amyloid treatments for Alzheimer’s disease, that should be more effective than one would think. Pulling the damaged molecules out of the brain should, on paper, make a dramatic difference ... but it doesn’t. I’m not saying they don’t have some benefit, but certainly not as much as you’d think. Of course, that’s based on our understanding of the disease mechanism being correct. We find there’s a lot more going on than we know.

Like so much in science (and this aspect of medicine is a science) the answers often lead to more questions.

Observation takes the lead over understanding in most things. Our ancestors knew what fire was, and how to use it, without any idea of what rapid exothermic oxidation was. (Admittedly, I have a degree in chemistry and can’t explain it myself anymore.)

The glossy ads and scientific data about MOA doesn’t mean much in my world if they don’t work. I’d rather have a drug that works, even if the MOA isn’t clear, than a known MOA without clinical benefit. My patients would say the same.

Clinical medicine, after all, is both an art and a science.

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

MOA — Mechanism of action — gets bandied about a lot.

Drug reps love it. Saying your product is a “first-in-class MOA” sounds great as they hand you a glossy brochure. It also features prominently in print ads, usually with pics of smiling people.

It’s a good thing to know, too, both medically and in a cool-science-geeky way. We want to understand what we’re prescribing will do to patients. We want to explain it to them, too.

It certainly helps to know that what we’re doing when treating a disorder using rational polypharmacy.

But at the same time we face the realization that it may not mean as much as we think it should. I don’t have to go back very far in my career to find Food and Drug Administration–approved medications that worked, but we didn’t have a clear reason why. I mean, we had a vague idea on a scientific basis, but we’re still guessing.

This didn’t stop us from using them, which is nothing new. The ancients had learned certain plants reduced pain and fever long before they understood what aspirin (and its MOA) was.

At the same time we’re now using drugs, such as the anti-amyloid treatments for Alzheimer’s disease, that should be more effective than one would think. Pulling the damaged molecules out of the brain should, on paper, make a dramatic difference ... but it doesn’t. I’m not saying they don’t have some benefit, but certainly not as much as you’d think. Of course, that’s based on our understanding of the disease mechanism being correct. We find there’s a lot more going on than we know.

Like so much in science (and this aspect of medicine is a science) the answers often lead to more questions.

Observation takes the lead over understanding in most things. Our ancestors knew what fire was, and how to use it, without any idea of what rapid exothermic oxidation was. (Admittedly, I have a degree in chemistry and can’t explain it myself anymore.)

The glossy ads and scientific data about MOA doesn’t mean much in my world if they don’t work. I’d rather have a drug that works, even if the MOA isn’t clear, than a known MOA without clinical benefit. My patients would say the same.

Clinical medicine, after all, is both an art and a science.

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

MOA — Mechanism of action — gets bandied about a lot.

Drug reps love it. Saying your product is a “first-in-class MOA” sounds great as they hand you a glossy brochure. It also features prominently in print ads, usually with pics of smiling people.

It’s a good thing to know, too, both medically and in a cool-science-geeky way. We want to understand what we’re prescribing will do to patients. We want to explain it to them, too.

It certainly helps to know that what we’re doing when treating a disorder using rational polypharmacy.

But at the same time we face the realization that it may not mean as much as we think it should. I don’t have to go back very far in my career to find Food and Drug Administration–approved medications that worked, but we didn’t have a clear reason why. I mean, we had a vague idea on a scientific basis, but we’re still guessing.

This didn’t stop us from using them, which is nothing new. The ancients had learned certain plants reduced pain and fever long before they understood what aspirin (and its MOA) was.

At the same time we’re now using drugs, such as the anti-amyloid treatments for Alzheimer’s disease, that should be more effective than one would think. Pulling the damaged molecules out of the brain should, on paper, make a dramatic difference ... but it doesn’t. I’m not saying they don’t have some benefit, but certainly not as much as you’d think. Of course, that’s based on our understanding of the disease mechanism being correct. We find there’s a lot more going on than we know.

Like so much in science (and this aspect of medicine is a science) the answers often lead to more questions.

Observation takes the lead over understanding in most things. Our ancestors knew what fire was, and how to use it, without any idea of what rapid exothermic oxidation was. (Admittedly, I have a degree in chemistry and can’t explain it myself anymore.)

The glossy ads and scientific data about MOA doesn’t mean much in my world if they don’t work. I’d rather have a drug that works, even if the MOA isn’t clear, than a known MOA without clinical benefit. My patients would say the same.

Clinical medicine, after all, is both an art and a science.

Dr. Block has a solo neurology practice in Scottsdale, Arizona.