Clinical care

Obstetricians and gynecologists are increasingly confronted with clinical situations and questions from patients about the impact of environmental chemicals on their general health, fertility, and pregnancy outcome. Obstetricians-gynecologists are well positioned to provide guidance on environmental health issues to patients. Obstetricians-gynecologists can inquire about environmental exposures by asking questions about key exposures, such as mercury, lead, pesticides, and endocrine-disrupting chemicals. Sathyanarayana et al published an article in the Journal that provides specific risk communication messaging, exposure reduction actions, and sample clinical questions for determining environmental exposures among patients.

Despite the opportunity to educate patients on reducing environmental exposures, most obstetricians-gynecologists do not ask patients about environmental exposures aside from smoking, alcohol consumption, and nutrition. A recent survey of 2514 American Congress of Obstetricians and Gynecologists (ACOG) fellows reported that half of the obstetricians-gynecologists surveyed rarely conduct an environmental health history, despite the majority of respondents agreeing that an environmental health history would identify patient exposures (86%) and help prevent harmful exposures (80%). Reasons for not asking patients about environmental exposures included concern about creating unnecessary anxiety among patients, not possessing adequate information to answer patient questions, and the inability of patients to take steps to reduce exposures.

Advocacy

Patient centered actions cannot reduce all exposure to environmental chemicals, and obstetricians-gynecologists can be influential advocates of environmentally safe policies. An example of an area in which obstetricians-gynecologists can advocate is for the strengthening of current regulatory oversight of industrial chemicals. Of the 80,000 industrial chemicals in commerce, the majority have little to no toxicity testing on their impacts on human health. Obstetricians and gynecologists can advocate for the development of robust screening regulations and make precautionary recommendations in the absence of complete data.

Obstetricians-gynecologists can take a precautionary approach to addressing emerging environmental contaminants. The Precautionary Principle “provides justification for public policy actions in situations of scientific complexity, uncertainty, and ignorance, where there may be a need to act in order to avoid, or reduce, potentially serious or irreversible threats to health or the environment.”

Delaying action until research provides causal support for an associated environmental exposure and adverse health outcome may take decades, time in which adverse reproductive health outcomes can be avoided. This strategy is not meant to be alarmist; rather, obstetricians-gynecologists should exercise a degree of caution, to avoid delay in protecting patients, when the preponderance of evidence seems to be pointing toward the adverse reproductive health outcomes from chemicals ubiquitous in the environment.

An example of an area in which the precautionary principle can be used is exposure to chemicals that influence the endocrine system. In standard toxicity testing, chemicals are tested to determine a threshold value, below which there are presumably no adverse health outcomes. Endocrine-disrupting chemicals have been shown to have nonmonotonic dose-response curves, wherein even low doses are capable of producing adverse health effects, and in some cases, more severe effects occur at low doses than higher doses.

Standard toxicity testing also does not account for the unique exposures of pregnant women and children, exposure to multiple chemicals, and susceptible windows of development. As a result, the Endocrine Society has called for use of the precautionary principle for regulation of endocrine-disrupting chemicals. By utilizing the precautionary principle, obstetricians-gynecologists can address reproductive health concerns related to environmental exposures without causing unnecessary stress for their patients.

Environmental health in obstetrics-gynecology medical education

Recognition of environmental hazards among obstetricians-gynecologists has gained momentum with the release of the ACOG Committee on Health Care for Underserved Women and the American Society for Reproductive Medicine (ASRM) Practice Committee joint committee opinion 575. In the opinion, ACOG and ASRM urge clinicians to become knowledgeable on potential environmental exposures and to conduct environmental histories of patients during preconception and prenatal visits.

The joint committee also published a longer, companion piece, which provides guidance to practitioners on specific issues, recommendations for prevention, and additional resources. The joint committee opinion demonstrates that reproductive health professionals can be advocates for protecting men, women, and their offspring from exposure to environmental hazards.

Further to creating awareness, a formal mechanism to educate obstetricians-gynecologists on environmental health hazards is needed to ensure all trainees are prepared to address patients’ concerns. Over the course of 4 years of medical education, one study found the average number of hours required for environmental health was only 7 hours total. Obstetrics-gynecology education has been largely void of environmental health topics aside from nutrition, smoking, and drinking during pregnancy. Instruction on taking an environmental history is limited among obstetrics-gynecology medical programs with only 1 in 15 obstetricians-gynecologists reporting training specific to taking an environmental history.

In response to this need, the Mid-Atlantic Center for Children’s Health and the Environment and the George Washington University Department of Obstetrics and Gynecology convened a meeting of faculty members and residents representing 16 academic medical programs of obstetrics-gynecology in the District of Columbia, Delaware, Maryland, Pennsylvania, Virginia, and West Virginia. The meeting promoted environmental health among the obstetrics and gynecology profession and sought to incorporate environmental health topics into graduate medical education. A work group of faculty members and residents was formed to continue the discussion beyond the meeting on how academic programs of obstetrics-gynecology can integrate environmental health topics. The work group will identify mechanisms to incorporate environmental health topics, barriers that may exist, and the resources needed to successfully integrate environmental health topics into graduate medical education.

Recommendation

Initial avenues identified by the work group for establishing formal training for obstetricians-gynecologists in environmental health include the following topics.

Medical school curriculum

Integration of environmental health topics for medical education is necessary at all levels. Methods have been established to assist educational programming development, including integration of environmental health topics into basic science courses and the organ systems approach applied by many curriculums. Faculty members at the George Washington University Department of Obstetrics and Gynecology have started creating a medical school and residency curriculum on environmental health specifically for obstetricians-gynecologists.

Clinical trainee programs

The University of California, San Francisco, Program on Reproductive Health and the Environment (PRHE) has an established program dedicated to creating awareness of environmental health among reproductive health professionals. The program includes a rotations program for obstetrics-gynecology clinical trainees and maternal-fetal medicine fellows. The PRHE has developed resources for reproductive health professionals, including patient educational materials and environmental health history forms for clinical practice ( http://prhe.ucsf.edu/prhe/clinical_resources.html ). Obstetrics and gynecology medical programs can use the PRHE as a model for integrating environmental health into fellowships and graduate medical education.

Inclusion on resident training and board-certifying exams

Inclusion of environmental health questions on resident training exams and board-certifying exams would prompt programs to include environmental health topics in their curriculum. The authors suggest that the Council on Residency Education in Obstetrics and Gynecology, the American Board of Obstetrics and Gynecology, and the American Osteopathic Board of Obstetrics and Gynecology consider including environmental health questions on their exams.

Faculty training

Leaders in medical education and faculty members could be trained on reproductive environmental health through the Association of Professors of Gynecology and Obstetrics or by establishing environmental health faculty champions programs for obstetricians-gynecologists.

Continuing education requirements

Requiring continuing education credits in environmental health would ensure that currently practicing obstetricians-gynecologists receive an introduction to environmental health topics. The Agency for Toxic Substances and Disease Registry has developed environmental medicine case studies available to all health professionals required to complete continuing education ( www.atsdr.cdc.gov/emes/health_professionals/index.html ).