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Environmental Impacts on Reproductive Health
Release Date: January 2010Expiration Date: January 2012
3 Introduction
4 GuidanceforProviders
6 TheLinksBetweenEnvironmentalExposuresandReproductiveHealth
11 PuttingRiskinPerspective
12 Pesticides
15 Methylmercury
19 ChemicalExposuresintheWorkplace
22 BisphenolAandOtherChemicalsinPlastics
26 ResourcesforPatientsandProviders
27 Conclusion
Accreditation/CreditDesignationTo receive credit for this activity, complete the online post-test and evaluation by January 31, 2012.
NurseMidwives—AMA PRA Category 1 Credits™acceptedbytheContinuingCompetencyAssessmentProgramoftheAmericanCollegeofNurseMidwivesforprogramsrelevanttonursemidwifery.NurseMidwiveswhocompletethisactivitymayreportupto2hoursofcredit.
NursesandNursePractitioners—ThiseducationalactivityhasbeenapprovedbytheContinuingEducationApprovalProgramoftheNationalAssociationofNursePractitionersinWomen’sHealthfor2contacthours,including1.0pharmacologyhours.CreditcanbeappliedtowardthenursingcontinuingeducationrequirementsofmostprofessionalorganizationsandstateBoardsofNursing.
Pharmacists—TheAssociationofReproductiveHealthProfessionalsisaccreditedbytheAccredita-
tionCouncilforPharmacyEducationasaproviderofcontinuingpharmacyeducation.Theassigneduniversalprogramnumberis0463-0000-10-001-H04-P.Thisactivityprovides2contacthoursofcontinuingpharmacyeducationcredit.
PhysicianAssistants—TheAmericanAcademyofPhysicianAssistantsacceptsAMA PRA Category 1 Credits™fromorganizationsaccreditedbytheAccreditationCouncilforContinuingMedicalEducation.PhysicianAssistantswhocompletethisactivitymayreportupto2credits.
Physicians—TheAssociationofReproductiveHealthProfessionalsisaccreditedbytheAccreditationCouncilforContinuingMedicalEducationtoprovidecontinuingmedicaleducationforphysicians.TheAssociationofReproductiveHealthProfessionalsdesignatesthiscontinuingmedicaleducationactivityforamaximumof2 AMA PRA Category 1 Credits™.Physiciansshouldonlyclaimcreditcommensuratewiththeextentoftheirparticipationintheactivity.
LearningObjectives:After completing this activity, health care providers should be able to:
• Whencounselingpatients,usetheCH2OPSmnemonictotakeacomprehensiveenvironmentalhealthhistorytoassessexposures.
• Nametwoadverseeffectsonreproductivehealththatmaybecausedbytoxicantsthatpatientstypicallyuseortowhichtheyarecommonlyexposed.
• Listthreestrategiesforreducingexposurestochemicalswithpotentialadverseeffectsonreproductivehealththatcanbeusedwhenprovidingguidancetoapatient.
• Whenseeingafemalepatientwhoisplanningtoconceiveinthenextsixmonths,discusstherisksandbenefitsoffishconsumptionandidentifyconsumptionguidelinesfromareputablesource,suchastheFoodandDrugAdministrationortheNaturalResourcesDefenseCouncil.
SupporterAcknowledgementThispublicationwasfundedbyaneducationalgrantprovidedbytheKresgeFoundationtoPlannedParenthood®FederationofAmericainpartnershipwiththeAssociationofReproductiveHealthProfessionals.
ScientificAdvisorsTedSchettler,MD,MPH
TraceyWoodruff,PhD,MPH
ThispublicationispartofajointprogramoftheAssociationofReproductiveHealthProfessionals(ARHP)andPlannedParenthood®FederationofAmerica(PPFA)onreproductivehealthandtheenvironmentthatalsoincludedthefollowingclinicaladvisors:KathleenHillBesinque,PharmD,MSEd,FCSHP;RivkaGordon,PA-C,MHS;BethJordan,MD;MaureenPaul,MD,MPH;BarbaraSattler,RN,DrPH,FAAN;MichaelThomas,MD;andSandyWorthington,MSN,WHNP-BC,CNM.
ARHPacknowledgesTraceyWoodruff,PhD,MPH,associateprofessoranddirector,theUniversityofCaliforniaSan-FranciscoProgramonReproductiveHealthandtheEnvironment(PRHE),andPatriceSutton,MPH,researchscientist,PRHE’sFromAdvancingSciencetoEnsuringPrevention(FASTEP)Alliance,fordevelopingtheoriginalcontentofthepesticideschapter.
ThecontentofthispublicationissolelytheresponsibilityofARHP.
ContributingStaffandConsultantsJenniferBaldwin,consultingdesigner
CarolineBrown,MPH,MS,MBA,educationassociate
EllenCohen,CertEd,DipEd,CCMEP,directorofeducation
RivkaGordon,PA-C,MHS,directorofstrategicinitiatives
BethJordan,MD,medicaldirector
AllisonTombrosKorman,MHS,associatedirectorofeducation
DianeShannon,MD,MPH,consultingwriter
WayneC.Shields,ARHPpresidentandCEO
FinancialDisclosureInformationThefollowingcommitteemembersand/orcontributingstaffhaveafinancialinterestoraffiliationwiththemanufacturersofcommercialproductspossiblyrelatedtotopicscoveredinthisissueofClinical Proceedings.Thesefinancialinterestsoraffiliationsareintheformofgrants,researchsupport,speakersupport,orothersupport.Thissupportisnotedtofullyinformreadersandshouldnothaveanadverseimpactontheinformationprovidedwithinthispublication.
Besinque:PharmacyAdvisoryBoardandSpeakersBureauforBarr/DuramedandWyeth(nowPfizer).
Worthington:SupportfromtheCedarTreeFoundationandtheKresgeFoundationthroughPlannedParenthood®FederationofAmerica.
Baldwin, Brown, Cohen, Gordon, Jordan, Tombros Korman, Paul, Sattler, Shannon, Schettler, Shields, Thomas, and Woodruffhavenoaffiliationstodisclose.
2| Environmental Impacts on Reproductive Health |January 2010
In the morning, a patient asks you during an annual well-woman visit how long before conceiving she should stop eating tuna fish. That afternoon, a woman in her third month of pregnancy asks you whether her headaches could be caused by exposure to chemicals in her workplace. On the drive home, you hear a report on the radio saying that the majority of infants are born with detectable blood levels of a chemical that leaches from plastics. When you arrive home, your teenage daughter asks whether she needs to rinse the bell peppers for your family’s salad. By the end of the day, are you wondering if you need a better understanding of environmental health issues?
Thepurposeofthismonographistoprovidefront-lineclinicianswithpracticalguidanceonenvironmentalreproductivehealthissues,basedonthebestavailableevidence.Becauseofethicalconcernsabouthumanstudieswithtoxicants,thebestavailableevidenceinmanycasesisderivedfromanimaldata.Inaddition,becauseofthemultifactorialnatureofmanyadversehealtheffects,itisoftenimpossibletoestablishdirectcause-and-effectrelationshipswithcertainty.Inmanyinstances,thismeansthatonecannotdefinitivelydeterminethataparticularsubstancewillresultinaparticularreproductivehealtheffect.However,oftenthereissufficientevidencefromanimalandpopulation-basedstudiestowarranttherecommendationthatpatientsreducetheirexposuretospecifictoxicants.
Thisdocumentprovidescliniciansatthefrontlinesofcarewiththeinformationtheyneedineverydaypracticetocounselpatientsonenvironmentalissuesthataffectreproductivehealth.Thismonographdefineskeyterms,discussesenvironmentalexposuresandhowtheymayaffectreproductivehealth,andhighlightsafewkeyexamplesofchemicalexposures.Throughtheuseofcasestudiesandvignettes,thedocumentillustrateshowclinicianscanhelppatientsassesspotentialenvironmentalexposuresandtakestepstoreducetheimpactontheirreproductivehealth.Thesecasestudiesandvignettesfocusonenvironmentalexposuresthatprimaryhealthcareprovidersarelikelytoencounterintheireverydaypracticeandthroughquestionsgeneratedbyanincreaseinmediaattention.Themonographconcludeswithacollectionoftoolsandresourcesthatclinicianscanusetoaddressenvironmentalhealthconcernsintheirdailypractices.
KeyDefinitionsEnvironmentalreproductivehealthisanemergingfieldthatincludesterminologyandbasicconceptsthatmaybeunfamiliartomanyclinicians.Animportantconcepttounderstandisthedistinctionamongthetermshazard,risk,andexposure.Althoughthetermshazard,risk,andexposurearesometimesmistakenlyusedinterchangeably,inenvironmentalreproductivehealth,thewordshavedistinctmeanings.
• Hazardisthepotentialforradiation,achemical,oranotherpollutanttocausehumanillnessorinjury.1,2
• Exposureistheprocessbywhichasubstancebecomesavailableforabsorptionbythetargetpopulation,organism,organ,tissue,orcell,byanyroute.3
• Riskisameasureoftheprobabilitythatdamagetolife,health,property,and/ortheenvironmentcanoccurasaresultofexposuretoagivenhazard.1
Thenextchaptercoversguidanceonenvironmentalreproductivehealthissuesforproviders.
References:
1.EnvironmentalProtectionAgency.Termsofenvironment.2009.Availableat:http://www.epa.gov/OCEPAterms/.AccessedNovember29,2009.
2.SchwartzJM,WoodruffTJ.Shaping Our Legacy: Reproductive Health and the Environment.SanFrancisco:UniversityofCalifornia-SanFrancisco,ProgramonReproductiveHealthandtheEnvironment.2008.
3.InternationalUnionofPureandAppliedChemistry.Glossaryoftermsusedintoxicology.2007.Availableat:http://sis.nlm.nih.gov/enviro/iupacglossary/frontmatter.html.AccessedNovember29,2009.
Introduction
Environmental Impacts on Reproductive Health |January 2010|3
ActionStepsforProvidersGiventhepotentialeffectsofenvironmentalexposuresonreproductivehealthandtheimportanceofpreventingpotentiallyharmfulexposures,itiscriticallyimportantthatfront-lineprovidersofwomen’shealthcareareabletoidentifypotentiallyharmfulenvironmentalexposuresandhelpmitigateorpreventthem.Inprovidingguidance,cliniciansmusttaketherealitiesofapatient’sdailylifeandthecertaintyofscientificevidenceintoconsideration.Ifthereisasimplewaytoavoidormitigateapotentiallyharmfulexposurethathasamoderateorgreatercertaintyofevidence,cliniciansshouldmaintainalowthresholdforrecommendingit.
Providerscantakeseveralspecificstepstosupporttheirpatientsinreducingenvironmentalexposures,including:
•Learningabouttheenvironmentalissuesintheirlocalarea,tobetterfocustheirinquirywithindividualpatients;
•Incorporatingquestionsaboutenvironmentalexposuresintoeveryhealthhistory;
•Suggestingstepstoreduceoravoidanyexposuresthatareidentified;
•Beingpreparedtogivespecificguidancetopatientswhoareormaybecomepregnant;
•Helpingpatientsassesstheirriskofenvironmentalexposureatwork;
•ProvidinginformationorreferringpatientstoreputableeducationalWebsites;and
•Usingtheirvoiceasclinicianstoshapepoliciesaimedatimprovingenvironmentalconditions.
TakinganEnvironmentalHealthHistory“CH2OPS,”whichstandsforCommunity,Home/Hobbies,Occupation/School,Personal,andSocioeconomic,isahelpfulmemoryaidforreviewingthevariousdomainsofapatient’slifeinwhichenvironmentalexposuresoccur.ProviderscanuseCH2OPSdomainswhentakingtheenvironmentalhistorytoassessapatient’senvironmentalexposuresandtoeducateandraiseawarenessaboutpotentialharmfulexpo-sures.Cliniciansalsocanhelpguidepatientsbylearningaboutandmakingpatientsawareofresourcesandalterna-tivesintheircommunities,homes,workplaces,andpersonallivesthatcanhelpthemtominimizeexposuretotoxicants.Clinicianscanconsultthefinalchapterofthismonograph,Resources for Providers and Patients,forresourcesfortheirowneducationandtohavereadyaccesstoinformationforpatients.Manyofthefollowingchaptersalsocontainresourcesandcounselingpoints,includedinshadedboxes,specifictothetopicaddressedinthatchapter.
Guidance for ProvidersThischapteroutlinesactionstepsthatclinicianscantake
andspecificguidancetheycanrecommendtohelp
patientsreducetheirexposuretoenvironmentaltoxicants.
4| Environmental Impacts on Reproductive Health |January 2010
Table1:ExamplesofGuidanceforPatients,BasedonCH2OPSMnemonic
Domain AreaofConcern ExampleofGuidance
Community
Hazardouswastesites Havewellwatertested
Solvents Patronizedrycleanersthatavoidtoxicsolvents
ToxicchemicalsAskbeautysalonstouseproductswithouttoluene,phthalates,andothertoxicchemicals
PesticidesBuyorganicproducewhenpossible;joincommunitygroupstoadvocateforrestrictionsonspraydriftsfromagriculturaloperations
Home/Hobbies
DrinkingwaterBeawareofthesafetyofprivatewellwaterandcommunitysourcesofdrinkingwater
FurnitureproductsReadlabelscarefully,contactmanufacturersifnecessarytoassesscontents,andavoidexposureifnecessary
Detergents
Automotivecareproducts
Adhesivesandsolvents(e.g.,forartprojects) Useinwell-ventilatedspaces
HouseholdcleanersUsenon-toxicproducts(e.g.,vinegarandbakingsoda);avoidmixingammoniaandchlorine;useammoniaandchlorinebleachsparingly,withventilation
HeavymetalsBeawareoffishadvisoriesforlocallycaughtfish(i.e.,forhobbyfishing);checkforleadpaintandpipes;followrecommendationsaboutseafoodconsumption(forbothspeciesandamount)
PlasticsAvoidfoodsandbeveragesinplasticsnumber3,6,and7;avoidvinylproducts;avoidheatingfoodinplasticcontainers
PesticidesAvoidusingpesticidesinhomes,lawns,gardens,oronpets;washfruitsandvegetables;buyorganicproducewhenpossible
Occupation/School
Chemicals
Becomefamiliarwithallchemicalsusedorencounteredatworkandlearnaboutanytoxicproperties;washexposedskin;changefromworkclothesattheworkplace;washexposedworkclothesseparately;useprotectivegear;takeextrastepstoavoidexposureifpregnantorplanningpregnancy
Radiation(e.g.,dentalorhealthcareworkers)orbiologicalagents(e.g.,laboratoryorhealthcareworkers)
Useprotectivegear;takeextrastepstoavoidexposureifpregnantorplanningpregnancy
Pesticides Avoiduseofpesticidesonschoolgroundsandintheworkplace
Heavymetals(e.g.,arsenic) Avoiduseofpressure-treatedwoodinplaygroundequipment
Personal
Diet,alcoholuse,tobaccouse,substanceabuse Reviewandmodifypersonalhabitstomaximizeoverallgoodhealth
MedicationsReviewanyprescriptionandnon-prescriptionmedicationswithhealthcareprovider
Insectrepellents Investigateingredientsofproducts;contactmanufacturerifnecessary
PersonalcareproductsandcosmeticsInvestigateingredientsofproducts;contactmanufacturerifnecessary;checkproductdatabases(e.g.,www.cosmeticsdatabase.com)
Socioeconomic
AirpollutionKnowtenantandcitizenrights;workwithcommunityorganizationsandgovernmentalagenciestoraiseawarenessofhazardsandadvocateforprevention
Heavymetals
Asbestos
Thenextchapterwilladdressthelinksbetweenenvironmentalexposuresandreproductivehealth,theconceptoftoxicity,andsomeofthemechanismsbywhichexposuresresultinnegativehealthoutcomes.
Environmental Impacts on Reproductive Health |January 2010|5
Environmentalhealthhasbeendefinedas“thebranchofpublichealththatprotectsagainsttheeffectsofenvironmentalhazardsthatcanadverselyaffecthealthortheecologicalbalancesessentialtohumanhealthandenvironmentalquality.”1Assuch,thefieldencompassesresearch,assessment,andguidanceaboutthehealtheffectsofavarietyofexposuresinourenviron-ment,includingradiation,chemicals,andsomebiologicalagents.Thismonographfocusesspecificallyonchemicalsandheavymetalssuchasmercurythatcanhaveadverseeffectsonreproductivehealth.
ChemicalsintheEnvironmentOfthe87,000chemicalsregisteredforcommerceintheUnitedStates,onlyone-tenthhavebeentestedforpotentialhealtheffects.2,3Ofthosethathavebeentested,onlyaportionhavebeenassessedforreproductivehealtheffects.Althoughmanyofthesechemicalsareintegralcomponentsintheproductionofimportantmaterialsandgoods,somemayadverselyaffecthumanhealthortheenvironment.
TestingofthechemicalsusedintheUnitedStatesislimitedbythefactthatcurrentlegislation—theToxicSubstancesControlAct(TSCA),whichwaspassedin1976—assumesthatmostchemicalsaresafeunlessprovenotherwise.ThesechemicalsmakeupalargemajorityofthechemicalsusedintheUnitedStatestoday.Furthermore,manychemicalsincommonuse—suchasthoseinpesticidesandmanypersonalcareproducts—arenotregulatedunderTSCA.3Inaddition,asaresultofadvancesintoxicology,includingbetterunderstandingoflow-doseeffects,manyexpertsbelievethatthecurrentregulatorymethodsfortestingtoxicityarenolongeradequate.
ConcernsAboutReproductiveHealthEffectsOverthepastseveraldecades,awarenesshasbeengrowingregardingthereproductivehealtheffectsofexposurestocertainchemicals.Scientists,clinicians,andpatientshaveconcernsaboutanumberofrecentlyidentifiedtrendsinfertilityandreproduction(seeFigure1).Someofthesetrendsarelocalizedtospecificgeographiclocations;othersaremorewidespread.
Giventhehistoryoftheslowresponsetoemergingdataontoxicants,manyscientists,clinicians,andadvocatesare
concernedthatdelaysinaddressingexposureswilloccuragain.14Experiencehasdemonstratedthatwaitinguntilfirm“proof”isavailablecancausesignificanttimelagsbetweenthepointwherethereisknowledgeofalinkbetweenhealthoutcomesandexposuretoanenvironmentaltoxicantandthetimewhenregulatoryactionistakenorclearguidancepro-vided.Inthepast,seriousstepstopreventandmitigatesomeenvironmentalthreatstopublichealthweretakenonlyafterdecadesofdatawerecollected—andthousandsoflivesaffected.Forexample,physiciansdidnotcounselpatientstoavoidtobaccoexposureuntilseveraldecadesaftertherewereclearscientificdataonthehealtheffectsofsmoking.Lead,mercury,andasbestosareotherexamplesofthisunfortunatelesson.Forthisreason,manyexpertsarefosteringmorewide-spreadadoptionofaprecautionary,orpreventive,approach.
Asearlyasthe1970sscientistsdevelopedtheconceptoftheprecautionaryprinciple,whichstates,“Whenanactivityraisesthreatsofharmtohumanhealthortheenvironment,precaution-arymeasuresshouldbetakenevenifsomecause-and-effectrelationshipsarenotfullyestablishedscientifically.”15Thisprincipleprovidesageneralapproachtoguidepolicy-making,patientcounseling,andpersonaldecision-makingaboutenvironmentalexposures.Onthebasisofcurrentlyavailableevidence,providerscantakeaprecautionaryapproachandrecommendactionstoavoidexposures.
The Links Between Environmental Exposures and Reproductive Health
6| Environmental Impacts on Reproductive Health |January 2010
Thischapterexplainshow
exposurestocertaintoxicants
mightresultinadverseeffects
onreproductivehealth.
ReproductiveTrendsinSomeGeographicAreasRaiseConcerns
•Increaseintesticularcancerincidence
•Decreasingspermcounts
•Declineinserumtestosterone
•Earlierpubertaldevelopmentingirls
•Fewermalesbeingborn
•Documentedincreasesincertaintypesofbirthdefects
Figure1:ReproductiveTrendsinSomeGeographicAreasRaiseConcerns4-13
ImpactonReproductiveHealthReproductivetoxicantsmaycontributetoaspectrumofadverseeffectsonreproductivehealth.Theseeffectsincludemenstrualirregularities,earlyordelayedpuberty,infertility,subfertility,earlypregnancyloss,fetaldeath,impairedfetalgrowth,lowbirthweight,prematurebirth,andstructural(e.g.,cardiacdefect)orfunctional(e.g.,learningdisability)birthdefects.16,17Theimpactofexposuretoareproductivetoxicantmaynotbeimmediatelyevident.Instead,theeffectsmayemergeatkeylifetransitions:forexample,whenattemptingconception,duringpregnancy,duringdevelopmentoftheembryoorfetus,inthenewborn,andduringtheoffspring’schildhood,puberty,andeventualfertilityasanadult.18Forthisreason,itisimportanttobeawareofthepotentialeffectsofasubstanceoveralongperiodoftime,ratherthanonlyduringtheperiodimmediatelyafterexposure.
ExposuretoReproductiveToxicantsSubstanceswithpotentiallyharmfuleffectsonreproductivehealtharepresentinwater,air,soil,dust,food,andconsumerproducts.Individualsmayencounterthesetoxicantsinthehome,community,school,orworkplace.Toresultinanadverseeffect,atoxicantmustcomeintocontactwithanindividualandenterthebody,astepreferredtoasbiologicuptake.Biologic uptakeisthepointatwhichexposureoccurs(seeFigure2).
Toxicantsenterthebodyinoneormoreofthreeways:inhala-tion,ingestion,orabsorptionthroughtheskin.Afterenteringthebody,toxicantsaredistributedtovarioustissuesandsubjecttometabolismandexcretion.Toxicants,ortheirmetabolites,traveltotargetorgans,suchasthethyroid,ovaries,ortestes,wheretheyexertbiologicaleffects.19Sometoxicantscanbestoredforlongperiodsoftimeinmuscle,bones,adiposetissue,orothersofttissues.Forexample,leadcanresideinbonefordecades.Thesesubstancesaredescribedashavinglong“half-lives”withinthebody.Theycancontinuetoleachfromthesetissuesandtraveltotargetorgansforlongperiodsoftime.
Inthesamewaythatallsmokersdonotdeveloplungcancer,everypersonexposedtotoxicantsdoesnotnecessarilyexperienceadversehealtheffects.Manyfactors—inadditiontotheexposuredoseandtheconcentrationoftoxicantintheenvironment—affectwhetheranexposureultimatelyresultsinaharmfulhealtheffect.19Thesefactors,whicharelistedinFigure3,candirectlyinfluencecells,tissues,andorgans,andtheycanaltergenefunctionorexpression.
Environmental Impacts on Reproductive Health |January 2010|7
Figure2:TheExposurePathway19
Hea
lth Effects Eva
luation
Exposure Evaluation
Environment
AccesstohealthcareAir,waterDietInfectionsNurturingenvironmentPhysicalagentsPovertyRadiationSocialsupportsystemsStressToxicchemicals
Genesandenvironmentareincontinuousconversation
Environmentalfactorscandirectlyimpactcells,tissues,organs
Environmentalfactorscanaltergenefunction,geneexpression
Genes
Figure3:EnvironmentalFactorsThatInfluencetheEffectsofToxicants
EnvironmentalTransportSite-specificExposureConditions
Contamination
Source
Exposure Point
EstimatedExposureDose
AbsorptionInternalDoseDistribution,Metabolism,Excretion
BiologicallyEffectiveDose
RepairandPhysiologicAdaptation Threshold
Biologic Update
(Exposure)
Target Organ Contract
Biologic Change
Clinical Disease
Whetherornotanenvironmentalexposureresultsinadverseeffectsonreproductivehealthinanindividualultimatelyde-pendsontheinteractionamongthesevariousfactors.Forthisreason,itisoftenimpossibletodocumentacleartiebetweenaspecifictoxicantandaspecificreproductivehealtheffect.
“Safe”LevelsEnvironmentalexpertsnowarechallengingthetraditionalassumptionsabout“safe”levelsoftoxicantexposuresatapopulationlevel.Recently,theNationalAcademyofSciencesstatedthatbasedontheextentofmultiplechemicalexposuresindividualsexperience,diseasefrequency,agestatusofthepopulation,andgeneticvariability,itisreasonabletoassumethatexposurestocertainchemicalswillcarrysomerisk,thoughthatriskmaybesmallorlarge.20Atpresent,itcanbechallengingtoquantifytheriskbecausetraditionaltestingofchemicals—usinghighdosesinadultanimals,oftenwithlittlegeneticorothervariability—makesitdifficulttopredictpreciselytheeffectsofeverydayexposures.14Forthisreason,itisdifficulttocreateclearclinicalguidancethataddressesthepotentialhealtheffectsoflowerlevelsofexposures,whicharemorecommoninthegeneralpopulation.Itisimportantforclinicianstorecognizethatsomeoccupationalexposurestohazardouschemicalsaresubstantiallyhigherthanthoseforthegeneralpopulation.
TimingofExposureThetimingofexposureisanotherfactorthatstronglyinfluencestheultimatebiologicaleffectofexposuretoenvironmentaltoxi-cants.Althoughexposuretothesesubstancescanaffect
individualsatallstagesoflife,exposureduringcriticalwindowsofsusceptibilitymayhavemoresignificance.Thesewindowsvarysomewhatdependingontheparticulartoxicantandincludeperiodsduringgestation,childhood,adolescence,andadulthood.Becausethesewindowsofsusceptibilityincludeveryearlypregnancy,cliniciansshouldcounselwomenaboutexposuresthroughouttheirreproductivelives.
MechanismsofEffectsSomechemicalshavedirecttoxiceffectsonthereproductivesystem.Endocrine-disruptingchemicals(EDCs)canexerteffectsonhormone-producingglands,suchasthethyroidorpituitary,whichinturnaffectreproductivehealth.EDCsalsomayhavedirecteffectsonthereproductivesystem.
Toxicantscanexertnegativereproductiveeffectsthroughseveralmechanisms,asshowninFigure4.21Somechemicalskillordamagecells.Ifthesecellsareoocytesorspermcells,exposuretothechemicalscanresultininfertility.Iftheyareothertypesofcells,developmentalproblemscanoccur.Forexample,theanti-seizuredrugphenytoincausesbirthdefectsbydisruptingnormalembryonicandfetaldevelopmentwithoutcausingmutationsinDNA.16,22OtherchemicalsalterthestructureofDNA,causinggenemutations.21Dependingonthegenesaffected,mutationscanresultinaninabilitytoconceiveorinbirthdefectsintheoffspring.SomechemotherapeuticagentscauseDNAmutations.Someindustrialchemicals,suchasbenzene,alsoaremutagenic.Finally,somechemicals,suchasdiethylstilbestrol(DES),causeanepigeneticeffect:theychangethewayinwhichgenesareexpressed,whichcanaffectreproductiveoutcomes.
8|EnvironmentalImpactsonReproductiveHealth|January 2010
Figure4:EnvironmentalEffectsHaveMultipleMechanisms21
Toxicants
Changes to DNAstructure/gene expression
▲
Interferencewith cell function
▲
Damage tooocytes/sperm
▲
PCBswereusedascoolantsandlubricantsinelectricalequipmentbeforetheirusewasbannedin1977.14,18Today,themainsourceofexposuretoPCBsisfoodcontamination.PCBsfirstenteredtheair,water,andsoilthroughmanufac-ture,use,anddisposal.Theymaystillbereleasedintotheenvironmenttodayfromhazardouswastesitesortheburningofcertainwastesinincinerators.BecausePCBsdonotbreakdownreadily,theyremainintheenvironmentformanyyears.Theyaretakenupbysmallorganismsinwaterandthenaccumulateinthefishthateattheseorganisms,insomecasesreachinglevelsthousandsoftimeshigherthanthatfoundinthewater.23ExposureandhumanlevelsofPCBshavedecreasedsince1977andhaverecentlyleveledoff.PCBexposureisamatterofconcernbecauseithasbeenlinkedtobothreproductiveeffects,includingmenstrualdisturbancesinwomenandreducedfertilityinmen,aswellasdevelopmentaleffects,suchasreducedbirthweight.24Table2liststhemanypotentialreproductiveeffectsofPCBs.
DESisanexampleofanendocrine-disruptingchemicalthatcausesdelayed,ratherthanrelativelyimmediate,effectsonreproduction.25-29Fromthe1930stothe1970s,thesyntheticestrogenDESwasprescribedtopregnantwomeninthemistakenbeliefthatthedrugwouldpreventmiscarriage.Later,researcherslearnedthatthedrugactuallyincreasestheriskofmiscarriageandotherpregnancycomplications(seeFigure5).Inaddition,thedrugcausesreproductivehealthabnormalitiesandreproductivetractmalignanciesinthechildrenofwomenexposedduringpregnancy.Animalstudiessuggestthatgrandchildrenalsomaybeaffected.17
Table2:LessonsLearnedfromPCBs18
Examplesofpotentialeffects:
• Alteredneurodevelopmentasaresultofinuteroexposure
•Endometriosis
•Reducedfertility
•Decreasedsemenquality
•Miscarriage
•Alteredpubertaldevelopment
•Reproductivetractmalformations
PolychlorinatedBiphenyls(PCBs)andDiethylstilbestrol(DES):
Well-Known Examples of Endocrine-Disrupting Chemicals
AlaterchapteraddressesbisphenolA,anotherEDC,indetail.
EnvironmentalImpactsonReproductiveHealth|January 2010|9
Figure5:GenerationalEffectsofDES18
WomenwhotookDESwhilepregnant
DESDaughters
DESGranddaughters DESGrandsons DESGranddaughters
DESSons
▲
▲
▲
▲
OvariesFallopian tubes
UterusCervix
VaginaBreastFertility
Pregnancy
Hormonal balanceMenopause
BonesImmune system
TestesPenis
ProstateEpididymis
FertilitySperm*
Seminal vesicles*
Ovaries*Uterus*
Immune system
PenisRete testis*
Seminal vesicles*Prostate
MenstruationOvaries*Uterus*
*=Effectsinanimals
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11.MackenzieCA,LockridgeA,KeithM.Decliningsexratioinafirstnationcommunity.Environ Health Perspect.2005;113(10):1295–8.
12.TravisonTG,AraujoAB,O’DonnellAB,etal.Apopulation-leveldeclineinserumtestosteronelevelsinAmericanmen.J Clin Endocrinol Metab.2007;92(1):196–202.
13.VuLT,NobuharaKK,LaurentC,etal.Increasingprevalenceofgastroschisis:population-basedstudyinCalifornia.J Pediatr.2008;152(6):807–11.
14.HarremoësP,GeeD,MacGarvinM,etal.,editors.ThePrecautionaryPrinciple in the 20th Century: Late Lessons from Early Warnings.Sterling,VA:EarthscanPublications.2002.
15.ScienceandEnvironmentalHealthNetwork.TheWingspreadConsensusStatementonthePrecautionaryPrinciple.1998.Availableat:http://www.sehn.org/wing.html.AccessedNovember13,2008.
16.TheCollaborativeonHealthandtheEnvironment.Birthdefectsandtheenvironment.2004.Availableat:http://www.healthandenvironment.org/birth_defects/peer_reviewed.AccessedNovember29,2009.
17.SchwartzJM,WoodruffTJ.Shaping Our Legacy: Reproductive Health and the Environment.SanFrancisco:UniversityofCalifornia-SanFrancisco,NationalCenterofExcellenceinWomen’sHealth.2008:39.
18.WoodruffTJ,CarlsonA,SchwartzJM,GiudiceLC.ProceedingsoftheSummitonEnvironmentalChallengestoReproductiveHealthandFertility:executivesummary.Fertil Steril.2008;89(Suppl1):e1–20.
19.CentersforDiseaseControlandPrevention.AgencyforToxicSubstancesandDiseaseRegistry.Public Health Assessment Guidance Manual.Chapter8:Healtheffectsevaluation:in-depthanalysis.Figure8-3.Availableat:http://www.atsdr.cdc.gov/HAC/phamanual/ch8.html.AccessedJanuary5,2009.
20.NationalAcademyofSciences.Science and Decisions:AdvancingRiskAssessment.Washington,DC:NationalResearchCouncil,CommitteeonImprovingRiskAnalysisApproachesUsedbytheU.S.EPA.2008.
21.KlaassenCD,editor.Casarett and Doull’s Toxicology:TheBasicScienceofPoisons.7thed.NewYork,NY:McGraw-HillPublishingCompany.2007.
22.WinnLM,WellsPG.EvidenceforRas-dependentsignaltransductioninphenytointeratogenicity.Toxicol Appl Pharmacol.2002;184:144–52.
23.AgencyforToxicSubstancesandDiseaseRegistry.ToxFAQs™forPolychlorinat-edBiphenyls(PCBs).2007.Availableat:http://www.atsdr.cdc.gov/tfacts17.html#bookmark04.AccessedNovember20,2009.
24.AgencyforToxicSubstancesandDiseaseRegistry.Toxicologyprofileforpolychlorinatedbiphenyls.2000.Availableat:http://www.atsdr.cdc.gov/toxprofiles/tp17.html.AccessedDecember15,2009.
25.TheDESCancerNetwork.Timeline:ABriefHistoryofDES.Availableat:http://www.descancer.org/timeline.html.AccessedDecember18,2008.
26.DieckmannWJ,DavisME,RynkiewiczLM,etal.Doestheadministrationofdiethylstilbestrolduringpregnancyhavetherapeuticvalue?1953.Am J Obstet Gynecol.1999;181(6):1572–3.
27.HerbstAL.Adenocarcinomaofthevagina.Associationofmaternalstilbestroltherapywithtumorappearanceinyoungwomen.N Engl J Med.1971;284(15):878–81.
28.NationalInstituteofEnvironmentalHealthSciences.DESStudy.Availableat:http://www.niehs.nih.gov/research/atniehs/labs/epi/studies/des/index.cfm.AccessedNovember13,2008.
29.SchragerS,PotterBE.Diethylstilbestrolexposure.Am Fam Physician.2004;69:2395–2400.
10|EnvironmentalImpactsonReproductiveHealth|January 2010
Althoughpatientscantakemanystepstomitigatetoxicexposuresandpotentiallyincreasetheoddsofasuccess-fulpregnancyoutcomeandoverallreproductivehealth,theeliminationofallhazardousenvironmentexposuresisanunrealisticgoal.Itismostimportanttomakechangesthatreduceoreliminatesignificant,knownreproductivehazards(e.g.,smokingcessationtoavoidknownadversepregnancyoutcomes,eliminationofknownreproductivetoxicantsintheworkplace)ratherthantryforcompleteeliminationofexposuretoallpotentialhazards.Patientsneedabalancedperspectiveonthereproductivehealthrisksofenvironmentalexposures.Theirperspectiveshouldbeinformedasmuchaspossiblebyempiricaldata,whilerecognizingthatmanypotentialtoxicantshavenotundergonesufficientsafetytestingtogeneratereliabledata.Healthcareproviderscanhelppatientsachievethisbalancedperspective.
PopulationVersusIndividualRiskCliniciansworkwithindividualpatients,notwholepopula-tions.Oneofthechallengesofclinicalcareistranslatingdataoneffectsseeninapopulationintoinformationonreal-liferisksforanindividualpatient.Providersshouldremember—andconveytopatients—thattheelevatedrisksidentifiedinpopulation-widestudiesmayrepresentasmallrisktoan
individualanddependonmultiplefactorsthatinfluencethatperson’svulnerabilitytotheeffect.Itisimportanttorememberthatarareeventwillremainrareforanindividual,eveniftheriskdoublesortriples.Forexample,ifachemicalincreasestheriskofaparticularhealthoutcomefrom1in100,000to3in100,000,itremainsasmallriskoverall.
However,evenamodestincreaseinriskcantranslateintoasizablepublichealthconcerniftheexposedpopulationislargeenough.Inaddition,alargeincreaseinthepopulation-wideriskhasimportantimplicationsforindividuals,evenifthenumberofexposedindividualsisnothigh.Figure6illustrateshowasmallshiftinthedistributionofanattributeinapopula-tion(inthiscaseIQ)canaffectalargenumberofindividuals.TheeffectoflowlevelsofleadexposureonIQisrelativelysmallforanindividualwithanIQscoreneartheaverage,whichis100.However,thissmallshifthasadramaticeffectatthelowandhighendsofthedistributioncurve,whicharereferredtoasthe“tails.”
Inthegraph,theareaunderthelefttailrepresentsthepropor-tionofthepopulationwithanIQoflessthan70,whichisthelevelusedtodefinesignificantintellectualimpairmentormentalretardation.WhentheaverageIQinthepopulationis100,thereareabout6millionpeoplewhomeetthecriteria
Putting Risk in Perspective Thischapterfocusesonhowproviderscanhelppatientstokeep
environmentalrisksinperspective.
Figure6:SmallIndividualEffectsCanHaveSignificantPopulationEffects1
EnvironmentalImpactsonReproductiveHealth|January 2010|11
40 60 80 100 120 140 160
Mean=100
70 IQ 130
6.0 million:“intellectually
impaired”
6.0 million:“intellectually
gifted”
▲
▲ ▲ 40 60 80 100 120 140 160
Mean=95
70 IQ 130
2.4 million:“intellectually
gifted”
▲
▲ ▲
9.4 million:“intellectually
impaired”
forsevereintellectualimpairment.IftheaverageIQwereshiftedto95,therewouldbeasignificantincreaseinthenumberofintellectuallyimpairedindividuals.Tragically,thisshifttotheleftcouldmeanthedifferencebetweenaperson’sabilitytoliveindependentlyandbeingunabletomanagehisorherowncare.Thus,population-basedshiftsinIQofjustafewpoints—duetolow-levelleadexposure,forexample—haverealeffectsinthemiddleofthedistributioncurvebutdramaticeffectsonthenumberofindividualsatthelowandhighendsofthedistribution.Ifthedistributioncurvesfortestosteronelevel,spermcount,orthyroidhormonelevelweresimilarlyshiftedduetoanenvironmentalexposure,theclinicalsignificancealsocouldbesimilar.
TheRelativeImpactofVariousFactorsonReproductiveOutcomesProviderscanhelppatientsputenvironmentalrisksinperspectivebyhelpingthemtakeabalancedapproachtoriskprevention.Forexample,apregnantwomanshouldunderstandthatchangessuchassmokingcessationandavoidanceofreproductivetoxicantsatworkarebothimportantstepsforreducingreproductiverisks.
Clinicianscansupportpatientsbyprovidingcomprehensiveguidancetoallwomenofreproductiveage.Topicsshouldincludenutrition,physicalactivity,familyplanning,chronichealthproblems,intimatepartnerviolence,substanceabuse,smoking,mentalhealth,andaccesstocare,aswellasavoidanceofharmfulenvironmentalexposures.Armedwiththisinformation,patientscanfocusonsettingprioritiesforchangestoincreasethelikelihoodofpositivereproductivehealthoutcomes.
Thenextchapterscoversomeexposuresthataresalientforfront-lineprovidersofwomen’shealthservices:pesticides,methylmercury,chemicalexposuresintheworkplace,andplastics-relatedchemicals,suchasbisphenolA.References:
1. Weiss B. Endocrine disruptors and sexually dimorphic behaviors: a question of heads and tails. Neurotoxicology. 1997;18:581–6.
Syntheticpesticidesaresubstancesusedtoinhibitthegrowthoforkillunwantedorganisms,suchasinsects,fungi,plants,androdents.1Thismonographaddressesonlysyntheticchemicalpesticidesorchemicallyderivedpesticides.
Chemicalpesticideformulationscontaintwotypesofingredi-ents:activeandinert.Activeingredientsarethosethatexertthedesiredpesticidaleffect:inhibitingthegrowthoforkillingtheunwantedorganisms.Inertingredientssupportthefunctionoftheactiveingredients.However,“inert”isnotsynonymouswith“benign.”2,3Someinertingredientshavebeenshowntobereproductivetoxicants.
ExposurestoPesticidesUseofchemicalpesticidesiswidespreadintheUnitedStates.AccordingtotheEnvironmentalProtectionAgency,morethan1.2billionpoundsofthechemicalsareusedeachyear.4Householduserepresentsasmuchas10percentofthetotalamountusedannually.Infact,pesticidesareusedin78millionUShouseholds.4Theyareoftenusedforinsectandrodentinfestation,lawnandgardencare,andprotectionagainstfleasandticks.
Individualsareexposedtopesticidesthroughanumberofdifferentsources:residueonfood,contaminatedtapwater,oc-cupationalexposure,andcommunityapplicationofpesticides.5,6Theyalsoareexposedfromtheuseofinsecticides,insectrepel-lents,rodenttraps,weedkillers,andpetfleaproductswithinthehome.Inaddition,individualsareexposedthroughcontami-nateddustinthehomeandpesticidestrackedinfromoutdoorsbypetsandhumans.5,6
Pesticides
Thischapterfocuseson
pesticides,chemicalstowhich
manyindividualsareexposed
intheirhomes,workplaces,
schools,andcommunities.
12|EnvironmentalImpactsonReproductiveHealth|January 2010
DataontheReproductiveHealthEffectsofPesticidesDataonthehealtheffectsofpesticidescomeprimarilyfromanimalstudiesandpopulation-basedepidemiologicalstudies.Randomizedclinicaltrialsthatstudytheeffectsofpesticideexpo-sureonhumanswouldbeunethical.Table3showssomeofthepotentialreproductivehealtheffectsofpesticides.Anexampleofaknownreproductivehealtheffectinanimalsisdecreasedeggproductionandembryoviabilityinbirdsassociatedwithexpo-
suretoatrazine,achemicalusedtocontrolgrassesandweedsincornfields.7Examplesofknownreproductiveeffectsinhumansincludeearlypregnancylossassociatedwithexposuretoethyl-eneoxide,achemicalusedasasterilanttokillbacteria,mold,andfungi;impairedneurologicaldevelopmentassociatedwithexposuretoorganophosphates;andreducedmalefertilityas-sociatedwithexposuretotheherbicidedibromocholorpropane(DBCP).8Theeffectsinhumanswerefoundinseveralepidemio-logicalstudiesthatdemonstratedfairlyconsistentassociationsandevidenceofexposure-riskrelationshipsaftercontrollingforpotentialconfoundingfactors.
Healthcareprovidersshouldeducatepatientsaboutthemanystepstheycantaketopreventexposuretopesticidesathome.Providersalsoshouldadvisepatientswhoworkinoccupationssuchaspestcontrol,landscaping,agriculture,gardening,orconstructionaboutlimitingormitigatingpesticideexposureattheworkplace.Providerscanrecommendthefollowingpointstoreducepatients’exposurestopesticides:12,13
•Preventpestproblemsinthehomeandthusreducetheneedforpesticides.Waystopreventpestproblemsinclude:
—Fixleakyplumbingandremovesourcesofwater,whichattractpests.
—Usetightlysealedcontainersforfood,foodscraps,andgarbage.
—Avoidleavingpetfoodoutovernight.
—Sealcracksinbaseboards,walls,andfloorstopreventaccesstothehome.
—Keepfloorsandsurfacesclean.
—Usealternativestopesticides.
•Reducepesticideexposurefromfood:
—Peelorthoroughlywashfruitsandvegetables.
—Ifpossible,buyorganicfoodsandproduce.
AdditionalProviderResourcesonPesticides:•PesticideActionNetwork:PesticideDatabase
AdditionalPatientResourcesonPesticides:•TheEnvironmentalWorkingGroup:the“DirtyDozen”list
(seeFigure7)ofthe12mostcommonlycontaminatedfruitsandvegetables.
CounselingPatientsonPesticideExposure
Table3:PotentialReproductiveHealthEffectsofVariousPesticides9-11
Female Male Offspring
•Reducedfertility•Earlypregnancyloss•Latepregnancyloss•Prematurebirth•Reproductivesystemeffects
•Reducedfertility•Geneticalterationsinsperm•Reducednumberofsperm•Damagetogerminalepithelium•Alteredhormonefunction
•Lowbirthweight/smallforgestationalage
•Developmentaldefects
EnvironmentalImpactsonReproductiveHealth|January 2010|13
Figure7:TheDirtyDozenFoodList14
References:
1.EnvironmentalProtectionAgency.AboutPesticides:WhatIsaPesticide?2009.Availableat:http://www.epa.gov/pesticides/about/index.htm.AccessedJuly14,2009.
2.CoxC,SurganM.Unidentifiedinertingredientsinpesticides:implica-tionsforhumanandenvironmentalhealth.Environ Health Perspect.2006;114(12):1803–6.
3.PesticideActionNetworkNorthAmerica.PesticideregulationintheU.S.Availableat:http://www.panna.org/node/835.AccessedJanuary3,2010.
4.KielyT,DonaldsonD,GrubeA.PesticidesIndustrySalesandUsage:2000and2001MarketEstimates.Washington,DC:USEnvironmentalProtec-tionAgency;2004.Availableat:http://www.epa.gov/oppbead1/pestsales/01pestsales/market_estimates2001.pdf.AccessedOctober15,2009.
5.EnvironmentalProtectionAgency.Pesticides.Availableat:http://www.epa.gov/pesticides.AccessedNovember15,2008.
6.NationalPesticideInformationCenter.http://npic.orst.edu/index.html.AccessedNovember15,2008.
7.EnvironmentalProtectionAgency.Decisiondocumentsforatrazine.2006.Availableat:http://www.epa.gov/oppsrrd1/REDs/atrazine_combined_docs.pdf.AccessedNovember29,2009.
8.WigleDT,ArbuckleTE,TurnerMC,etal.Epidemiologicevidenceofrelationshipsbetweenreproductiveandchildhealthoutcomesandenvironmentalchemicalcontaminants.J Toxicol Environ Health B Crit Rev.2008;11(5−6):373–517.
9.Figà-TalamancaI,TrainaME,UrbaniE.Occupationalexposurestometals,solvents,andpesticides:recentevidenceonmalereproductiveeffectsandbiologicalmarkers.Occup Med.2001;51(3):174–88.
10.WhortonMD,KraussRM,MarshallS,MilbyTH.Infertilityinmalepesticideworkers.Lancet.1977;2:1259–61.
11.BretveldRW,ThomasCMG,ScheepersPTJ,etal.Pesticideexposure:thehormonalfunctionofthefemalereproductivesystemdisrupted?Reprod Biol Endocrinol.2006;4:30.
12.UniversityofCalifornia-SanFransisco,ProgramonReproductiveHealthandtheEnvironment.Toxicmatters.Availableat:http://www.prhe.ucsf.edu/prhe/index.html.AccessedDecember26,2009.
13.EnvironmentalProtectionAgency.Do’sanddon’tsofpestcontrol.2008.Availableat:http://www.epa.gov/pesticides/controlling/dosanddonts.htm.AccessedDecember27,2009.
14.EnvironmentalWorkingGroup.Shopper’sguidetopesticides.Availableat:http://www.foodnews.org/.AccessedDecember27,2009.
15.MichelsTC,TiuAY.Secondtrimesterpregnancyloss.Am Fam Physician.2007;76:1341–-46.
CaseStudy:Kate
Kateisa29-year-oldwomanwhorecentlyexperiencedapregnancylossat10weeks’gestation.Therewerenosignsofanyproblemswiththepregnancy.Sheiscurrentlyworkingtowardadegreeinlandscapedesignandworkspart-timeataplantnursery.Sheasksyouwhetherpesticidescouldhavecausedthemiscarriage.
ThefirststepyoutakeistocompleteanenvironmentalhistorytoassessKate’sexposuretopesticidesandotherreproduc-tivetoxicants.YouaskKateaboutotherpotentialsourcesofpesticideexposure.Shetellsyouthatbecauseoffinancialconstraintswhileshe’sinschool,sheandherhusbandnowchooseconventionallygrownratherthanorganicproduce.Theyusepesticidesontheirhouseplantstocontrolaphidsbutdon’tuseanyintheirvegetablegarden.Theydonothaveanypets.Youaskhertofindoutmoreaboutthespecificchemicalsshe’sexposedtoathomeandatwork.
Katereturnsthenextweekandtellsyouthatthenurseryownersaidtheyprimarilyusetheherbicidepropazine.Athome,Kateandherhusbanduseaninsecticidetokillroaches.
YoutellKatethatitisimpossibletoknowwhatcausedthepregnancyloss.Youexplainthatasmanyas40percentofallconceptionsendinpregnancyloss,manyoccurringbeforeawomanrealizessheispregnant.15However,therearesomestepsshecantaketoreduceherexposuretopotentiallyharmfulchemicalsbyaddressingoccupationalexposuresandpesticidesinthehome.YouhelpKaterankheroptions,firstaddressingoccupationalexposures,becausetheseareprob-ablythemostsignificant,thenreducingpesticideexposureinthehome.Yourecommendthefollowing:
Toreduceworkplaceexposure,yourecommendthatKate:
•Bylaw,employersareresponsibleformaintainingasafeworkenvironmentandmustprovideinformationandeducationabouthazardouschemicalsintheworkplace.YouinformKateoftheserightsandreferhertoanoccupationalhealthexpertandresourcesforadditionalhelpandinformation.
•Takestepstominimizeexposurebywashingexposedskin,changingoutofworkclothesattheworkplace,launderingworkclothesseparately,andleavingworkshoesattheentrywayofthehome.
Toreducepesticideexposureinthehome,Kateshould:
•Switchtolesstoxicmethodsforcontrollinginsectsonhouseplants,suchascitrusspray.
•Ifpossible,buyorganicproduce.Ifnot,chooseconventionallygrownfruitsandvegetablesthatarelesslikelytobecontaminatedandwashthoroughlyorpeelproduce.
Thiscasestudyillustratestheneedtoconsiderallareasofpotentialpesticideexposurewhenconductinganenvironmentalhealthassessment.Althoughthelinkbetweenpesticideexposureandthepregnancylossisnotcertain,itisprudenttorecommendprecautionstoreduceexposure,especiallyduringpregnancy.
Thenextchaptercoversanenvironmentalsubstancetowhichmanypeopleareexposed:methylmercury.
14|EnvironmentalImpactsonReproductiveHealth|January 2010
TheReproductiveImpactofMethylmercuryMethylmercuryisconsideredadevelopmentaltoxicantthatisfoundprimarilyinpredatorymarineandfreshwaterfish.However,therearemanyhealthbenefitsfromconsumptionoffishandseafood,whichcanmakeprovidingguidancetopatientsonfishandseafoodconsumptioncomplicated.TheNationalAcademyofSciences,inits2000review,supportscontinuedfishintake.1Thereportstates, “Because of the ben-eficial effects of fish consumption, the long-term goal needs to be a reduction in the concentrations of methylmercury in fish rather than a replacement of fish in the diet by other foods. In the interim, the best method of maintaining fish consumption and minimizing mercury exposure is the consumption of fish known to have lower methylmercury concentrations.”
SourcesofMethylmercuryThemostcommonsourceofmethylmercuryexposureintheUnitedStatesisseafoodthathasbecomecontaminatedwiththeheavymetal.2Therearebothgeophysicalandhumancausesofenvironmentalmercurycontamination,inparticular,pollutionfromcoal-firedpowerplants.3Airbornemercuryfromthesepowerplantsandothersourcesfallstotheearth
andaccumulatesinstreams,lakes,oceans,andwetlands.Inorganicmercuryisconvertedtoorganicmethylmercurybybacteriainaquaticsediments.Methylmercuryisaparticularlytoxicformofthechemicalthatbioaccumulates,orcollectsingreaterconcentrationthaninthesurroundingenvironment,assmallerfishareconsumedbylargerfishthatareconsumedbyevenlargerfishinthefoodchain.4Ingeneral,methylmercuryconcentrationsarehighestamonglargepredatorymarinefishthathavelivedlonger,becauseofthegreateraccumulationofmethylmercuryintheirbodiescomparedwithyounger,smallerfish.4However,somesmallpredatoryfreshwaterfishcanbehighlycontaminatedwithmethylmercuryaswell.
AsshowninFigure8,whichisbasedonNationalHealthandNutritionExaminationSurvey(NHANES)datacollectedfrom1999to2004,thereisasignificantpositivecorrelationbetweenreportedintakeofseafoodandbloodmercurylevel.2
Forexample,childrenborntowomenlivingintheFaroeIslandswhoconsumedaheavydietofcontaminatedseafoodduringpregnancywerefoundtohavelowerscoresinIQ,languagedevelopment,visual–spatialskills,grossmotorskills,memory,andattention.5Whenthosechildrenreducedtheirconsumptionoftheheavilycontaminatedseafood,severaloftheobservedneurologicaldeficitsimproved.
Methylmercury Thischapterfocusesonmethylmercury,anenvironmentalcontaminantthathasdocumented
adverseeffectsonfetaldevelopment.
Figure8:FishIntakeandBloodMercuryLevel2
Never/rarely 1–2/mo 1–2/wk 3/wk 4/wkormore(n = 1,220) (n = 1,470) (n = 1,917) (n = 301) (n = 212)
Reported frequency of fish/shellfish consumption
6–
5–
4–
3–
2–
1–
0–
Tota
l BH
g (
µg/L
)
75th percentile Geometric mean 25th percentile
EnvironmentalImpactsonReproductiveHealth|January 2010|15
Seafoodintake—andbloodmercurylevels—varyacrosstheUnitedStates.Figure9demonstratesthatbothintakeandbloodmercurylevelsarehighestintheNortheastregionofthecountry.2AstudybasedonNHANESdatafoundthatAsianethnicityandhigherincomealsowereassociatedwithgreaterseafoodintakeandhigherbloodmercurylevels.A2008NewYorkTimesjournalistreportedthatsushi
purchasedinManhattanwasfoundtohavehighlevelsofmethylmercury.6Sushiobtainedatfiveofthe20restaurantstestedhadmercurylevelshighenoughtomeetcriteriafortheFoodandDrugAdministration(FDA)totakelegalactiontoremovetheproductsfromthemarket.Thisexampleillustrateshowimportantitisforproviderstoconsidertheriskofmethyl-mercuryexposureinallwomen.
Figure9:FishIntakeandBloodMercuryLevel2
BHg concentration[geometric mean (95% CI)]
1.14(0.84–1.56)0.95(0.82–1.09)0.90(0.80–1.02)0.66(0.58–0.74)
Estimated 30–day Hg intake [arithmetic mean (95% CI)]
0.87(0.67–1.07)0.68(0.57–0.79))0.69(0.61–0.78)0.48(0.438–0.52)
West
Midwest
South
Northeast
MinamataDisease,whichwasfirstidentifiedinMinamata,Japan,in1956,demonstratedadirectlinkbetweenhigh-dosemercuryexposureandsevereneurologicalsymptoms.Methyl-mercurydischargedfromachemicalfactoryintotheYatsushiroSeacontaminatedfishandshellfishinthelocalarea.7Localresidentsandfishermenbeganexhibitingsymptomsthatsug-gestedmercurypoisoning,suchasparesthesias,blurredvision,concentricvision,deafness,dyskinesia,seizures,coma,andinsomecases,death.8Deficitsinneurologicdevelopmentwereseeninchildrenwhosemotherswereexposedwhenpregnant.Urinetestsrevealedhighlevelsofmethylmercuryinaffected
individuals,andtestingofwastewaterfromthefactoryshowedmethylmercurycontamination.Thecompany—ChissoCorpora-tion—onlyceasedpollutingin1968,whenthemethodofmer-curyproductionpreviouslyusedbecameoutdated.In1969,thecompanywasforcedintocourt.Later,researchersdeterminedthatthecompanyhadconsistentlyreleasedmethylmercuryintothebayfrom1932until1968,despitethegrowingevidenceofadverseeffects.9TheMinamatatragedyledscientiststoexplorethepossibilitythatadversehealtheffectswouldbeseenatfarlowerexposuresthanthoseexperiencedinMinamata.
16|EnvironmentalImpactsonReproductiveHealth|January 2010
RecommendationsforFishIntakeRecommendationsforfishintakemustbalancetwofactors:thenutritionalbenefitsofseafoodandtherisksassociatedwithmethylmercuryexposure.TheFDAadvisesthatchildrenandpregnantwomenavoideatingshark,swordfish,kingmack-erel,andtilefish,becausetheyarelargepredatorymarinefishthatareexcessivelycontaminatedwithmethylmercury.10Insomelocations,freshwaterfishalsoarehighlycontaminated.Saferchoicesaretrout,shrimp,salmon,tilapia,andsardines(seeTable4).TheFDAalsorecommendsthatpregnantwomenandchildreneatnomorethan12ouncesperweekofthesefish.10TheNaturalResourcesDefenseCouncil,anenvironmentalactiongroupwithastrongscientificfoundation,advisesthatinadditiontotheguidelinesonspeciesselectionandservingsperweek,pregnantwomenandchildreneatnomorethantwocansoflighttunaperweek,ortwo-thirdsofacanperweekofwhitealbacoretuna.11TheEnvironmental
WorkingGroup,aconsumeradvocacygroup,recommendsthatpregnantwomenchoosefishspeciescarefully,anditusesscientificguidelinesfromtheFDA—nottheFDAconsump-tionadvisory—tocalculatethemaximumamountoftunathatcanbeconsumedsafely.12ThegroupproposesthattheFDAconsumptionadvisorycouldexposewomentounsafelevelsofmercury,iftheironlyintakeofseafoodistuna.
Table4:RecommendationsforSeafoodSpecies10
SpeciestoAvoid SaferSpecies
•Shark•Swordfish•Kingmackerel•Tilefish•Albacoretuna
•Trout•Salmon•Tilapia•Sardines•Shrimp
Inmanystates,freshwaterfishhaveextremelyhighlevelsofmethylmercury.Cliniciansshouldbefamiliarwiththesituationintheirregiontobetteradviseallwomenofreproductiveage—whetherpregnantornot—aboutsafefishconsumption.TheycanaccessinformationaboutthesafetyoffishinlocalwatersthroughfishadvisoriesfromtheEnvironmentalProtectionAgencyandstatehealthdepartments.
Providerscanrecommendthefollowingpointsaboutsafefishconsumption:•Patientsshouldcontinuetoeatfishbutshouldselectspecies
carefully;limitweeklyconsumptionofthe“lesssafe”speciestoreducetheriskofmethylmercuryexposure.
•Becausepolychlorinatedbiphenyls(PCBs),anotherseafoodcontaminant,accumulateinfattytissue,individualsshouldtrimthefatfromfishbeforecooking.10,11,13
•Wheneatingoutatrestaurants,patientsshouldusethesamepreventivetacticsasathome:avoidspecieshighonthefoodchain,suchasshark,swordfish,andkingmackerel(referringtowalletcards,liketheSeafoodWatchPocketGuide,mayhelp)andtrimfatfromthefishbeforeeating.
AdditionalProviderResourcesonFishConsumption:•ARHPQuickReferenceGuideforClinicians:FishConsumption
toPromoteGoodHealthandMinimizeContaminants
AdditionalPatientResourcesonFishConsumption:•ARHPfactsheet:HealthMatters:HealthyFish,HealthyFamilies
•EnvironmentalWorkingGroup:TunaCalculator
•NaturalResourcesDefenseCouncil:MercuryContaminationinFish(includesamercurycalculator)
CounselingPatientsonFishConsumption
EnvironmentalImpactsonReproductiveHealth|January 2010|17
References:
1.NationalAcademyofSciences.Toxicologicaleffectsofmethylmercury.2000.Availableat:http://nap.edu/openbook.php?record_id=9899&page=R1.AccessedDecember3,2009.
2.MahaffeyKR,ClicknerRP,JeffriesRA.Adultwomen’sbloodmercuryconcentrationsvaryregionallyintheUnitedStates:associationwithpatternsoffishconsumption(NHANES1999-2004).Environ Health Perspect.2009;117:47–53.
3.ChenCY,SerrellN,EversDC,etal.Meetingreport:methylmercuryinmarineecosystems—fromsourcestoseafoodconsumers.Environ Health Perspect.2008;116:1706–12.
4.EnvironmentalProtectionAgency.Whatyouneedtoknowaboutmercuryinfishandshellfish.March2004.Availableat:http://www.epa.gov/water-science/fish/advice/.AccessedAugust31,2009.
5.GrandjeanP,WeiheP,WhiteRF,etal.Cognitivedeficitin7-year-oldchildrenwithprenatalexposuretomethylmercury.Neurotoxicol Teratol.1997;19:417–28.
6.BurrosM.HighMercuryLevelsAreFoundinTunaSushi.New York Times.January23,2008.Availableat:http://www.nytimes.com/2008/01/23/dining/23sushi.html.AccessedNovember4,2009.
7.NationalInstituteforMinamataDisease.MinamataDiseaseArchives.Avail-ableat:http://www.nimd.go.jp/archives/english/tenji/e_corner/etop.html.AccessedDecember11,2009.
8.BolgerPM,SchwetzBA.Mercuryandhealth.N Engl J Med.2002;347:1735–6.
9.TheTrade&EnvironmentDatabase.AmericanUniversity.Casestudy:Minimatadisaster.1997.Availableat:http://www1.american.edu/TED/MINAMATA.HTM.AccessedDecember11,2009.
10.FoodandDrugAdministration.Whatyouneedtoknowaboutmercuryinfishandshellfish:adviceforwomenwhomightbecomepregnant,womenwhoarepregnant,nursingmothers,andyoungchildren.March2004.Availableat:http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm110591.htm.AccessedAugust31,2009.
11.NaturalResourcesDefenseCouncil.Mercurycontaminationinfish:protectyourselfandyourfamily.2008.Availableat:http://www.nrdc.org/health/effects/mercury/protect.asp.AccessedJuly27,2009.
12.EnvironmentalWorkingGroup.EWGtunacalculator.2009.Availableat:http://www.ewg.org/tunacalculator.AccessedDecember3,2009.
13.EnvironmentalProtectionAgency.Polychlorinatedbiphenyls(PCB)update:impactonfishadvisories.September1999.Availableat:http://www.epa.gov/waterscience/fish/files/pcbs.pdf.AccessedAugust31,2009.
CaseStudy:Lori
Loriisa32-year-oldwomanwhois30weekspregnant.Shehastwosmallchildrenathomeandisaschoolteacher.Atherprenatalvisit,sheasksyouaboutanarticleshereadrecentlyinawomen’smagazine.ThearticlestatedthatchildrenofmotherswhoatefishduringpregnancyhadhigherIQscoresthanchildrenofmotherswhoavoidedfish.Loriisconfused.Shehasavoidedallfishsinceshelearnedshewaspregnantbecauseofconcernaboutmercurycontamination.Whatdoyoutellher?
YoucouldbeginbytellingLorithatscientificreportshavecontinuedtoshowthevalueofomega3fattyacids,whichareabundantinseafood.Thesefatsappeartobeespeciallyimportanttohealthyneurologicaldevelopment.Forthisreason,Lorimaywanttoaddseafoodbackintoherdiet,althoughwithcaution.Shealsocouldobtainthesenutrientsbytakingdistilledfishoilcapsules.Othersourcesofomega3fattyacidsincludemanygreenvegetables,canolaoil,walnuts,flaxseed,andflaxseedoil.Inaddition,wildAlaskansalmonisagoodsourceofomega3fattyacidsandlowinmethylmercurycontamination.
YoumightaskLoritodescribeherfishintakepriortopregnancy.Didsheeatcannedtuna?Ifso,whatkind?Didsheeatsushi?Swordfish?Didsheeatfishlocallycaughtforsport?Howmanyservingsofseafooddidsheeateachweek?TheanswerstothesequestionscanhelpyouguideLoriinmakingsaferchoicesaboutseafoodspeciesandamounts.Finally,giveLoriresources,likethoseprovidedinthismonograph,tohelpherplanandmonitorherseafoodintakeandthatofherchildren.
Thenextchaptercoversexposurestosyntheticchemicalsintheworkplace.
18|EnvironmentalImpactsonReproductiveHealth|January 2010
Workplaceexposureisanimportantwaythatpatientscomeintocontactwithreproductiveanddevelopmentaltoxicants.Workplaceexposuretosuchchemicalsisnotlimitedtoemployeesofchemicalmanufacturingplantsorotherfacilitiesthatdirectlyinvolvetheuseofchemicals.Exposuretosubstanceswithdevelopmentalandreproductivehealtheffectscanoccurinalltypesofoccupations,includingbutnotlimitedtohealthcare,farming,nailandhairstyling,professionalhomecleaning,andlandscaping.Individu-alsalsomaybeexposedinthehomeorthroughhobbiestothesamereproductiveanddevelopmentaltoxicantsthatarefoundintheworkplace.Forexample,solvents,whichincreasetheriskofadversepregnancyoutcomes,areusedinanumberofworkplacesettingsandarealsofoundinavarietyofconsumerproductssuchaspaintstrippersandhobby-relatedproductssuchaspaintorink.1
TheReproductiveHealthImpactofChemicalExposuresAnumberofadversereproductiveeffectscanoccurasaresultofexposuretotoxicantsintheworkplace,andexposuretotoxicantscanaffectthereproductivehealthfertilityofbothmenandwomen.Forexample,womenexposedtohazardoussubstancesmayexperiencehormonalchangesthatcanleadtosubfertility,andmenmayexhibitabnormalspermmorphologyorareducedspermcount.2
Manyoccupationsmayresultinexposuretoreproductivetoxi-cants.Someoftheoccupationsthataremorelikelytoinvolveexposureareobvious—pestcontroltechnicians,forexample.Table5listsexamplesofoccupationsthathaveahigherriskforexposurestotoxicsubstances.Individualsintheseoc-cupationsshouldbemadeawareofthepotentialforadverseeffectsandencouragedtotakestepstomitigateexposure.
Otheroccupationswithpotentialforexposurearelessobvi-ous.Infact,itisimpossibletopredictwithcompleteaccuracywhichworksettingsarelikelytoexposureindividualstoreproductivetoxicants;thesechemicalscouldbepresentinsettingsthatonewouldn’texpect,suchasapatient’shomeoranacademicorofficebuilding.Forthisreason,itisimportantforpatientstoconsiderwhethertheyareorhavebeenexposedtochemicals,fumes,orpotentiallyproblematicsubstances,nomattertheirworkplacesetting.
Chemical Exposures in the Workplace Thischapterfocusesonexposuresto
syntheticchemicalsintheworkplace.
Knownreproductivetoxicantsincludeheavymetalssuchasmethylmercuryandchemicalcompoundssuchasbenzene.Benzeneisanaromaticliquidorvapor.Inthepast,itwasusedasasolventinvariousmaterialsincludinginks,glues,andpaintremover.Itisnowusedasaprecursorinthesynthesisofplasticsanddyes.Inaddition,gasolinecontainsbenzene.Forthisreason,workerswhocleanorremoveundergroundfuelstoragetanksmaybeexposedtothetoxicant.Exposuretoben-zenehasbeenlinkedtoaplasticanemia,cancer,andadversereproductiveeffects.3IntheUnitedStates,othersolvents,suchastolueneandnaphthalene,areusedincreasinglytoreplacebenzene.Becauseofthewide-spreaduseofthesesolvents,individualsmayencountertheminavarietyofsettings,includingtheworkplaceandthehome.Forexample,gasoline,householdaerosols,paints,paintthinners,adhesives,nailpolishremover,andsolvent-basedcleaningproductsmaycon-taintoluene.4Naphthaleneisusedinmothrepellents,coaltarproducts,andcertaindyesandinks.5
Benzene:An Example of a Reproductive and Developmental Toxicant
EnvironmentalImpactsonReproductiveHealth|January 2010|19
Table5:ExamplesofOccupationswithHigherRiskofExposuretoToxicants3
Arts&MediaAssembling&FabricationCleaning&PestControlConstructionCrop&LivestockProductionEngineering,Sciences&EducationExtractiveIndustries(i.e.,mining)FarmWorkFishing&HuntingFoodProcessingFoodServiceGroundsMaintenanceHealthServicesInstallation,Maintenance&Repair
Logging,Forest&ConservationMaterialMovingMetalworking&PlasticworkingMiscellaneousProduction(e.g.,electronicsmanufacture)NailandHairSalonsPrintingTextile,Apparel&FurnishingsUtilities&TransportationWelding,Soldering&BrazingWoodworking
Providersmustweighthebenefitsofinterventionwiththepo-tentialchallengesassociatedwithjoblossordiscrimination.Anincidentalexposuremaynotbeofconcernwhenviewedagainsttheconsequencesofajobloss.However,significantexposuretoatoxicantmustbeaddressedandmitigated.Ifaprovideridentifiesareproductiveordevelopmentalhazard,heorsheshouldreferthepatienttoanoccupationalhealthexpertwhocanassessthehazardandprovideknowledge-ablecounselingabouttherisksandtheindividual’slegalrights.Bylaw,employersareresponsibleformaintainingasafeworkenvironmentandmustprovideinformationandeducationabouthazardouschemicalsintheworkplace.Providerscaninformpatientsoftheserightsandreferthemtooccupationalhealthexpertsandresourcesforadditionalhelpandinformation.
20| Environmental Impacts on Reproductive Health |January 2010
CaseStudy:Jennifer*
Jenniferisanulliparous,30-year-oldhealthywomanwhopresentstoyourofficeforherannualwell-womanexam.Shewasrecentlymarriedandiscontemplatingpregnancywithinthenextyear.Shehasnocomplaintsexceptforoccasionalheadaches,whichoccursometimesatworkbutneveronweekends.
Jenniferhasworkedasalabtechnicianatalocalpolymermanufacturerforthepast6years.Sheisconcernedaboutpossiblechemicalexposureatwork.Forprotectiveequipmentsheuseseyeprotection,anapron,andlatexgloves.Thereisnoventilationhoodinthelab.TheprimarychemicalsheworkswithisN-methylpyrrolidone(NMP),achemicalusedtodissolveawiderangeofotherchemicals.SheisexposedtoNMPonaweekly,andoftendaily,basis.
Jennifer’sexamisnormal.Thepregnancytestthatyouorderisnegative.Youpullupthematerialsafetydatasheet(MSDS)forNMPonline,whichyoureviewwithJennifer.TheMSDSmentionsnoadversereproductiveeffects,andJenniferisrelieved.However,knowingthatMSDSentriesareoftenincompleteandinaccuratewithregardtoinformationonthereproductiveeffectsofthechemical,youinvestigateNMPinmoredetailontheInternet.Youlearnthatin2001,NMPwaslistedasaknownreproductivetoxicantinthestateofCaliforniaonthebasisofanimalstudies.6YousearchthedevelopmentalandreproductivetoxicologydatabaseattheTOXNETWebsiteandfindseveralentries,includingacaseofapregnancylossinalabtechnicianexposedtoNMP.
OnthebasisoftheinformationfromtheInternetandthetoxicologydatabase,youreferJennifertoanoccupationalhealthspecialist.YoureceiveanotefromthespecialistafterJennifer’sconsultation.ShehasrecommendedtheuseofadditionalsafetyprecautionsatJennifer’sworkplace,includingaventilatorhood,awell-fittedrespirator,neopreneratherthanlatexgloves(theformeraremoreresistant),andcontinueduseoftheapronandeyeprotection.
TheoccupationalhealthspecialistasksyoutoexplorewithJennifertheoptionsfortransferringoutofthelabtoalesstoxicworkenvironment,bearinginmindherlegalrightsandthepotentialforjoblossordiscrimination.YouwritealettertoJennifer’semployeridentifyingNMPasapotentialreproductivetoxicant,highlightingtheimportanceofavoidingreproductivetoxicants,andtheneedtotransferJennifertoajobwithoutsuchexposurewhilesheistryingtogetpregnantandduringpregnancy.
TheemployertransfersJennifertoapositionwithlesstoxicexposureandinvestsinadditionalsafetyequipmentforJenniferandotheremployees.Hadnootherjobsbeenavailable,Jennifermighthavedecidedtocontinueinthesamejobwithimprovedprotection.Afterthetransfer,Jennifer’sheadachesresolve.
Thiscaseillustratesthatexposurestoreproductivetoxicantscanoccurattheworkplace.Withunderstandingandappropriateinformation,healthcareproviderscanadvocatefortheirpatientsandmakespecificworkplacerecommendationsthatreducetheriskofexposuretoreproductivetoxicants.
*Case study adapted from GENERATIONS AT RISK: REPRODUCTIVE HEALTH AND THE ENVIRONMENT, published by The MIT Press.7
Whencounselingpatientsaboutexposurestoindustrialchemicals,providersshould:•Askaboutthepatient’soccupation,includingthesetting,
job-relatedtasks,andanyknownchemicalexposures.
•Askaboutpotentialchemicalexposures,includingspecificquestionstouncoverexposuresthatthepatientmightmistakenlybelieveareinsignificant(e.g.,“Doesyourworksiteusefumigationtodealwithpests?”).
•Recommendthatpatientstrytobecomefamiliarwithallchemicalsusedorencounteredintheirworksettingandlearnaboutthepotentiallytoxicpropertiesofthesechemicals.
•Directpatientstoappropriatesourcesofinformationaboutchemicals(seeResourcesforProvidersandPatientschapter).
•Instructpatientsonstepstotaketomitigateexposureorreferthemtoanoccupationalhealthexpertwhocansuggestexposure-reducingstrategies(e.g.,substituteasaferchemical,washexposedskin,changefromworkclothesbeforeleavingtheworkplace,washanyexposedclothesseparatelytopreventcontaminationofotherclothing).
•Checkthatpatientshaveaccesstoandareusingappropriateprotectivegear.
•Advisepatientstoavoidcontactwithclothesthatothersinthehouseholdwearhomeifthereisapotentialfortoxicantexposure.
•Advisepatientstotakeextracaretoavoidexposureiftheyarepregnantorplanningpregnancy,becausestandardpersonalprotectiveequipmentmaynotbesufficienttoguardfromexposuretoreproductivetoxicants.
AdditionalProviderResourcesonIndustrialChemicals:Providersshoulduseavailableresourcestoinvestigatethetoxicpropertiesofspecificindustrialchemicalstowhichtheirpatientsareexposed.
•Forgeneraltoxicantinformation:
—TheHazMatdatabase:providesinformationaboutsymptomsandconditionsassociatedwithtoxicantsandtheoccupationalactivitiesmostlikelytoleadtoexposure.
—Materialsafetydatasheet(MSDS):thesesheetsprovidegeneralinformationaboutthehealtheffectsofexposuretoaparticularchemical.However,theMSDSentriesareoftenincompleteandinaccuratewithregardtoinformationonthereproductiveeffectsofthechemi-cal;providersshouldnotrelyonthelackofmentionofreproductivetoxicityintheMSDSasanindicationofsafety.Providersandpatientsshouldcheckproductlabels(withthecaveatthatthesemaybeinaccurateorincomplete)andtoxicologydatabasesforinformationaboutpotentialreproductiveeffects.
•Forinformationspecifictoreproductivetoxicants:
—CaliforniaProposition65Website:Listofchemicalsrecognizedtocausecancerorreproductivetoxicity;approximately800chemicalsarelisted
—EnvironmentalHealthandToxicologyWebsiteoftheNationalLibraryofMedicine:Educationalresourcesandlinkstodatabasesthatidentifysubstancesknowntocausereproductiveorothertoxicity
—ReproTox:Anonlinedatabaseforprovidersandconsumersthatpresentsinformationonmorethan5,000agentsandexposuresandtheirreproduction-relatedeffects
—ToxNetWebsiteoftheNationalLibraryofMedicine:Linkstoseveraldatabasesthatidentifysubstancesknowntocausereproductiveorothertoxicity
References:
1.McDiarmidMA,GehleK.Preconceptionbrief:occupational/environmentalexposures.Matern Child Health J.2006;10:S123–8.
2.CentersforDiseaseControlandPrevention.Theeffectsofworkplacehazardsonmalereproductivehealth.1997.Availableat:http://www.cdc.gov/niosh/malrepro.html.AccessedOctober6,2009.
3.HazMatdatabase.LastupdatedSeptember2009.Availableat:http://hazmap.nlm.nih.gov/cgi-bin/hazmap_cgi?level=0&tree=Job.AccessedOctober6,2009.
4.AgencyforToxicSubstancesandDiseaseRegistry.Toluenetoxicityexposurepathways.Casestudy.2001.Availableat:http://www.atsdr.cdc.gov/csem/toluene/exposure_pathways.html.AccessedDecember26,2009.
5.AgencyforToxicSubstancesandDiseaseRegistry.Naphthalene,1-methyl-naphthalene,and2-methylnaphthalene.ToxFAQs.™2005.Availableat:http://www.atsdr.cdc.gov/tfacts67.pdf.AccessedDecember26,2009.
6.CaliforniaOfficeofEnvironmentalHealthHazardAssessment.Proposition65.Availableat:http://www.oehha.ca.gov/prop65/prop65_list/091009list.html.AccessedJanuary7,2010.
7.SchettlerT,SolomonG,ValentiM,HuddleA.Generations at Risk: Reproduc-tive Health and the Environment.Boston,MA:MITPress.1999.
CounselingPatientsonExposurestoIndustrialChemicals
Thenextchapteraddressessomechemicalsinplastics,includingbisphenolA,anendocrine-disruptingchemicalinsomeplasticbottlesandintheliningofcansusedforfoodandbeverages.
EnvironmentalImpactsonReproductiveHealth|January 2010|21
Thismonographincludesadiscussionoftheendocrine-disruptingchemicalbisphenolA(BPA)forthreereasons:
•PatientsarerequestingmoreinformationaboutplasticsandBPA.
•Animaldatasuggestanincreasedsusceptibilityofthedevelopingorganism,whichraisesconcernsabouteffectonthehumanfetus,especiallyduringearlygestation(whenmanywomenareunawarethatthey’repregnant).1
•BPAisunderscrutinybystateandfederalagencies,andcliniciansmaybeaskedtodiscussthepotentialeffectofBPAexposureonreproductivehealthwithotherhealthpro-fessionals,patientgroups,policy-makers,andthemedia.
SourcesofBisphenolABisphenolAisachemicalusedinsomeepoxyresinsandadhesives.BPA-containingresinsareusedintheliningofmetalfoodandbeveragecans,andtheliningofsuchcans(e.g.,softdrink,food,andinfantformulacans)isasignificantsourceofBPAinfooditems.2,3BPAispolymerizedtomakepolycarbonateplastic.Polycarbonateisahardclearplasticthatisidentifiedbythe“otherplastics”categoryforrecycling,designatedbyatrianglewiththenumber7oftenfoundontheundersideofrecyclablecontainers.BPAalsomaybeaddedtootherkindsofplastic.BPAcanleachfromplastic
containers,devices,andmedicalequipmentintofoodorbeverages,especiallywhenheated.
NowyouknowthatthecorrectanswertothequizquestionisA:cannedvegetablesaremostlikelytocontainBPA.FoodstoragecontainersandhardplasticwaterbottlesmaycontainBPA.StretchfilmusedinfoodpackagingalsomaycontainBPA.4Medicalequipment,includingendotrachealtubes,umbilicalcatheters,andplasticbagscontainingintravenousfluids,sometimescontainBPA.3OtherpotentialsourcesofBPAincludedust,PVCpiping,cashregisterreceipts,anddentalcompositesandsealants.
PopulationstudieshaveshownthatBPAexposureiscommonintheUnitedStates.A2008studyreportedthatalmost93percentofindividualsage6orolderhaddetectableBPAlevelsintheirurine.3Levelswerehigherinchildrenthanadults(seeFigure10).Inaddition,humanstudieshaveshownthatinterventionstoreduceexposuretoBPAdodecreasebloodBPAlevels.
TestinginvariouscountrieshasfoundBPAincannedfoods,suchasvegetables,soups,fruits,meatproducts,fish,anddesserts.7Plasticbabybottlesandliquidbabyformula(i.e.,notpowdered)mayalsocontainBPA.6,7
Bisphenol A and Other Chemicals in Plastics
Thischapterfocusesonsomeofthechemicalsinplastics,including
bisphenolA,whichhasbeenshowntohaveestrogen-likeeffects
andtodisruptthyroidfunctioninanimals.
A. Cannedvegetables
B. Freshvegetables
C. Frozenvegetables
D. Allofabove
We’llgettotheanswersoon.
Do you know which of these food items is most likely to contain bisphenol A?
ScopeoftheBPAProblem
Figure10:ScopeoftheBPAProblem5-7
22|EnvironmentalImpactsonReproductiveHealth|January 2010
6–11 12–19 20–59 ≥60 AllAges
Ages in Years
5–
4.5–
4–
3.5–
3–2.5–
2–
1.5–
1–
0.5–
0–BPA
Uri
ne C
once
ntra
tion
(mgc/
L)
DataontheReproductiveHealthImpactofBisphenolALaboratoryresearchhasdemonstratedthatBPAisanestro-genreceptoragonistandblocksbothandrogenandthyroidhormonereceptors.8StudiesinanimalshaveshownthatBPAexposureisassociatedwithearlypubertyinfemales,lowerspermcounts,andincreasedsusceptibilitytoreproductivetractcancersandalteredbraindevelopmentinmalesandfemales.8-13Morerecently,BPAhasbeenassociatedwithdiabetesandcardiovasculardiseaseinhumans.14
DefinitivedatalinkingBPAexposuretospecificpathologicalconditionsinhumansarenotyetavailable.However,someoftheadverseeffectsinanimalstudiesareobservedatlevelsofexposureclosetothosecommoninpeople.Forthisreason,clinicians,scientists,andconsumeractivistsareconcerned,eveniftheeffectsarenotyetclearlydocumentedinhumans.Giventhestrengthoftheemergingdata,manyexpertsbelievethatitisprudenttorecommendnowthatpatientsreduceBPAexposureandtoprovideclinicianswithtoolstohelppatientsreducetheirriskofexposure.
OtherChemicalsinPlasticsInadditiontoBPA,otherchemicalsassociatedwithplasticshaveraisedconcerns.Theseincludephthalatesandpolyvinylchloride(PVC).Phthalatesareplastizicers,substancesaddedtoplasticsorothermaterialstomakethemmorepliable.15Thesechemicalsareusedtocreatebuildingmaterials,pack-aging,andplastictoys.Theyalsoareingredientsinpersonalcareproducts,suchascosmetics,shampoos,andperfumes,andinsomepharmaceuticals.Asmall(n=145)pilotstudyinhumansrecentlyshowedthatpreschoolboyswhosemothersduringpregnancyhadhigherurinaryconcentrationsoftwocommonphthalateswerelesslikelytoengageintypicallymaleplay(e.g.,playfights)thanboyswhosemothershadlowerurinarylevelsduringpregnancy.16Previousresearchhasshownthatgender-relatedplaybehaviorreflectstheeffectsofendocrine-disruptingchemicals,suchasPCBs.
Hundredsofstudiesinlaboratoryanimalshaveshownthatthedevelopingmalereproductivetractisparticularlysensitivetoexposuretosomephthalates.Theexposuresthatcausetheseeffectsaremuchlowerthanthosenecessarytocauseeffectsinadults.Someadultsareexposedtothosephthalatesatlevelsthatapproachthosethatcauseeffectsinlaboratoryanimals.Preliminarydatafromthefirsthumanstudieshaveshownconcerningreproductivehealtheffectswithphthalateexposure,relatingtotheirendocrine-disruptingeffects.Onestudyfoundasmalleranogenitaldistance(AGD),whichisthespanbetweentheanusandthegenitalsandamarkerforfeminization,inthemaleinfantsofwomenwithhigherurinarylevelsofphthalates.17ReducedAGDisamarkerforprenatalexposuretoandrogenantagonists(anti-androgens).Afollow-upstudyfoundthattheserumlevelsofphthalatesinthemothersofmaleinfantswithreducedAGDwereactuallylowerthantheEnvironmentalProtectionAgency’sdesignatedreferencedosesforthesechemicals;inotherwords,theseproblemsweremanifestingintheoffspringofwomenwhosephthalatelevelswerewithintherangeconsidered“safe.”15Severalpreliminarystudieshavefoundinconsistenteffectsonbirth—eitherdelayingbirthorincreasingthechanceofprematurebirth.Althoughonecannotmakeafirmconclusionabouttheclinicalsignificanceofthesefindings,theresultssuggestthatexposuretophthalatesmayresultinchangesinreproductivetractdevelopment.Therefore,clinicianscanexerciseprecautionandrecommendwaystheirpatientscanlimitexposuretophthalates.
Polyvinylchloride,atypeofplastic,isapolymerusedtomanufactureavarietyofproductsincludingpipes,wireandcablecoatings,buildingmaterials,andpackagingmateri-als.18Italsoisusedinsomehouseholditems,suchasshowercurtainliners,furnitureandautomobileupholstery,wallcover-ings,housewares,andautomotiveparts.19Dependingontheapplication,othersubstancesareoftenadded.Phthalatesmakeapolymerlessbrittle.Heavymetalsareoftenaddedasstabilizers.20ThesesubstancescanleachfromPVC-containingproducts(e.g.,ifachildsucksonanobject)orbereleasedintotheair(e.g.,fromnewshowercurtainliners).
EnvironmentalImpactsonReproductiveHealth|January 2010|23
IndividualscantakeseveralpracticalstepstoreduceexposuretoBPAandotherchemicalsassociatedwithplastics.Healthcareprovidersshouldrecommendtheseactionstepstopatientswhilehelpingthemkeepasenseofperspectiveaboutexposures.Ratherthanbecomefearfulaboutallthepotentialsourcesforexposure,patientscanbegintotakeimportantstepstoreducetheiroverallexposuretoBPAandotherplastics-associatedchemicalsaboutwhichtherearelegitimateconcernsforreproductivetoxicity.
Althoughprovidersmusttakeintoaccountpatients’individualcircumstances,theymaywanttorecommendthatpatients:21-23•Checkthebottomofplasticfoodandbeveragecontainersfor
numbersandavoidplasticcontainersnumbered3,6,or7forfoodanddrinkingwater(seeTable6);
•Limitcannedfoodsandbeveragesorthosestoredinplasticcontainers;chooseitemsinglasscontainerswheneverpossible;
•Eatfreshfoodwhenpossible;choosefrozenfoodsovercannedfoods;
•Usenon-polycarbonateplasticorglassbabybottles;
•Drinkfromunlinedstainlesssteelbottles,glassbottles,orplasticcontainersdesignated“PCfree”or“BPAfree”(note:thesedesignationsarenotguaranteesthattheplasticisfreeofpotentiallyharmfulchemicals);
•Wherepossible,avoidstoringfoodinplasticcontainersorplasticwrap.Glasscontainersareagoodalternative;
•Avoidheatingallplasticsinmicrowaves;and
•Asamatterofprudence,avoidPVCproducts(e.g.,vinylshowercurtainliners)wheneverpossible,becausetheyreleasephthalatesandotherchemicalsintotheair.
Table6:DecodingRecyclingNumbers23
PlasticstoAvoidforFoodandBeverageUse
PlasticsConsideredAcceptableforFoodandBeverageUse
•No.3:Polyvinylchloride(PVC)•No.6:Styrene(Styrofoam)•No.7:Polycarbonate(BPA)(Notethat
some#7plasticsdonotcontainpolycar-bonate.Consumersshouldcheckthepackagingfor“polycarbonate”or“PC”orcontactthemanufacturer.)
•No.1,2,4,5
AdditionalProviderResourcesonBPA:•TheEndocrineSociety:Endocrine-DisruptingChemicals:
AnEndocrineSocietyScientificStatement
AdditionalPatientResourcesonBPA:•EnvironmentalWorkingGroup:BisphenolA:ToxicPlastics
ChemicalinCannedFood
•NaturalResourcesDefenseCouncil:ChemicalsinPlasticBottles:HowtoKnowWhat’sSafeforYourFamily
CounselingPatientsonExposuretoBPAandRelatedChemicals
24|EnvironmentalImpactsonReproductiveHealth|January 2010
References:
1.vomSaalFS,HughesC.Anextensivenewliteratureconcerninglow-doseeffectsofbisphenolAshowstheneedforanewriskassessment.Environ Health Perspect.2005;13:926–33.
2.Parker-PopeT.Ahardplasticisraisinghardquestions.New York Times.April22,2008.Availableat:http://www.nytimes.com/2008/04/22/health/22well.html.AccessedJanuary10,2010.
3.CalafatAM,WeuveJ,YeX,etal.ExposuretobisphenolAandotherphenolsinneonatalintensivecareunitprematureinfants.Environ Health Perspect.2009;117(4):639–44.
4.Lopez-CervantesJ,Paseiro-LosadaP.DeterminationofbisphenolAin,anditsmigrationfrom,PBVstretchfilmusedforfoodpackaging.Food Addit Contam.2003;20:596–606.
5.CalafatAM,YeX,WongLY,etal.ExposureoftheU.S.populationtobisphe-nolAand4-tertiary-octylphenol:2003–2004.Environ Health Perspect.2008;116:39–44.
6.FoodandDrugAdministration.DraftassessmentofbisphenolAforuseinfoodcontactapplications.August2008.Availableat:http://www.fda.gov/ohrms/dockets/AC/08/briefing/2008-0038b1_01_02_FDA%20BPA%20Draft%20Assessment.pdf.AccessedSeptember10,2009.
7.NationalToxicologyProgram.USDepartmentofHealthandHumanServices.NTP-CERHRExpertPanelReportontheReproductiveandDevelopmentalToxic-ityofBisphenolA.2007.Availableat:http://cerhr.niehs.nih.gov/chemicals/bisphenol/BPAFinalEPVF112607.pdf.AccessedOctober12,2009.
8.NewboldRR,JeffersonWN,Padilla-BanksE.PrenatalexposuretobisphenolAatenvironmentallyrelevantdosesadverselyaffectsthemurinefemalereproduc-tivetractlaterinlife.Environ Health Perspect.2009;117(6):879–85.
9.JenkinsS,RaghuramanN,EltoumI,etal.OralexposuretobisphenolAincreasesdimethylbenzanthracene-inducedmammarycancerinrats.Environ Health Perspect.2009;117(6):910–5.
10.HoSM,TangWY,BelmontedeFraustoJ,PrinsGS.DevelopmentalexposuretoestradiolandbisphenolAincreasessusceptibilitytoprostatecarcinogenesisandepigeneticallyregulatesphosphodiesterasetype4variant4.Cancer Res.2006;66(11):5624–32.
11.HowdeshellKL,HotchkissAK,ThayerKA,etal.ExposuretobisphenolAadvancespuberty.Nature.1999;401(6755):763–4.
12.ChapinRE,AdamsJ,BoekelheideK,etal.NTP-CERHRExpertpanelreportonthereproductiveanddevelopmentaltoxicityofbisphenolA.Birth Defects Research.2008;83:157–395.
13.LeranthC,HajszanT,Szigeti-BuckK,etal.BisphenolApreventsthesynaptogenicresponsetoestradiolinhippocampusandprefrontalcor-texofovariectomizednonhumanprimates.Proc Natl Acad Sci U S A.2008;105(37):14187–91.
14.LangIA,GallowayTS,ScarlettA,etal.AssociationofurinarybisphenolAconcentrationwithmedicaldisordersandlaboratoryabnormalitiesinadults.JAMA.2008;300(11):1303–10.
15.MarseeK,WoodruffTJ,AxelradDA,etlal.Estimateddailyexposuresinapopulationofmothersofmaleinfantsexhibitingreducedanogenitaldistance.Environ Health Perspect.2006;114:805–9.
16.SwanSH,LiuF,HinesM,etal.Prenatalphthalateexposureandreducedmasculineplayinboys.Int J Androl.2009Nov16.[Epubaheadofprint]
17.SwanSH,MainKM,LiuF,etal.Decreaseinanogenitaldistanceamongmaleinfantswithprenatalphthalateexposure.Environ Health Perspect.2005;113:1056–61.
18.AgencyforToxicSubstancesandDiseaseRegistry(ATSDR).ToxicologicalProfileforVinylChloride(Update).Atlanta,GA:PublicHealthService,USDepartmentofHealthandHumanServices.1997.
19.EnvironmentalProtectionAgency.VinylChloride:HazardSummary.2000.Availableat:http://www.epa.gov/ttn/atw/hlthef/vinylchl.html.AccessedOctober13,2009.
20.ThorntonJ.EnvironmentalImpactsofPolyvinylChlorideBuildingMaterials.HealthyBuildingNetwork.2002.Availableat:http://www.healthybuilding.net/pvc/Thornton_Enviro_Impacts_of_PVC.pdf.AccessedOctober13,2009.
21.UniversityofCalifornia-SanFransisco,ProgramonReproductiveHealthandtheEnvironment.Toxicmatters.Availableat:http://www.prhe.ucsf.edu/prhe/index.html.AccessedDecember26,2009.
22.CenterforHealth,EnvironmentandJustice.Volatilevinyl:thenewshowercurtain’schemicalsmell.June2008.Availableat:http://www.chej.org/docu-ments/VolatileVinyl.pdf.AccessedSeptember9,2009.
23.NaturalResourcesDefenseCouncil.Chemicalsinplasticbottles:howtoknowwhat’ssafeforyourfamily.May2008.Availableat:http://www.nrdc.org/health/bpa.pdf.AccessedAugust27,2009.
Thenextchapterhighlightshelpfulenvironmentalhealthresourcesforprovidersandpatients.
CaseStudy:Lauren
Laurenisa35-year-oldwomanwhorecentlyreceivedanegativepregnancytestafterninemonthsoftryingtobecomepregnant.Herhusbandsawanewsreportaboutthepossibleeffectsofplasticwaterbottlesonreproduction.Laurenasksyouwhethertheplasticwaterbottlestheyuseathomecouldhaveanyrelationshiptoherdifficultybecomingpregnant.
YouhavepreviouslycompletedamedicalhistoryonLauren.YouconductanenvironmentalhealthhistoryusingtheCH2OPSmnemonic.Inparticular,youaskaboutanyexposuresthroughtheworkplace,hobbies,orhomepesticidesexposures.
IndiscussingconcernsexpressedbyLaurenandherhusband,youshouldexplainthatitisimpossibletoassignblametoaparticularenvironmentalexposure,butshecantakestepstoreducethechanceofharmfulexposures.ThesestepsincludeswitchingtounlinedaluminumwaterbottlesthatdonotcontainBPA.
Thiscaseillustratestheimportanceoftakinganenvironmentalhistoryandtailoringguidanceaccordinglyandtheopportunityforhealthcareproviderstoaddresspotentialenvironmentalriskswithoutbecomingoverlyconcernedabouteverypossibleexposureorpromptingexcessiveconcernintheirpatients.
EnvironmentalImpactsonReproductiveHealth|January 2010|25
ForProvidersManyresourcesareavailableonenvironmentalhealthandreproductivetoxicants.Providersshouldinvestigatetheseresourcesfortheirowneducationandtohavereadyaccesstoinformationforpatients.AgoodstartingplaceisARHP’sReproductiveHealthandtheEnvironmentTopicArea.Thesiteprovidesnewsarticles,factsheets,researchupdates,linkstootherorganizations,andclinicianresources,including:
•LinkstotheEnvironmentalImpactsonReproductiveHealthcurriculum,FoundationsofScienceandPesticideExposure,intheCurriculaOrganizerforReproductiveHealthEducation(CORE);
•QuickReferenceGuideforClinicians:FishConsumptiontoPromoteGoodHealthandMinimizeContaminants;
•EnvironmentalReproductiveHealthResourcesforHealthCareProviders.
Inadditiontothosealreadydiscussedinthismonograph,anumberofotherclinician-orientedresourcesareavailabletoeducateandraiseawareness,whichwillaidinpatientcounseling.Thoseresourcesinclude:
•TheAmericanCollegeofOccupationalandEnvironmentalMedicine,amembershiporganizationforphysicianswhospecializeintheenvironmentalhealthandsafetyofwork-ers,workplaces,andenvironments;
•“CriticalWindowsofDevelopment,”anonlinetoolprovidedbyTheEndocrineDisruptionExchangethatshowsatimelineofhumanembryonic/fetaldevelopmentandfeaturesanimalresearchdataonlow-doseEDCexposureandalteredhealthoutcomes;
•EnviRN,aWebsitehostedbytheUniversityofMarylandSchoolofNursing,whichsupportsnursesinpromotingenvironmentalhealthinhomes,schools,workplacesandcommunities;
•TheEnvironmentalWorkingGroupWebsite,whichincludesseveraltoolsrelatedtotoxicantexposuresthroughconsumerproductsandfood,aswellasgeneralinforma-tionaboutenvironmentalchemicalsandcontaminants;
•TheNaturalResourcesDefenseCouncilWebsite,whichhassignificantinformationaboutmethylmercuryandotherchemicals;
•PhysiciansforSocialResponsibilityWebsite,whichincludesaPediatricEnvironmentalHealthToolkit;and
•TheUniversityofCalifornia-SanFranciscoProgramonReproductiveHealthandtheEnvironment,whichworksattheintersectionofscience,medicine,policy,andcommunity.
Localenvironmentalhealthspecialistsalsomaybehelpfulsourcesofinformation.
Resources for Providers and Patients Thischapterlistsenvironmentalhealth
resourcesforprovidersandpatients.
26|EnvironmentalImpactsonReproductiveHealth|January 2010
ForPatientsTherearemanyresourcesavailableforpatientstohelpthembetterunderstandtheseissuesandtakestepstoreduceexposuretotoxicants.Belowisasampleofresourceshealthcareproviderscouldsharewiththeirpatients.
TheARHPReproductiveHealthandtheEnvironmentTopicAreaprovidesvaluablepatienteducationresources,including:
•HealthMatterspatientfactsheets:
—TheConnectionBetweenYourHealthandtheEnvironment:TipsandToolsforHealthandHome;and
—HealthyFish,HealthyFamilies.
Severalnationalorganizationspublishreliablepatienteducationmaterialsabouttopicsrelatedtoenvironmentalexposures:•AmericanCollegeofObstetriciansandGynecologists
pamphlet,“NutritionDuringPregnancy,”whichincludesinformationaboutseafoodintake;
•CollaborativeonHealthandtheEnvironment(CHE),whichprovidesmanyofitsresourcesinArabic,French,Russian,andSpanish;
•TheCampaignforSafeCosmetics,whichincludesaproductreviewthatprovidesanevaluationofthesafetyofspecificbrandsofconsumerproducts;
•EnvironmentalWorkingGroup,whocreatevaluabletoolssuchaswalletcards,phoneapplications,andsearchabledatabases;
•HealthyChild,HealthyWorld,whoexpandawarenessandunderstandingofenvironmentalhazardstochildren’shealth;
•TheMarchofDimesWebsite,whichcoversseafoodintakeandothertopicsrelatedtopreconceptioncare,includingalcoholconsumptionandvitaminsandmineralsduringpregnancy(alsoavailableinSpanish);
•TheNaturalResourcesDefenseCouncilWebsite,includingtheGreenLivingsection,whichprovidesvaluableconsumerinformation;
•PlannedParenthood®FederationofAmericapatientfactsheetsonmultipleexposures(availableearly2010);
•SaferChemicals,HealthyFamilies,acoalitionofdiversegroupsunitedbytheircommonconcernabouttoxicchemicals;
•UniversityofCalifornia-SanFrancisco’sProgramonReproductiveHealthandtheEnvironment’sFASTEPProgram:“ToxicMatters”—abrochurethatprovidesguidanceforpatientsonavoidingharmfulenvironmentalexposures;
•Women’sVoicesfortheEarth,whichengageswomentoadvocatefortherighttoliveinahealthyenvironmentandprovidesmaterialsinSpanish.
Environmentalexposureshavebeenlinkedtoreproductivehealtheffectsandmayaffectfuturegenerations.Theseexposuresmayhavemoresig-nificanceatcriticalpointsinanindividual’slifespan.Healthcareproviderscanhelpbyofferingpatientsguidance,counseling,andresources.Specifically,providerscanemphasizetheimportanceofpreconceptioncare,incorporateanenvironmentalandoccupationalhistoryaspartofthepatienthealthhistory,becomeawareofrisksintheircommunity,workwithcommunitygroupsandpolicymakerstoreduceexposurelevels,andprovideandreferpatientstoeducationandinformationresources.Helpingpatientsreducetheirexposurestoreproductivetoxicantsnowwillincreasethelikelihoodofcontinuedreproductivehealthforthemselvesandtheirfamilies.
Conclusion
EnvironmentalImpactsonReproductiveHealth|January 2010|27
BoardofDirectorsExecutive CommitteeMichaelA.Thomas,MDChairPabloRodriguez,MDImmediate Past ChairLouiseH.Bateman,RN,FNP-BC,MPHTreasurerEveEspey,MD,MPHChair, Education CommitteePatriciaMurphy,CNM,DrPHSecretaryWayneC.ShieldsPresident and CEO
Directors at Large KathleenHillBesinque,PharmD,MSEd,FCSHPLindaDominguez,RN-C,NPEmilyGodfrey,MD,MPHCaroleJoffe,PhDKatharineSheehan,MDScottJ.Spear,MDDianaTaylor,RNP,PhD,FAAN
Standing PostitionE.SteveLichtenberg,MD,MPHPPFA National Medical Committee Chair
Medical Director BethJordan,MD
1901LStreet,NWSuite300Washington,DC20036www.arhp.org
1330BroadwaySuite1100Oakland,CA96412
© 2010
434West33rdStreetNewYork,NY10001www.plannedparenthood.org/
Please circle the best answer for each question.
1. The CH2OPS mnemonic can be used to query about environmental exposures of which patient populations?
a. Pregnant women. b. Couples considering pregnancy. c. Male infants. d. All of the above.
2. Which is an accurate statement regarding guidance for avoiding reproductive toxicants in the home?
a. Well water is generally safe, but community sources of water can be contaminated.
b. Patients should ensure proper ventilation when working on art projects that involve solvents.
c. Automotive care products can be a problem, but household detergents are almost always safe.
d. Chlorine bleach should be used liberally to disinfect the home.
3. Which statement is true about the reproductive health effects of pesticides?
a. Such effects occur only in agricultural workers and other individuals exposed to high levels of pesticides in their workplace.
b. Adverse effects may include premature birth and developmental defects.
c. Data from human trials have shown a direct causal link between several pesticides and reduced fertility in women.
d. Reproductive effects are seen in women; male reproduc-tive health does not appear to be affected by pesticide exposure.
4. Bisphenol A (BPA): a. Has anti-androgen effects. b. Has adverse reproductive effects that have been clearly
documented in humans. c. Has been associated with early puberty in female animals. d. Has known epigenetic effects.
5. Which is a way to reduce exposure to harmful chemicals in plastics?
a. If drinking tap water, use filtered water only. b. Choose canned over frozen foods. c. Avoid unlined stainless steel drinking bottles. d. Avoid heating food in plastic containers.
6. Which is true about the current Toxic Substances Control Act (TSCA)?
a. Under TSCA, most chemicals are safe unless proven otherwise.
b. Pesticides are regulated under TSCA. c. Personal care products are regulated under TSCA. d. Most experts believe that the current regulatory toxicity
testing methods are adequate.
7. Which is true about reducing exposure to synthetic chemicals in the workplace?
a. Significant exposures occur only within manufacturing plants.
b. Occupational health experts can accurately predict which work settings are likely to expose individuals to reproductive toxicants.
c. Changing from work clothes before leaving the workplace is recommended to mitigate exposure.
d. Standard personal protective equipment is generally sufficient to guard women from exposure to reproductive toxicants during pregnancy.
8. Which is a NOT an effective way to reduce of the need for and exposure to pesticides?
a. Leave pet food outside. b. Peel or thoroughly wash fruits and vegetables. c. Use citrus spray on houseplants. d. Remove sources of water near the home.
9. Which is true about fish consumption during pregnancy? a. Recommendations for fish intake must take into account the
nutritional benefits of seafood. b. It is hazardous and should be completely discouraged. c. Methylmercury exposure can be effectively avoided by
trimming the fat from fish before cooking. d. Swordfish is at low risk for methylmercury contamination.
10. Consumption of which fish species should be avoided by pregnant women because of its high mercury level?
a. Swordfish b. Shrimp c. Salmon d. Canned light (not albacore) tuna
Post-TestPlease circle the best answer for each question.
To obtain credit, return the completed post-test and evaluation form by January 31, 2012 to: Association of Reproductive Health Professionals, 1901 L Street, Suite 300, Washington, DC 20036, Fax: (202) 466-3826
Evaluation Form
First Name:
Last Name:
Degree(s):
E-mail address:
Phone number:
Mailing address:
Your professional category (choose one):❍ Health Professional Educator ❍ Nurse Practitioner❍ Patient Educator/Counselor ❍ Pharmacist ❍ Physician Assistant ❍ Physician/Resident ❍ Registered Nurse ❍ Student ❍ Other (please describe): Do you interact with patients? ❍ Yes ❍ No
1. On a scale from 1 to 5, with 5 being best, please rate how competent you are after this training to:When counseling patients, use the CH2OPS mnemonic to take acomprehensive environmental health history to assess exposures.Name two adverse effects on reproductive health that may be caused by toxicants that patients typically use or to which they are commonly exposed. List three strategies for reducing exposures to chemicals with potential adverse effects on reproductive health that can be used when providing guidance to a patient.When seeing a female patient who is planning to conceive in the next six months, discuss the risks and benefits of fish consumption and identify consumption guidelines from a reputable source, such as the Food and Drug Administration or the Natural Resources Defense Council.
2. On a scale from 1 to 5, with 5 being best, please rate the following by circling the one most appropriate answer:Importance of this topic for improving reproductive health careUse of evidence-based material in educational contentFairness and balance of content
3. What recommendations would you have for improving any of the criteria above?
4. I intend to use the information I have learned from this publication to enhance my personal clinical practice.❍ Yes ❍ No ❍ N/A
5. I anticipate the following barriers in using the information from this course. (check all that apply)❍ Insurance barriers ❍ Coding barriers ❍ Institutional protocols ❍ Patient resistance ❍ Clinic/colleague resistance❍ Lack of resources ❍ Lack of time ❍ I don’t anticipate any ❍ I don’t have a clinical practice❍ Other (please specify):
6. What can ARHP do to assist you in making any desired changes and fully integrate this information into your practice? (check all that apply)❍ Develop CME live sessions ❍ Develop CME web-based sessions ❍ Develop CME monographs/publications❍ Develop Mobile CME (CME on your PDA) ❍ Develop CME via a podcast❍ Provide networking opportunities with colleagues to learn how they have integrated this information❍ Develop patient education brochure❍ Develop patient education fact sheet Develop patient education online tool Develop patient education podcast❍ Other (please specify):
7. What topics do you suggest for future medical education activities?
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To obtain credit, return the completed post-test and evaluation form by January 31, 2012 to: Association of Reproductive Health Professionals, 1901 L Street, Suite 300, Washington, DC 20036, Fax: (202) 466-3826
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Continuing Education Credits Claimed __________________