Environmental Impacts on Reproductive Health€¦ · California San-Francisco Program on...

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.


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.


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


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.


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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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.


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


40 60 80 100 120 140 160

Mean=100

70 IQ 130

6.0 million:“intellectually

impaired”


gifted”

▲

▲ ▲ 40 60 80 100 120 140 160

Mean=95

70 IQ 130


gifted”

▲

▲ ▲


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.


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


Figure7:TheDirtyDozenFoodList14

http://www.pesticide.org/factsheets.html

http://www.pesticideinfo.org/

http://www.foodnews.org

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.


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


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.


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


http://www.epa.gov/waterscience/fish/states.htm

http://www.montereybayaquarium.org/cr/cr_seafoodwatch/download.aspx

http://www.montereybayaquarium.org/cr/cr_seafoodwatch/download.aspx

http://www.arhp.org/publications-and-resources/quick-reference-guide-for-clinicians/fish-and-health

http://www.arhp.org/Publications-and-Resources/Patient-Resources/Fact-Sheets/Healthy-Fish

http://www.ewg.org/tunacalculator

http://www.nrdc.org/health/effects/mercury/protect.asp

http://www.nrdc.org/health/effects/mercury/protect.asp

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.


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


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.


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

http://toxnet.nlm.nih.gov

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.


http://hazmap.nlm.nih.gov/

http://oehha.ca.gov/prop65/prop65_list/NEWlist.html

http://sis.nlm.nih.gov/enviro.html

http://www.reprotox.org

http://toxnet.nlm.nih.gov/

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


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).


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


http://www.endo-society.org/journals/scientificstatements

http://www.endo-society.org/journals/scientificstatements

http://www.ewg.org/reports/bisphenola

http://www.ewg.org/reports/bisphenola

http://www.nrdc.org/health/bpa-facts.asp

http://www.nrdc.org/health/bpa-facts.asp

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.


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.


http://www.arhp.org/topics/enviro-repro-health

http://www.arhp.org/topics/enviro-repro-health

http://www.arhp.org/publications-and-resources/core

http://www.arhp.org/publications-and-resources/core



http://www.arhp.org/professional-education/programs/environmental-impacts/RHE-Provider-Resources

http://www.arhp.org/professional-education/programs/environmental-impacts/RHE-Provider-Resources

http://www.acoem.org

http://www.acoem.org

http://www.endocrinedisruption.com/prenatal.criticalwindows.overview.php

http://envirn.umaryland.edu/

http://www.ewg.org

http://www.ewg.org

http://www.nrdc.org

http://www.psr.org/

http://www.psr.org/resources/pediatric-toolkit.html

http://www.prhe.ucsf.edu/prhe/about/index.html

http://www.prhe.ucsf.edu/prhe/about/index.html

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


www.arhp.org/topics/enviro-repro-health

www.arhp.org/topics/enviro-repro-health

http://www.arhp.org/publications-and-resources/patient-resources/fact-sheets/RHE



http://www.arhp.org/Publications-and-Resources/Patient-Resources/Fact-Sheets/Healthy-Fish

http://www.acog.org/publications/patient_education/bp001.cfm

http://www.healthandenvironment.org/

http://www.safecosmetics.org

http://www.ewg.org/home

http://healthychild.org/

http://www.marchofdimes.com

http://www.nacersano.org

http://www.nrdc.org/greenliving/

http://www.plannedparenthood.org/

http://www.saferchemicals.org/

http://www.prhe.ucsf.edu/prhe/toxicmatters.html

http://www.womenandenvironment.org/

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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