Letters to the Editor

Home Schooling Can Be a Beneficial Educational Option

to the editor: This letter is in regards to the article, "School Refusal in Children and Adolescents,"1 that appeared in the October 15, 2003, issue of American Family Physician. I wish that the author had included information about home schooling. Our family and many families worldwide have benefited from this educational option. Home schooling is less complicated and is wonderful for children of all ages and their families. More information on home schooling is available online at the Home School Association of California Web site (http://www.hsc.org). The family physician can prevent a lot of heartache and damage to children by being aware of this option.

ERIKA THOST, M.D.
Goleta, CA 93117

Reference

Treatment of Polycystic Ovary Syndrome in Adolescents

to the editor: The article1 on polycystic ovary syndrome (PCOS) by Dr. Richardson in the August 15, 2003, issue of American Family Physician was an excellent review of the diagnosis, treatment, and currently recognized long-term sequelae of the disease. The author acknowledged that young women may have symptoms of PCOS and that these symptoms can begin as early as puberty. The article1 effectively discussed treatment strategies for adult women; however, it did not address options for affected adolescents. It should be noted that there is a small yet growing body of knowledge regarding the efficacy and tolerability of treatment for adolescents with PCOS. Given the long-term adverse effects of this condition, it makes sense to begin counseling and treatment as soon as possible.

All patients, including adolescents, should be counseled regarding diet, exercise, and maintaining an appropriate weight. The use of oral contraceptive pills is one treatment option that has been used in the adolescent population for irregular menses and should be considered for treatment of PCOS in this age group. Recent studies investigating metformin therapy in adolescents with PCOS or PCOS symptoms have shown that metformin improves glucose tolerance,2 normalizes menses,3,4,5 results in resumption of ovulation,3,4 improves insulin sensitivity, reduces elevated androgen levels,2,4 improves lipid profiles,5 and decreases hirsutism.5 Additionally, metformin is generally well tolerated.2,3,5 Further research with larger, randomized controlled trials will expand our scope of the treatment possibilities for adolescents with PCOS.

KIRSTEN STOESSER, M.D.
University of Utah
Department of Family and Preventive Medicine
50 N. Medical Dr.
Salt Lake City, UT 84132

References

Differentiating Types of Dementia During Diagnosis

to the editor: I enjoyed the article1 on the use of antipsychotic medications in the elderly by Motsinger and colleagues and found the content to be very helpful. However, the authors failed to differentiate the types of dementia and to mention a rather common, and often underdiagnosed, form of dementia-Lewy bodies dementia. This disorder is heralded by cognitive decline, Parkinson-type behaviors, and behavioral issues, including psychosis. Often, antipsychotic medication would seem appropriate and useful for these patients. However, with this form of dementia, antipsychotics, including atypical antipsychotic drugs, can exacerbate the problem and lead to iatrogenic complications. Therefore, a family physician who is presented with a patient who has dementia and behavioral issues should be careful with the diagnosis and type of dementia. These physicians should be aware that not all dementias are alike and not all are Alzheimer's disease.

CRAIG BENNETT, M.D.
Midelfort Clinic
2049 15th Ave.
Cameron, WI 54822

Reference

Importance of Continuous Doula Support During Labor

to the editor: I would like to respond to the article and editorial on managing labor pain that appeared in the September 15, 2003, issue of American Family Physician. The authors of the article1 appropriately defined maternal satisfaction (which is not necessarily 100 percent pain relief) along with stressing the value of labor support. However, in the editorial,2 the authors state that "few women are afforded this option (of a doula and continuous labor support)."

Most physicians are not familiar enough with the concept of doulas to fully understand their role, where to find one, or how to recommend them to their patients. The two largest professional certifying organizations of doulas in North America are Doulas of North America (DONA, http://www.dona.org) and Childbirth and Postpartum Professional Association (CAPPA, http://www.cappa.net). These organizations maintain online directories of certified doulas by geographic area and current evidence-based research of the benefits of having a doula present during labor.

Experienced doulas charge between $50 and $900 per birth, depending on experience, geographic area, demand, patient's needs, traveling time, and sliding scale. Without knowing the "doula climate" in one's area, it is presumptive to insist that patients cannot afford the labor support. A requirement to become certified is three "certification" births. These are done without the expectation of monetary payment. It is beneficial to the physician and the patient to find out through DONA and CAPPA who is pursuing certification in their area for patients who may not be able to afford a doula. There also is a program, Operation Special Delivery (http://www.operationspecialdelivery.com) that supports the United States military by providing free doula services during wartime to women who are preparing for and giving birth while their partners are on military deployment.

Physicians should not dismiss the value of recommending certified doulas to their patients based on a preconceived difficulty of obtaining one. The authors of the article clearly stated: "Continuous labor support provided by a doula, a lay woman trained in labor support, consistently has decreased the use of obstetric interventions….Fewer women had unsatisfactory birth experiences."1

I also would like to stress the significance of recommending a certified doula or one pursuing certification if you are not familiar with the doula's skills, because anyone can call themselves a doula (friends, sisters, and other relatives). Referring to a doula as a lay woman should not be confused with "lack of credentials." Birth experience, physician references, and formal training are required to become certified as a doula. Continuing education also is required to maintain certification.

DENISE PUNGER, M.D.
Coquelet & Punger Family Medicine, P.A.
4640 S. 25th St.
Ft. Pierce, FL 34981

References

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, fax number, and e-mail address. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

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