Pap smears: How often to get them

Over the past ten years recommendations regarding the Pap smear screening test for cervical cancer have changed dramatically.  While we formerly started doing them at 18 years old and continued annually until death, we now start at 21 (or within 3 years of first intercourse).  The advent of the test for high risk HPVvirus types that is now done along with the Pap has revolutionized the frequency with which we do them.  If a woman is NOT a carrier for one or more of the high risk virus types, she may only need Paps every 3 years until the age of 65, and not at all thereafter.  If new sexual partners are introduced, we need to rescreen for HPV.  Gardisil vaccination can significantly reduce but not eliminate the chance of acquiring an HPV virus via sexual intercourse.

Annual gynecologic exams are still recommended even when Paps are not required, which can be performed by either an ObGyn or other provider of women's healthcare.

Abnormal Paps or those with HPV positive results require more intensive monitoring that your doctor will review with you in detail if necessary.

For more information go to:  http://www.acog.org/~/media/For%20Patients/faq085.pdf?dmc=1&ts=20120821T1136234943

What do we do if we can't get pregnant on our own?

The official definition of infertility is one year of regular unprotected intercourse without a conception.  That means if you conceive but miscarry, you are not actually infertile.  There are many aspects of the process of conception that cannot be studied or tested, and if a couple who has not yet started trying to conceive comes in asking me how they know whether or not they're fertile, I tell them we won't know until they try.  Clearly there are greater concerns in older (especially >34 year old) moms,  in women who have a history of pelvic inflammatory disease/sexually transmitted infections and in women who have had a number of abdominal surgeries.  Also, those women who menstruate infrequently are also likely to be having problems with ovulation, and may require evaluation before a full 12 months has passed.  For men with a history of mumps, genital injury, or age greater than 56 there may also be concerns.  For couples that have problems having regular intercourse, ovulation predictor kits can help them know when to try to create time for sex when it is most likely to result in conception.  Basal body temperature testing can be helpful, but is more cumbersome and vulnerable to inaccuracies with illness, etc.

The basic set of tests we order are a semen analysis or "sperm count", a tubal dye study ("hysterosalpingogram" or HSG), and a measure of "ovarian reserve" with a test called FSH (follicle stimulating hormone)as well as thyroid hormone and prolactin hormone levels.  The semen analysis is best performed at the laboratory after about 48--72 hours of abstinence.  The bloodwork is done on the 3rd day of the menstrual period in order to be accurate.  The  HSG is done after the period is over but before ovulation, about day 9 of the menstrual cycle.  If all the test results are normal, we will then usually refer on to the specialists in infertility called Reproductive Endocrinologists (REI).  They will oftentimes offer a plan that may include ovulation moniotoring and intrauterine insemination (with or without medications).  If that is unsuccessful, IVF or in-vitro fertilization may be discussed.  Fortunately many insurance companies have expanded their benefits regarding both testing and treatment over the years.  It's always a good idea to consult with your carrier ahead of time to get a general idea of what your coverage is for such interventions.

Infertility can be stressful for a couple and it is important to take good care of yourself and your relationship during evaluation and treatment for the problem.  The website resolve.org  is a great resource for information and support for individuals and couples. 

Screening for Chromosomal and Genetic Disorders

Most of the testing we offer during prenatal care is routine, but certain testing is optional.  Specifically those tests include testing for chromosomal disorders in the fetus and for genetic carrier status in the parents.  Chromosomal screening tests have evolved significantly over the years, starting with second trimester (15--20wks) screening (blood test) and now to first trimester screening including a blood test and ultrasound for the NT (nuchal translucency=the thickness of the skin fold on the back of the baby's neck) done at 12--13 weeks.  For older moms (> or = 35) there is a new test that measures the fetal DNA in the mother's blood as well ("Panorama" testing).  The main abnormalities that can be determined are Trisomy 21/Down's syndrome, Trisomy 18/Edward's syndrome and Trisomy 13/Patou syndrome.  Panorama testing can also pick up Monsomy X/Turner' Syndrome.  The only tests that can measure all the chromosomes are Chorionic Villous Sampling (CVS) or Amniocentesis, both of which are slightly invasive and can be associated with a small risk to the pregnancy/fetus.  They are therefore only offered when the risk is thought to be rather high that a disorder is present.  The majority of chromosomally abnormal fetuses will miscarry spontaneously, but these few disorders have occurred with enough frequency in liveborn infants to allow tests to be developed.

Genetic carrier screening can be done pre-conceptually or after conception of a pregnancy.  The most familiar example of such a test would be Cystic Fibrosis screening, which has been available for a number of decades.  As an example, 1/29 Caucasian people are carriers and the random chance a baby could be born would be about 1/3000.  However, if either the mother or father were to screen negative for the 20--40 most common genetic mutations associated with the disorder, the risk decreases to 1 in 6 million.  Other genetic tests have been available for a number of years including a panel of diseases for which Ashkenazi Jewish people are at risk, a form of mental retardation called Fragile X, and a muscular disorder called Spinal Muscular Atrophy.  A few companies have also come up with a much more comprehensive panel of disorders that can be screened for as well.  Many are quite rare, but for those families who have an affected child, most say they wish they'd had some information ahead of time about the disorder.  Some disorders can be treated while others cannot.  Genetic counseling is provided to those families in whom carrier status is found to exist in BOTH parents (with the exception of Fragile X, which only requires one parent be affected).  More information on this can be found at:  http://www.genpathdiagnostics.com/womens-health/for-patients/inherigen/

Many patients will ask why to do screening tests if they don't intend to terminate an abnormal pregnancy.  My answer to this question is that while there is no cure for many of the conditions for which we screen, there are a number of ways that it would change the way in which we care for you during your pregnancy should we discover certain conditions in your baby.  For example, when I'm taking care of a fetus with Down's syndrome, I'll order a special ultrasound of the fetal heart called a fetal echocardiogram  around 22 weeks of pregnancy to look for defects that are more common in these babies.  I'd also follow the fetal growth and amniotic fluid volume more closely in the third trimester to look for signs of problems that could put the baby at a higher risk of stillbirth.  Other specialists are also sometimes consulted for assistance in planning care for the baby immediately after birth or in the weeks and months thereafter.

All that being said, we have many patients who opt out of all or most of this testing, and that is perfectly OK with all of us.  We just like to make sure that our patients are kept fully apprised of what is currently available in order to be able to make a thoughtful and educated decision regarding their prenatal options.  

Why do we check for Group B Strep colonization

About 20 % of women normally carry Group B streptococcus as part of their nomral flora.  We culture all our pregnant women at about 35--6 wks along to determine who is a carrier.  We then treat them with antibiotics in labor not to eradicate but to reduce the amount of replicating bacteria in the birth canal so that when the baby is born, it is minimally exposed.  Most full term babies would do fine regardless of treatment, but a small number of untreated babies are vulnerable to an infection caused by GBS, so the American Academy of Pediatrics prefers we treat all colonized women in order to minimize that risk.  The most serious potential consequence of untreated GBS in the newborn is bacterial meningitis, and if a GBS+ patient is not adequately treated in labor (less than 4 hours from administration of the first antibiotics to delivery), the pediatrician may need to do bloodwork on the baby to insure it is well enough to go home from the hospital without antibiotics.  Even if you've been cultured positive in a prior pregnancy, we will still culture you again with each baby, as colonization can wax and wane over the years.  If you happen to test positive for GBS in the urine earlier in pregnancy, we will not re-culture at 35--6 weeks but rather treat you as a GBS+ patient.

For more information go to:
http://www.acog.org/~/media/For%20Patients/faq105.pdf?dmc=1&ts=20120821T1112475461

So What Exactly IS "Prenatal Care" Anyway?

Prenatal care consists of a series of visits with a qualified provider of prenatal care (ObGyn, Women's Health Nurse Practitioner or Certified Nurse Midwife) during the course of a pregnancy to insure the optimal health and well-being of mother and child(ren).  In a low-risk pregnancy, we like to see a patient within 8--10 weeks since their last menstrual period.  The first visit includes extensive history-taking, counselling, physical exam, lab tests and education.  After that we see patients monthly until 32 weeks.  Those visits usually consist of a urine specimen, weight, blood pressure, a routine list of questions, a brief exam including a fetal heart rate check and belly measurement, and an opportunity to address any questions or problems that have arisen since the last visit.  At 32--36 wks the visits are 2 wks apart and after 36 wks they occur weekly.  A variety of routine tests are done at the first visit and we offer several optional tests for chromosomal or genetic abnormalities at that time.  At 20 wks a routine anatomic ultrasound study is performed (usually at an outside facility with a high-resolution ultrasound machine), and at 26--28 wks patients under screening for gestational diabetes.  At 35--36 wks we get a routine vaginal culture for group B strep of the vagina and after 36 wks we do weekly cervical checks for fetal position and cervical dilitation and effacement.

With high risk patients or patients who develop certain medical problems during a pregnancy, we sometimes ask them to come in a little more frequently.  Other patients we might have see the maternal fetal specialist (formerly known as "perinatologist") along with us during the pregnancy for a more intensive level of monitoring for a variety of fetal or maternal conditions, including multiple pregnancies, babies with growth or developmental issues, women with a history of preterm labor/delivery, or those with significant problems with blood pressure, diabetes, kidney/heart/endocrine or rheumatologic disease, etc.  Occasionally we also consult specialists in other fields for assistance in managing non-obstetric conditions during the pregnancy, but most minor ailments can be managed by our providers here in the office.  

Baby Blues

Most of us are familiar with the idea that having a baby can cause mood changes in women, and in fact 80% of women experience some level of the "baby blues" in the first 6--8 weeks after giving birth.  Certain scenarios are riskier for the development of postpartum depression, including lack of a support system, financial stress, pre-existing mental health issues, twins/multiples, prematurity or other illness of the baby, and a prior history of postpartum depression.  The symptoms of depression include frequent crying/sadness, inability to enjoy things that one would normally have done, early morning awakening (other than for a crying baby) and other sleep disturbances, weight loss/lack of appetite, feelings of being overwhelmed or guilty about one's parenting skills, extreme irritability with loved ones, exhaustion, panic attacks, etc.

Fathers can sometimes experience some of these symptoms too.   We often will hear from fathers before the patients are willing to admit there might be a problem.  Obviously, if there are any thoughts about hurting oneself or the baby, that constitutes an emergency situation which we will help you get addressed right away by a mental health professional.  However, even when symptoms don't rise to that level, we have tools to help you cope with these difficulties including both counseling and medications.

Sometimes all a mom needs is some help with the baby so she can get some quality rest so that she can come back to her new responsibilities stronger and more refreshed.  Pediatricians can also be very helpful dealing with "colicky" babies or babies that have medical issues that need to be resolved.  Family support can be a big help, but occasionally can be part of the problem if it is overly intrusive into the new family unit.  Mom and Dad coming together as a team and communicating the need for boundaries is very important for some families in the early days.

We routinely have our patients fill out a screening to find out if they are at an increased risk for postpartum depression:
http://www.psychiatrictimes.com/all/editorial/psychiatrictimes/pdfs/EdinbPostDepScale.pdf.

For more information go to: http://www.acog.org/~/media/For%20Patients/faq091.pdf?dmc=1&ts=20130519T1554038320

Getting ready for Surgery

So you've been told you're going to have to have an operation.  What do you need to know to get ready?  The most important thing is that there should be no eating or drinking for at least 8 hours before the scheduled time of your surgery, otherwise the anesthesiologist will refuse to put you to sleep.  This is to prevent a serious complication from aspiration of stomach contents or acid that could cause pneumonia.   Occasionally you will be asked to perform a bowel prep the day/night before to clean out the contents of your bowels.  If so, you will get written instructions on how to do that.  You will be informed which if any of your regular medications can be taken with a sip of water that morning.  You can brush your teeth, but just be sure to spit out the rinse water in the sink.

You will be asked to review your medical history with the surgeon in the office and again on the phone with the Pre-Op nurse.  You'll probably have to review it one more time with the anesthesiologist when you get to the hospital as well.  This serves as a series of checks and balances to make sure you have every opportunity to inform the staff about you and any health issues you may have that could affect how your surgery is done.

You will be required to sign an informed consent document prior to going back to the operating room.  This is to verify that you have been counseled by your surgeon regarding the main risks of, benefits of, and alternatives to your surgical procedure(s).  If you feel you have not received adequate counseling, do not sign the form until you are comfortable.  Your surgeon will see you before you go back to the operating room and give you a chance to do so.

Sometimes before performing vaginal surgeries, we will have a patient use local estrogen creams to help strengthen and improve blood supply to the tissues of the vagina so that they will heal better after surgery.  This is usually done for a number of weeks ahead of time.

Usually about a week before planned surgery we discourage the use of aspirin or other antiinflammatory medications like ibuprofen, naproxen, etc. which can contribute to bleeding.  Acetaminophen is usually fine, as well as narcotic medications for pain.  If you are someone who takes blood thinning medications like Coumadin, Plavix, Heparin, etc., you will be instructed how to wean this preoperatively and then restart afterwards.

After your surgery, you may or may not have a great memory for the events of the day, but the nurse discharging you from the hospital should give be able to give you a general idea as well as instructions for self-care at home.  She will have any prescriptions the doctor left for you to take at home (usually pain meds for the more major surgeries).  If a family member or friend is present immediately after surgery in the waiting area, we always stop by to fill them in on the details of how your surgery went.  We can always be reached by phone if you have any unanswered questions, but of course we always ask for you to schedule a postoperative follow-up appointment in the office in a couple of weeks.

After going home from the hospital, we want to hear from you if you have any signficant bleeding, pain, dizziness, nausea/vomiting or fever/chills.  Also, burning with urination, skin redness/drainage or pain on the back near the ribcage (over the kidneys) should be reported if it occurs.

"I Think I'm Done Having Babies: Now What?"

The options for longer term or permanent birth control are several.  They include a variety of sterilization techniques, intrauterine devices, hormonal implants, injectable contraceptives, and hormonal contraceptives such as the NuvaRing, OrthoEvra patch and the "pill".  Except for smokers over age 35 and those with signficant risk factors for early onset breast cancer or blood clots, it is perfectly reasonable to continue to use hormonal contraceptives (all of which are very low dose these days) up through to the age of menopause (around 50 or 51 is average).

There are 3 available IUDs, one lasting for 10 years (the Paragard, which is copper based), one lasting for 5 years (the Mirena, which is progesterone based) and the new Skyla, which is a 3 year progesterone-based device.  These can be placed in the office postpartum or during a menstrual period.  They require pre-authorization with the insurance company and then are ordered for you if requested.  The progesterone-based IUDs only act locally, so they are still good options for those who can't or don't like to use hormonal contracetpives such as the pill.  They also generally cause periods to be lighter, which the copper IUD can sometimes make periods a little heavier for some patients.

Sterilization options include a tubal ligation which can be performed laparascopically or is sometimes done right after the birth of a child while you're still in the hospital.  The failure rate is less than 1% but in those rare instances we always caution about the risk of ectopic (usually tubal) pregnancy.  Vasectomy is a safer procedure by and large, since there are no vital organs immediately adjacent to the scrotum where the incision is made.  However, when a woman is having a cesarean section already, the addition of a tubal ligation does not increase her surgical risk considerably over the C section itself.  Of course, a failed vasectomy (also < 1% chance) is not associated with an increased risk of ectopic pregnancy.

The latest addition to the options for sterlization is a minimally invasive surgical placement of a device called Essure, which are very small metal coils inserted into the inside openings of the fallopian tubes via a surgical process called hysteroscopy.  The patient then undergoes a tubal dye study (Xray) 3 months later to make sure that the tubes are completely occluded by the natural scar tissue formation process.  There is no need for an incision and pain is much less than after a standard laparascopic sterlization.  More information on this is available at:  http://essure.com/how-essure-works/how-essure-works.  We offer this procedure as part of our office surgery services.

"Help! Something's Falling Out Down There!": Pelvic Organ Prolapse

Twice last week I had some pretty nervous ladies come in thinking that their insides were about to drop out on the floor.  In both cases, they had some mild to moderate pelvic organ prolapse and I was able to reassure them that they weren't going to die or inadvertently drop internal organs on the ground while they walked around the Safeway.  Pelvic organ prolapse encompasses a variety of conditions were portions of the female anatomy are starting to droop downwards to various degrees.  It may or may not be associated with pain, pressure, bowel or urinary dysfunction, or irritation/bleeding of the vaginal tissues.

In many cases the cause of this condition is thought to be related to having had a number of vaginal deliveries of large children.  It can also happen to patients with chronic constipation, obese patients, or patients with tissues that are just getting weaker and less supportive over the years after the onset of menopause.  Occasionally we also see it in younger patients as well.  The treatments for the condition(s) depend in part on how much the symptoms are bothering the patient, if there is incontinence present or absent, or if there is pain involved.  Surgical options such as vaginal hysterectomy with bladder/rectal repairs are frequently chosen but some patients prefer to avoid the operating room for a number of reasons including age, financial reasons, recovery time, other medical conditions, etc.  Nonsurgical remedies include Kegel exercises, wearing tampons or using a device called a Pessary which can be fitted in the office by the doctor.  Some patients simply reduce the prolapse with their fingers if it occurs intermittently.  For patients who have had previous surgeries and then had recurrent prolapse symptoms, we have specialists called Urogynecologists to whom we sometimes refer our patients.

For more information go to:   http://www.acog.org/~/media/For%20Patients/faq012.pdf?dmc=1&ts=20120821T1128376721

To Circ or Not To Circ, That is the Question...

The question of whether to circumcise a male child arises from a variety of cultural, traditional and medical perspectives.  The majority of babies around the world are in fact NOT circumcised, although certain religious groups like Muslims and Jews have adopted the practice as a ritual over the centuries.  By and large, the medical benefits are small overall, although some interesting research out of Africa has actually shown lower rates of transmission of HIV and other STDs in the circumcised male population versus the uncircumcised.  Urinary tract infections and penile cancer are slightly decreased in the circumcised population as well.  Uncircumcised boys need to be trained in how to keep themselves clean under their foreskin, but this is not usually difficult to do.

The medical risks of circumcision, like any surgical procedure, include infection, bleeding, scarring, and damage to adjacent tissues.  Fortunately, these are all fairly rare.  Sometimes a baby's penis is developmentally slightly asymmetric, or a little "twisted" which can sometimes make the circumcision a little uneven in the end.  Occasionally there can be a condition of the male urethra called hypospadias or epispadias, and circumcision is postponed until after the urologist assesses the situation (as a surgical repair may require the use of some of the foreskin).  Prematurity, jaundice, or other medical conditions of the infant may require a circumcision to be delayed.

In our practice we routinely use buffered Lidocaine solution injected at the base of the penis, which makes it numb in a few minutes.  The nurse also lets the baby suckle a sucrose solution which really does a good job at distracting the babies during the procedure.  We use a device called a "Gomco" for the procedure, which comes in a variety of sizes.  Vaseline on gauze is used between the penis and the diaper the first few days after the procedure to keep the raw skin from sticking to the diaper.  The glans (tip of the penis) is usually rather "hot pink" after the procedure but grandually become the same color as the rest of the penis.

For more information see:
 http://www.acog.org/~/media/For%20Patients/faq039.pdf?dmc=1&ts=20120821T1106326496
or http://www.mayoclinic.com/health/circumcision/MY01023

Screening Versus Diagnostic Mammograms: What's the Difference and Who Needs What?

I often get phone calls from patients who are upset because they didn't get an order for a diagnostic (or comprehensive) mammogram but rather a screening mammogram.  They may have needed a diagnostic mammogram in the past and are under the impression that they will always need one, or perhaps they have a family history of breast disease.  Actually we are required to follow some pretty strict guidelines regarding ordering diagnostic mammograms, which include a palpable mass, focal and persistent breast pain, skin retraction, personal history of breast cancer, spontaneous nipple discharge, and follow-up of a previously (usually within the last 6 months) seen mammographic abnormality.  A family history, breast implants or fibrocystic breasts may or may not require the additional views and radiation associated with a diagnostic study.

Actually most people aren't aware that the basic screening mammogram is done exactly the same as the diagnostic study:  same machine, same technician, etc.  The main difference is that in someone with a stronger likelihood of an abnormal finding, the radiologist reads the first two views on each breast while the patient is still physically present in the building.  The doctor reading the films can then decide then and there if additional views or sonography (aka ultrasound) is indicated, saving the patient a trip back.  This does incur a higher charge level, however, and so without the appropriate reason for the study to be diagnostic, the extra cost could be declined by the insurance company and passed onto the patient, and that could be considerable.

About ten percent of screening mammogram studies lead to a "call-back" for more views.  I have had that experience myself, and it certainly can produce anxiety.  However, be reassured that most of the additional studies end up showing no evidence of serious breast disease in the end.  We have the same experience with our patients in our office when we have to call and tell them to come back to evaluate abnormal Pap smears.  Just as in the case of breast disease, however, we only rarely will actually diagnose a life-threatening condition.

We rely heavily on our radiology colleagues to guide our decisions regarding whether a patient needs a diagnostic versus screening mammogram.  Usually their reports to us will tell us when to order the next study and what kind of study to order.  As guidelines change in the future, we are kept informed and in turn will keep you informed of the need for and timing of various types of breast studies.

Bumps and lumps

We get a lot of anxious patients worried when they find a variety of bumps/lumps on their bottoms and other locations.  Starting in the more southerly location, what should be the most concerning and what can wait to be evaluated?  Certainly anything causing severe pain we want to see sooner than later to get you relief.  This would include Bartholin's cysts/abscesses (usually the largest things we see and among the most painful).  They usually require surgical drainage to get better.

Herpes lesions, especially in large clusters, can be extremely uncomfortable and require medication for pain, for the viral infection and sometimes even urinary catheterization if a patient can't urinate normally due to the pain.  In the more severe herpes outbreaks, lymph nodes in the groin can also become enlarged and painful.

Sometimes sebaceous cysts or hair follicles can become infected and fill with pus (an "abscess") requiring incision and drainage in the office or treatment with topical or oral antibiotics.  Genital warts are usually more embarrassing than painful, but are most often treatable with topical medication.  Occasionally surgical excision or laser treatment is used for extensive disease.

Sometimes we encounter benign cysts, usually inside the vagina and often related to the way a laceration healed after childbirth.  Rarely we encounter tumors in the genital area.

Moving north,  the other area of concern for bumps/lumps is the breasts.  Fortunately many of the lumps we find (or that patients come to us with) are benign cysts or tumors that are commonly found in breasts.  We are always conscious of the fact, however, that even our younger patients aren't immune to breast cancers.  The characteristics of a breast lump that are reassuring are when they are tender, move around well with the rest of the surrounding breast tissue, have smooth edges,  and often wax and wane in different areas of the breasts (especially with the menstrual cycle).  Concerning signs of a breast lump are when it doesn't have smooth edges or move around easily, when it does NOT feel tender, when it is hard and when it keeps growing in the same place in the breast.  Obviously, a family history of breast cancer is also of concern, but the absence of a family history doesn't mean one isn't vulnerable to breast cancer.  Most patients with a palpable mass will get an imaging study of some kind (mammogram =/- Ultrasound) and the more concerning lesions occasionally merit an MRI.  Needle or surgical biopsies are sometimes needed to tell whether a lesion is benign or not.

Skin tags are very frequently seen and can often be removed in the office if they are getting in the way of clothing/jewelry/etc.  Darkly pigmented, irregular, irritated/bleeding or rapidly growing lesions should be evaluated by a dermatologist for possible skin cancer/precancer.  People with risk factors such as a history of sunburns, very fair skin, abundant moles, or family history of skin cancer should schedule regular skin checks with a dermatologist as well.  

When should my teenager come to the Gyn for the first time?

Another question I get all the time:  When should I bring in my teenage daughter for the first time?  In general the answer is between 15 and 16 years old, according the the experts in adolescent gynecology.    That doesn't necessarily mean they need to have a physical examination, which is what most of them are afraid of!  In the majority of cases, in fact, we just have a conversation about menstruation, safe sex, contraception, substance abuse, driving safety, and general personal responsibility for one's own health and welfare as they mature.  The first Pap doesn't have to be done until age 21 or within 3 years of first intercourse.  Oftentimes the child has already had her HPV vaccine series, but if not we can arrange for that.  STD testing is available when applicable, and we don't have a problem with prescribing hormonal contraceptives without a formal pelvic examination in the absence of any unusual personal/family history or symptoms.  I think the main reason to have your daughter come in is to establish a doctor-patient relationship and an avenue through which she can access care in the future with or without mom and dad's escort.  It gives her permission and encouragementto take care of herself now and forever.

Bleeding in Pregnancy

Nothing strikes fear into a woman's heart like discovering she's bleeding while pregnant.  The first thought is usually "is the baby alright?"  The answer to that depends on a variety of things including the amount of bleeding, the stage of pregnancy, the age of the mom, other medical conditions that may be present, and so on.

Bleeding in the first trimester is most concerning for miscarriage or occasionally for an ectopic pregnancy.  I tell my patients that call with early bleeding that only about half the time is bleeding an indication that the pregnancy will be lost, so to try not to panic right away.  If the bleeding is very heavy (more than a pad an hour) or associated with any severe pain or lightheadedness, we will often have patients go to the hospital emergency department for evaluation.  We also have a portable ultrasound machine in our office that can help determine the status of the pregnancy.

Bleeding later in pregnancy can often be associated with sexual intercourse or in more serious cases with preterm labor, placenta previa, or placental abruption.  Another common source of bleeding late in pregnancy is the cervical examinations we start doing around 35--36 weeks of pregnancy, although it is usually not very much and stops quickly.  Active labor is often accompanied by what we refer to as "bloody show" which is a mixture of blood and mucous that occurs when the cervix begins to dilate.

Whenever in doubt, we're of course always available to answer your questions and help you decide if the amount of bleeding you're experiencing needs to be immediately evaluated or not.  

You have a self-cleaning oven!

One of the most frequent  reasons to see a gynecologist is vaginal irritation.  While yeast infections, bacterial, and parasitic infections are commonly found, it is also very common to find no evidence of infection at all.  In those situations the first question I ask patients is "what is you personal hygiene regimen?"  The answer to that question is almost always the wrong one.

The right answer to the question should be "a little warm water", but it is usually some sort of soap, body wash, feminine cleanser, wipe, etc.  I respond by telling patients that for the most part they have a built in "self-cleaning oven" and that introducing all these cleansing techniques often does more harm than good.  As in the gastrointestinal tract, there is a mixture of normally-occurring microorganisms in the vagina that live together in a very delicate balance.  This balance can be affected by changes in pH, exposure to antibiotics/medications, chemicals, etc.  When the balance is off, symptoms such as discharge, odor and itching can result.

Many women, particularly fair-skinned women and older patients, can also have very sensitive skin around the vagina (the perineum) which can become red, itchy and irritated like an allergic reaction when exposed to soaps, pool chlorine, pads (especially scented ones), condoms, lubricants, etc.  As in other dermatologic disorders, sometimes it takes a little careful investigation to find out exactly what the source of the discomfort is.  Stopping the chemical irritants and waiting 4--8 weeks is often all that is necessary for balance to be restored, but intense itching can be symptomatically treated in the short run with antihistamines such as diphenhydramine or topical steroid creams such as 1% hydrocortisone cream.  Postmenopausal patients sometimes need topical estrogens to restore natural protections to the vaginal mucous membranes.

With regard to discharge, a certain amount of clear or light yellow mucous is a normal finding, particularly around the time of ovulation.  Some patients certainly experience more than others, and pregnant patients find that discharge naturally increases throughout pregnancy.  When you're not sure what normal is for you, your gynecology care provider can help you figure it out.  

Break-Through Bleeding, aka "BTB"

I asked my nurse today what she gets the most telephone questions about on a day-to-day basis and she said without hesitation:  Break-Through Bleeding!  What is BTB, anyway?  Generally we doctors refer to bleeding between periods as BTB or "metrorrhagia", heavy bleeding with the period as "menorrhagia", and both together as "menometrorrhagia".  Depending on your age, BTB can be caused by different things.  Probably the most common cause in our younger patients is starting a new (<3months), hormonal contraceptive  (pill/patch/ring/shot/etc).  While your body is getting used to having the exogenous hormones controlling the bleeding cycle, there can still be the occasional irregular shedding of uterine lining, leading to the bleeding.  This is more likely nowadays with the very low estrogen dose pills, which are a little more unforgiving if the pill is taken at different times of day.  Even perfect usage can be associated with some BTB at first though. BTB does not mean that the contraceptive is not working to prevent pregnancy, however.

More concerning is bleeding that occurs between periods without any exogenous hormone treatment.  A normal menstrual cycle is between 21--45 days in length.  I tell patients that I need them to tell me if they have bleeding episodes less than 21 days apart (counting from the first day of the period to the first day of the next period).  Sometimes we discover benign polyps or fibroids of the cervix or uterus.  Rarely, we diagnose pre-cancer or cancer of the uterus, however.  This is higher risk in patients at the end of their reproductive years of course, but I've also seen it in younger patients with long periods of absent periods followed by heavy or irregular bleeding episodes.  I like patients to let me know if they miss more than 3 menstrual periods in a row, as hormonal treatments can make them more regular and prevent mutations that could lead to abnormal cells in the uterine lining.

Sometimes we do an office biopsy ("EMB") for abnormal bleeding, sometimes an ultrasound, sometimes both.  Occasionally we do a procedure with a hysteroscope that allows us to see inside the uterus fiberoptically and identify pathology during a D and C procedure (dilitation and currettage).
If abnormal bleeding patterns persist despite all our best efforts and diagnosis and medical management, we do have surgical procedures that can decrease or eliminate menstrual bleeding.

Letting it All Out: Nausea and vomiting in pregnancy

I enjoyed seeing just how many euphemisms there are for vomiting on this webpage:  http://jakersdelight.blogspot.com/2009/08/vomit-euphemisms.html.  Every pregnant woman knows, however, that there's nothing funny about the nausea (aka "morning sickness") that affects most women at some point during pregnancy.  Some of us can suffer for half or more of the pregnancy, while most women peak at 7--12 weeks then find that the symptoms decrease and then disappear.  So what's to be done about it?  Well,  if there's just nausea but no vomiting it is certainly reasonable to try just modifying one's diet to foods that seem to agree with them (which will be different for everyone, but typically bland foods low in fat and higher in carbs work for many).  Vitamin B6 or pyridoxine, 100mg daily, can also be helpful.  Some women also try "sea-bands" and accupuncture to help themselves.  Sipping lemonade or sucking on lemon drops can take away some of that bad taste women frequently complain about.  Being careful during tooth brushing not to stimulate too much retching is also a challenge, but a fluoride mouthwash can help you keep up with your oral hygiene.

I tell my patients that some weight loss is not as concerning in the beginning as is dehydration.  If a patient calls with an inability to hold down fluids for more than 12 hrs, I usually have them come to the hospital for IV hydration in order to help break the cycle of nausea and vomiting that can often ensue from getting dehydrated.  This is true both for pregnancy-related nausea and vomiting, as well as gastroenteritis or food poisoning.  Late in pregnancy the dehydration can also cause preterm contractions, which is another reason we like to intervene sooner than later.

Medications that we use for nausea in pregnancy include promethazine or Phenergan, Reglan, and Zofran.  Promethazine can be sedating and Zofran can cause constipation, so being prepared for side effects is a good thing.  In extreme cases we occassionally hospitalize patients and even more rarely send them home with long-term intravenous nutrition formulas for home infusion.  Having severe nausea can also lead to depression, so we monitor these patients closely for those signs and symptoms too.

The good news is that the reason many women suffer with nausea is that the level of their hormones is nice and high, often an indicator of a normally developing pregnancy.  All pregnancies are associated with a plateau in these levels around 10 wks or so, and that's why most women can expect their symptoms to wane shortly thereafter.

"I'm feeling so HORMONAL lately!" Mood Swings in Women

Many patients will come to the office saying they're feeling "hormonal" at various times.  When pressed, what I almost always learn is that what they are really saying is that they are feeling depressed, anxious, irritable or generally moody. While certain times of the menstrual cycle (a week before the onset of menses to about 2 days into the period) can produce transient mood changes, I'm always careful not to allow my patients to blame all of their emotional changes simply on their hormone fluctuations.  Mood problems are very common in both men and women (23--46% chance) and can wax and wane over one's lifetime for a variety of reasons.  Some people are more prone than others to disturbances in their moods, and looking at your family history can often give a clue as to whether there are some vulnerabilities that may have been passed down the family tree.  This includes not only formally diagnosed conditions such as depression, anxiety, bipolar disorder, etc. but also a tendency toward substance abuse (often associated with self-medication of mood disorders).

20% of pregnant women may experience mood disorders and up to 80% of postpartum patients experience some level of "the blues".  Fortunately less than 1--2% suffer postpartum psychosis.  We monitor all our pregnant and postpartum patients for such symptoms.  Often patients who are struggling to conceive a pregnancy or who have had prior poor pregnancy outcomes are vulnerable to mood changes and require special attention.

PMS is often manageable with excercise, lifestyle changes, dietary modifications, and sometimes medications (hormonal and non-hormonal) given part or all of the month.  Mood changes associated with the transition to menopause (the "peri-menopause") are frequently related to the hot flashes, night sweats and disruption of normal sleep patterns.  Addressing those symptoms so that a woman gets good rest can go a long way toward helping restore a more stable mood.  Low dose hormonal contraceptives can also help regulate fluctuations in hormones during this transition as well, making periods more predictable.  This is an option even for those who have had tubal ligations or other long term/permanent contraceptive methods of birth control.

After the menopause transition, mood problems are no more common than in the general population, but certainly managing chronic health conditions, changing levels of independence, and the grief of losing a spouse or other friends and family members can produce changes in mental health that should be addressed regularly by one's physician or mental health professional.

http://www.34-menopause-symptoms.com/mood-swings.htm

"I Didn't Sleep a Wink Last Night, Doc!" Part 2, Nonpregnant patients

For those who don't have a baby inside nudging them awake all night long, there are still lots of reasons  why you might have trouble sleeping.  Stress, excess stimulation, various types of physical discomfort, anxiety/depression, and age-related changes in the need for sleep can all be involved.

There are basically two types of insomnia:  the kind where you can't fall asleep and the kind where you fall asleep just fine but awaken earlier than you'd like and then you can't fall back to sleep.  The second kind in general is frequently associated with anxiety and depression, so getting those problems treated is very important as well as reducing those sources of stress that you can control.  I've had several patients with longstanding insomnia that resolved after finally leaving a stressful job, for instance.

Physical discomfort can also awaken people during the night, including the need to urinate.  It is considered abnormal if you have to get up more than twice a night to empty one's bladder.  I often look at a patient's medications to see if they are using diuretics to manage high blood pressure.  While diuretics are great medications for blood pressure, there are also lots of alternatives out there that may do just as good of a job without causing frequent urination.  (Of course, your family/internal medicine doctor would need to be consulted regarding the best plan for your blood pressure management.)  Caffeine and alcohol are also potent diuretics that should be avoided close to bedtime, and avoiding drinking fluids for two hours prior to bedtime can also help keep your bladder from becoming excessively full during the night.

Other medications that can be excessively stimulating for many patients are those used to treat nasal congestion caused by allergies or upper respiratory tract infections.  Antihistamines in general are more sedating while decongestants are more stimulating.  Neti pots are a good non-pharmaceutical alternative to managing chronic nasal congestion.

Other sources of physical pain and discomfort need to be addressed if they interfere with sleep, as lack of sleep tends to perpetuate pain syndromes.  Many chronic pain patients can be managed well with certain antidepressants, anti-seizures medications, and other agents that reduce pain without leading to drug dependence.

One of the more serious issues of sleeplessness is sleep apnea.  Common symptoms are snoring reported by one's sleeping partner along with periods of absent breathing followed by a sudden intake of breath.  This can be associated with obesity, alcohol intake, certain medications, sleeping position (mostly back sleepers), and certain anatomic conditions of the neck and throat.  Untreated, sleep apnea can be very hard on the heart and is associated with an increased risk for sudden cardiac death.  Many local neurology practices offer sleep studies to help identify the extent of the condition and recommend treatment options, which may include a special breathing machine called CPAP.

As people age, many do not need as many hours of sleep at night as they might have in preceding years.  If you awaken after 6 hours of sleep feeling refreshed and don't develop significant fatigue during the day thereafter, that may be all you require.

If daytime fatigue is a problem, there are a number of ways to help yourself get back to sleep including avoiding bright lights/computer screens/TV/suspenseful books, etc.  Avoiding heavy meals close to bedtime is also important, particularly for those who tend to suffer with heartburn.  Making sure your bedroom is dark, quiet and that the temperature is right around 70 degrees, and sticking to a regular sleep schedule all work toward good sleep hygiene.  I like to use a white noisemaker myself to drown out random noises around my house.  Warm milk, a light snack or herbal teas can be relaxing, or even a warm bath.  Meditation techniques to control persistent worrisome thoughts are also very effective for many people.  Daytime exercise (ending at least 4 hours before bedtime) is also associated with a variety of health benefits, including more sound sleep.  Short naps in the daytime can be a wonderful way to refresh oneself, but long naps (more than 45 minutes) can interfere with nightime sleep.   Short term sleeping medications are useful for acute insomnia, although in older patients, I worry about sedatives contributing to falls at night. 

"I Didn't Sleep a Wink Last Night, Doc!" Part 1--Pregnancy Insomnia

I'm often asked by pregnant patients and their partners what they can do to help them get better sleep.  Oftentimes, they are physically uncomfortable in the back and hips and cannot seem to find a comfortable sleeping position.  Other times hand numbness/tingling/discomfort is the culprit, and nasal congestion and shortness of breath can also be reasons for difficulty resting.  Finally, a very common source of insomnia for both pregnant and non-pregnant patients is stress and anxiety.

The most common sleep aid I recommend is a "body pillow" to provide support for the full length of the body while sleeping on either the left or right side (after 16 weeks it's a no-no to sleep on one's back in pregnancy).  Other smaller pillows may also be useful to support the enlarging abdomen or to place in the lumbar area.  If the bed is just not comfortable to sleep in at some point, it may be necessary to find another place in the house that's more comfortable--the guest room bed, the couch, the recliner, etc.  I always say "whatever works".  

For those with hand discomfort, wrist braces can be purchased at a pharmacy that carries medical supplies and adjusted to keep the hand(s) at a neutral position during sleep, decreasing compression on the nerves.  Avoiding hi sodium/salty foods is also useful in reducing fluid retention and nerve compression in the wrists as well.

For those with nasal congestion, using saline nasal spray and/or a humidifier can be helpful, and many of my patients with chronic sinus congestion swear by the "Neti Pot" irrigation techniques.  We only recommend nasal decongestants for short term (i.e. 3 days or less) management of upper respiratory tract infections, as they are stimulants to the cardiovascular system, and can actually worsen insomnia as well.

Shortness of breath is a very common symptom in advancing pregnancy, in part due to the compression of the diaphragm from below as well as to other physiologic changes in pregnancy.  Proper positioning and posture can help, as well as elimination of common allergens such as pet dander (no sleeping with Fido!), mold/dust (break out the vacuum, Dad!), and appropriate prescription medications for those who suffer with asthma.  Of course, we always recommend avoiding smoking in pregnancy and exposure to second hand smoke.

Stress and anxiety are very common, especially with the excitement of impending birth and changes to family structure, financial concerns, relationship issues, and so on.  This is particularly true if you are carrying a high risk pregnancy that has caused you to be on bedrest or to modify your work hours.  There are also lots of patients who were anxious people long before they conceived a pregnancy.  Doing what you can to control the sources of stress in your life is an obvious (though not always easy) fix.  Avoiding stimulants such as caffeine, exercising close to bedtime, too much screentime (TV, computer, smartphone, etc) close to bedtime, and so on can be very effective.  Sometimes sleep aids are recommended short term such as diphenhydramine, Ambien, etc., but we like to clear the system prior to the onset of labor of any sedative medications that may hang around longer in baby than in mom.  Finally for those who are clinically depressed/anxious, certain prescription medications may be recommended to avoid the consequences of those conditions in pregnancy, including insomnia.

Finally, one of the most frequent complaints I get from pregnant women is that they have to urinate all the time, including during the night.  Clearly avoiding over-drinking prior to bedtime can help, and as long as your urine is a light yellow color you don't have to worry about being dehydrated.  If there is burning with frequent urination, a urine culture should be done to rule-out infection.

Sometimes I look at a little insomnia as God's way of getting us ready for the true sleep deprivation yet to come after baby's arrival, but getting as much sleep as you can before baby is a gift to yourself.  Happy dreams!

When should I call the doctor in labor?

If you are full term (37--41 weeks) and you are having contractions lasting at least 30--60 seconds every 5 minutes for more than an hour, they are getting intense enough to make you not be able to converse normally during the contraction, and they don't go away with rest and fluids, then you may very well be in labor.  If it's during office hours, feel free to call us there.  If not, The Birthing Inn is always open and the staff there will be happy to evaluate your contraction pattern and cervical exam and determine if it's false labor or the real thing.  If you are just not sure you can call us on the on-call number any time after hours at (703)740-5378.  If you have a history of having had rapid labors in the past, or you have already had cervical dilitation of 3 or more centimeters, we may want you to come in a little sooner, especially if you live distant from Leesburg.

If you are contracting prior to being full-term, drink lots of water, empty your bladder, lie down, and if the contractions continue to occur more than 5 or 6 times in an hour, come over to TBI to be evaluated.  If you think your water has broken or if you have significant vaginal bleeding, we'd like you to be evaluated as well.  Finally, the baby should move at least a dozen times a day in the last 2 months of pregnancy.  If you think it is moving less than that, we would like to have you monitored at TBI.  

Is it HOT in here or is it just me?

Oftentimes we have patients complaining about hot flashes or night sweats.  About 80% of women will have some degree of these symptoms as they enter menopause.  Those who enter surgical menopause (by having both ovaries removed in their pre-menopausal years) have the most dramatic onset of symptoms.   Hormone replacement therapy (available in a wide variety of forms) has gotten a bad rap over the last decade, but in reasonably low doses used short term, it is still a very effective and safe option for many patients. http://www.menopause.org/for-women/menopauseflashes/the-experts-do-agree-about-hormone-therapy

For those patients who are unable or unwilling to use hormone replacement, there are also a number of alternative behavioral, nutritional and pharmeceutical options as well.  For patients with mild to moderate symptoms, we often start simply by recommending dressing in layers in natural fibers, using fans at home and work, avoiding alcohol and spicy foods, etc.  Aerobic exercise on a regular basis also has been shown to reduce hot flashes.  Soy supplements contain plant estrogens and can be helpful.  Estroven is one such supplement, although drinking soy milk or eating tofu or edamame can give you similar benefits.  The benefit of black cohosh products is controversial, although I have had patients say Remifemin works for them. http://www.menopause.org/for-women/menopauseflashes/the-experts-do-agree-about-hormone-therapy

I have also had patients do well with accupuncture in some cases as well.   Many patients find relief on an antihypertensive medication called Clonidine (aka Catapress).   It is usually given once a day in a 0.1mg dose.  It can also be given as a patch.  There are a number of antidepressant medications that have been shown to have benefit for patients with hot flashes including Effexor and Pristiq.  Gabapentin has also been shown to help reduce symptoms, although it usually has to be given 2 or 3 times a day.  Most patient's symptoms will reduce spontaneously without treatment within a year, and those using hormone therapy are generally recommended not to stop treament "cold turkey" but rather to do a gradual wean in order to prevent recurrent symptoms. 

Healthy Bones and How to Keep Them

How does one keep from getting osteoporosis?

Well, the most important thing is probably paying more attention to building a good skeleton in childhood and adolescence by giving ourselves lots of calcium-rich foods.  We want to encourage girls to be lean and active, but intense physical exercise or dieting that leads to the disappearance of periods is bad for the bones. 

As we age, our bones naturally start to lose minerals and become thinner starting in our late 20's.  The most rapid period of decline is in the first few years after menopause.  The National Osteoporosis Foundation and other organizations agree that for low risk women without a history of fracture, the first test of bone density should be at 65 and then periodically thereafter if indicated.  Higher risk patients may need to be evaluated earlier, especially heavy smokers and drinkers, very thin patients, anyone on chronic steroid therapies, those with a strong family history of osteoporosis/fracture, or those with a premature onset of menopause.  

Most medications available to treat osteoporosis are not indicated for the pre-menopausal patient population, but there are a number of nutritional and lifestyle recommendations that are helpful, particularly with regard to Vitamin D and Calcium intake.  Medications include bisphosphonates, estrogen replacement,  raloxifene, and Prolia injections.  

For post-menopausal patients, we use prescription medications for those diagnosed with osteoporosis (T score of -2.5 or worse) or for patients with osteopenia (T score -1.0 to -2.4) who have fractured or who have a FRAX score indicating a high risk of fracture.  Go to the  FRAX calculation tool at http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=9 to calculate your risk of fracture.  

Given the increasing lifespan of women, it is vital we start early in preventing fractures that can disable us as we age and rob us of our independence.  

WEIGHT LOSS AND YOU

So...It's a Happy New Year and you're thinking about losing weight.   You've put it off long enough.  You tried not to put on the usual 5-10 pounds that usually occurs during the holiday season, but did anyway.  Where do you start?

Well, you first might want to figure out why you want to lose weight.  Likely, you think if you lose the weight you will look great!  This is like the feeling you experienced while dating the best looking guy in the history of your love life;  nice for a while, but superficial and ultimately not as satisfying as you imagined, not to mention short-lived.  How about to live a longer life?  That has to be it!  No again.  A recent study published in the Journal of the American Medical Association found that only people with body mass indices (BMIs) of greater than or equal to 35 were at a higher risk of death from any cause than compared to people that were normal weight or moderately overweight.  That's right, I said OVERWEIGHT.  In fact, they found that people that were overweight actually had a LOWER chance of dying (by 6%) than people with normal BMIs (equal to 19-25).  I can actually hear all of you breathing a sigh of relief. 

Why would people that are overweight have a lower chance of dying than those of a normal weight?  Well, the experts theorize that possibly people that are overweight are treated more aggressively for medical conditions such as diabetes, elevated cholesterol, and high blood pressure than their normal weight counterparts.  Overweight people are less likely to have osteoporosis, a condition that leads to an increased risk for life threatening hip fractures.   Another factor may be that if you are overweight and develop a life threatening illness, that those extra pounds provide needed energy reserves.

Ok, so now you say, why should I lose weight at all?  How about to FEEL GOOD!?  How about to have the energy we need to meet the demands of our fast paced lives?  How about so you don't need all those medications to treat medical conditions that come from eating the wrong foods and not being active enough?  That sounds pretty good.  If we eat healthily and maintain an active lifestyle (watching TV or playing on your Ipad does not constitute an active lifestyle) but are not rail thin, let's not beat ourselves up too much.  Make sure you are getting screened for elevated cholesterol, diabetes, and hypertension on a regular basis.  Make sure you are eating a diet rich in a variety of vegetables (yes, these come first in priority and amounts), fruits, lean proteins, and complex carbohydrates.  Minimize your alcohol intake (ladies, this is <7 glasses of alcohol per week and no more than 2 glasses at a time).  Move, exercise, dance, walk, park your car far away from the mall entrance/from the grocery store entrance, take the stairs, just get going!  If your BMI happens to fall into the "overweight" category, but you are living a healthy lifestyle, don't fret.  You'll have less of a chance of dying than the skinniest person you most envy!


To calculate your BMI (body mass index): take your weight converted into kilograms and divide it by your height (converted into meters) squared. 

Happy New Year from Loudoun Physicians for Women

Happy New Year, 2013!
We at Loudoun Physicians for Women wish you and yours all the best for the new year.  Now that we've narrowly averted going over a fiscal cliff, what's next for the coming months?  For those interested in a resolution to lose weight and get healthy, I'm a big fan of the Weight Watchers program, both online and in-person.  It's been shown to help folks maintain their losses better than those other programs that provide you their food options without really teaching you better attitudes toward your food/shopping/cooking/eating out, etc.  Even modest losses (10-15% of your total body weight) have measurable health benefits to your blood pressure, cholesterol and glucose levels.  Small increases in your physical activity (taking stairs instead of elevators, parking at the far end of the parking lot, stretching and doing some light weight-lifting while watching TV in the evenings, etc.) can make noticeable differences in your energy level and flexibility, as well as your ability to maintain your weight.  Paying attention to your calcium and vitamin D intake can help to stave off the risk of osteoporosis and fracture as you age, especially the younger you start.  Reducing stress wherever you can affects not only your mental health but your physical status as well.  Making time for friendships, leisure activities, and spiritual growth are all important in keeping your "happiness quotient" up.  We see many of our patients doing wonders at taking care of everyone but themselves, and we want you to remember you're no good to them if you're not in the best shape you can be.  We're behind you all the way!