Thursday, May 23, 2013

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.

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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  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:

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.

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Monday, May 20, 2013

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.  

Sunday, May 19, 2013

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:

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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.

Friday, May 17, 2013

"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:  We offer this procedure as part of our office surgery services.

Wednesday, May 15, 2013

"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.

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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:

Wednesday, May 1, 2013

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.