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.