"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.