According to the World Health Organization, 1 in 5 women will suffer from excess menstrual bleeding during their lifetime. These women have been labeled “Silent Sufferers.” A study reported that only 5% women recalled that their doctor inquired about menstrual bleeding patterns as part of their annual physical exam; whereas 38% of these physicians reported doing so; Why the discrepancy? A classic study in 1966 compared a woman’s perception of their menstrual flow to actual measurements. Surprisingly, half the women with heavy menstruation rated it as normal or light. So asking a straightforward question “Is your period normal?” does not reveal many who are afflicted. Hence, these women suffering with heavy periods are left unidentified, and consequently tolerating their embarrassing condition.
In a study published in the British Journal of Medicine, 1 in 5 women responded “yes” to the question, “Does your period disrupt your life?” Notice the question is not judging whether the amount of bleeding is normal or not, but rather focuses on impact on lifestyle.
In 2012 the menu of treatment options includes Treatments target the inside lining of the uterus, since bleeding originates from sloughing this tissue. The Good news is there are often alternatives to hysterectomy (the removal of the uterus):
- Hormonal therapy (Birth control pills or progesterone minimize growth of the inside uterine lining)
- Progestin IUD (The Mirena® Intra-Uterine Device only delivers progesterone to the uterine lining, so less side effects)
- Lysteda® (non hormonal medication taken 1st 5 days of period)
- Endometrial Ablation (NovaSure is a 90 second treatment to remove the inside lining of the uterus so it doesn’t grow back)
- Hysterectomy (preferably laparoscopic or vaginal as minimally invasive routes)
At Women’s Health Specialists we offer women the convenience and efficiency of a complete work up for abnormal uterine bleeding in a single office visit that includes a pelvic ultrasound, hemoglobin, and endometrial biopsy as indicated. We can then promptly proceed to treatment options that you’re comfortable implementing. This saves time, expenses, and most importantly lessens anxiety.
Cervical cancer is typically slow growing, and most cancers are found in women who have never been screened or who have not been screened in the past 5 years. Annual screening with PAP testing has been shown to lead to a very small increase in cancers prevented, but greatly increases the number of unnecessary procedures and treatments. Transient Human Papillomavirus (HPV) infections are common (80% of people) and associated low-grade pre-cancer is high. Most of these will lesions will regress within 1 to 2 years. So treating these patients does not provide a benefit large enough to outweigh the harms. The small fraction of lesions that do not regress will, on average, require many years to progress to cancer.
Consequently 2 weeks ago several national agencies* announced extended intervals for cervical cancer screening. For women 30 years and older, co-testing with PAP & Hi-Risk HPV every 5 years is preferred to PAP alone, but the later every 3 years is an acceptable strategy. In choosing to make co-testing the preferred strategy, these agencies focused on evidence from multiple randomized clinical studies showing that co-testing has improved accuracy compared with PAP alone. Specifically, co-testing has increased sensitivity (over 99%) for detecting advanced pre-cancer of the cervix. Because of this improved performance, co-testing can be used for screening at less frequent intervals than PAP alone. Recommendations for other age group are noted in this table:
|1st PAP||21 years old (and after intercourse initiated)|
|PAP Every 3 years||20’s|
|PAP & HPV Every 5 years||> or equal to 30 years old|
|Stop Screening||> 65 years old|
Women with a history of advanced pre-cancer should continue annual screening for at least 20 years
It is very important to emphasize that the revised recommendations do not imply the end of the annual well woman visit. Counseling and education on topics varies by age:
- Adolescents and young women can benefit from counseling on healthy diet, risky behaviors, family planning, and—if they are sexually active—testing for sexually transmitted diseases. The focus for cervical cancer for this age group should be on primary prevention through HPV vaccination.
- Women of reproductive age will benefit from counseling and shared decision making on family planning, and treatment of excess menstrual bleeding.
- Women in the later reproductive years and perimenopausal women will benefit from counseling on the menopausal transition, osteoporosis prevention, and referral for mammography and colorectal cancer screening.
- Both women of reproductive age and postmenopausal women benefit from breast cancer screening and evaluation and treatment urinary incontinence and pelvic floor function.
This visit has always been more than just a “PAP smear,” and the decreased need for cervical screening actually constitutes a minor change to an important aspect of a woman’s health care.
Most contraindications to oral contraceptives (OC) are due to the estrogen component in the pill. Clearly, there are women for whom OCs should not be prescribed. These include women who have a history of migraines with aura due to the increased risk of stroke. Women with uncontrolled high blood pressure or smokers older than age 35 should not be prescribed OCs because of increased heart disease risk. Caution should be used when initiating combined OCs in women who already have elevated blood pressure.
OCs are contraindicated in several other groups of women. These include diabetics with end-organ damage (kidney, eye, vascular); a personal history of breast cancer or estrogen-dependent tumor; active liver disease; a history of blood clots in veins. Women with mild high cholesterol who do not have other cardiovascular risk factors can be prescribed OCs if their low-density lipoprotein cholesterol is less than 160. Combined OCs are also contraindicated in breast-feeding women who are within 6 weeks of delivery (Progesterone only pill OK).
Potential side effects of OCs should be discussed with patients considering OC use. The most common side effects include nausea, headaches, breast tenderness, and breakthrough bleeding which often resolve in first few months. A more serious, but uncommon side effect of OC use is a small increase in the risk of venous blood clots compared to women who do not use OCs; this risk may be higher in obese women. This increase is much lower than the risk blood clots associated with pregnancy.
Unplanned pregnancy in women with medical illnesses like those described above can be disastrous for both mother and child. Other contraceptives may be better suited for these women. Nevertheless, contraception, while not perfect nor risk free, allows time to optimize medical conditions so as to reduce impact on pregnancy or avoid it altogether if that is what a woman desires.
Sometimes it’s the little things that can make a big difference. Here are 7 practical, evidence-based recommendations you and your docotr can impliment now to improve contraceptive care:
- Do not require a pelvic examination before prescription of an oral contraceptive
Both the World Health Organization and the American College of Obstetricians and Gynecologists recommend doctors consider a pelvic exam optional before prescribing an oral contraceptive (OC). This removes a barrier to care for a patient who may fear it, postponing the exam to the near future when she may be more comfortable with her health care provider.
- To encourage continuation, begin now
Starting OC pills immediately—instead of waiting for the Sunday after the next menstrual period can improve the short-term continuation rate (Use condoms as back up for first cycle if >7 days since the beginning of your last period).
- Provide more, not less—Dispense at least 3 to 6 months of an OC
This results in a lower discontinuation rate. One study showed that dispensing a 12-month supply of OCs reduced unplanned pregnancies by 30% and abortions 46% (why aren’t health insurers listening to this?).
- Move away from every-day regimens
Forgetting to take your pills? Consider a non daily method, such as Ortho Evra® patch (weekly) or vaginal Nuva Ring® (monthly).
- Make a case for long-acting reversible contraceptives
IUDs and the skin implant Implanon® as first-line contraception more often—convenient, removes user errors, and much more effective ( 1% vs. 5% pregnancy rate with OCPs)
- Emphasize non contraceptive benefits
Hormonal contraception reduces acne, menstrual flow and cramps. Counter false fears about weight gain or lingering effects on subsequent fertility.
- Preemptive prescribing “Morning after pill”
If you are a sexually active woman using nothing, withdrawal, or condoms then ask your doctor for a prescription for emergency contraception—Plan B® or Ella. You can fill the prescription and keep it at home in case of unprotected sex.
Finally, let us reassure you that every method of birth control is safer for them then the risk of complications during pregnancy—after all this is the “disease” we are trying to prevent.
Over the years we have been presented with pregnant patient’s concerns about something that a well intending friend or relative has warned them to be cautious about. We asked our staff to share with us their favorites. Here’s a brief, albeit entertaining, list:
- Reaching above your head will cause the umbilical cord to wrap around the baby’s neck.
- If you see something ugly when you’re pregnant, your baby will be ugly.
- A pointed belly indicates you are carrying a boy. If you carry your baby sideways you have a girl.
- If you have heartburn your baby will have a lot hair
- Is it safe to drive while pregnant? (When is it safe to drive?).
- If you wear a crucifix, your baby will have a birth mark on their face.
- During postpartum do not go outside without a sweater or walk barefoot.
- Spicy foods can cause premature labor.
- If you eat saffron during your pregnancy, your baby will have light skin.
- Can I go on the Internet while pregnant?
On the other hand some advice warrants concern. The U.S. Department of Health and Human Services recommends pregnant women avoid sushi altogether, because raw fish may can contain bacteria and parasites. Other fish (Grouper, Marlin, Orange Roughy, Swordfish, Shark, & Mackerel) are high in mercury which can be a potent neurological toxin and hence should be avoided.
While we may never be able to set these superstitions to rest, if you listened to these pregnancy wives tales you would probably sit and worry the whole nine months of your pregnancy. We’re here to help too.
With the frequent use of transvaginal ultrasound, CT scans, and MRIs; the diagnosis of uterine polyps has increased. Endometrial polyps are small growth from the inner lining of the uterus. They occur in menstruating and postmenopausal women, and in some cases are thought to be related to unopposed estrogen and medications like tamoxifen. Some women are asymptomatic at the time of diagnosis; whereas others experience abnormal bleeding patterns such as spotting between periods, heavy menstrual bleeding, or postmenopausal bleeding.
So when should we be concerned? A recent review of 17 studies was published in the Journal of Obstetrics & Gynecology about the cancer potential of uterine (not cervical) polyps. Those women with uterine polyps and abnormal bleeding or in menopause only have a 5% chance of cancer. Fortunately we can easily remove polyps by hysteroscopy to send to the lab for analysis (inserting a thin scope into the uterine cavity similar but more accurate than an old fashioned D&C). It’s low risk, relatively painless, and requires no recovery time other than the day of the outpatient procedure. Even if malignancy is detected, most of the time the prognosis is excellent when confined to a polyp as hysterectomy is curative.
Bleeding between periods? Heavy periods? Menopausal bleeding? Come see us today… Modern gynecologists conveniently offer ultrasound in their offices where they can enhance detection of small intra-uterine growths by placing water in the uterus (Sonohysterography), or alternatively perform hysteroscopy.
The discovery that persistent cervical infection by sexually transmitted high-risk human papillomavirus (HPV) causes virtually all cervical cancer has led to revolutionary advances in cervical cancer prevention, including HPV vaccination for young women and HPV testing.
A recent article published in the Journal of Obstetrics & Gynecology found a number of disturbing patterns regarding overuse of HPV testing. First, approximately one quarter of the surveyed clinicians ordered both high-risk and low-risk HPV tests. Testing for low-risk HPV offers no benefit to patients because these HPV types are unrelated to potential cervical cancer (though they can cause warts). Second, approximately 60% of the doctors reported routine testing for HPV for women under the age of 30, despite guidelines that strongly recommend against such testing because most occurrences of HPV in this age group have proven to be transient. 80% of women will contract HPV and most will clear it in short order thanks to their immune systems—just like a cold virus. Third, many practitioners are co testing (PAP & HPV) annually and biannually rather than triannually as recommended. Finally, high volumes of unnecessary PAP tests are being performed on women who receive no benefit from cervical cancer screening, such as hysterectomized women without a cervix, and young women who are not yet sexually active and thus have never been exposed to the HPV virus. It was estimated that more than half of the 75 million Pap tests performed in the United States in 2010 were probably outside of guidelines and therefore unnecessary.
National guidelines for high-risk HPV DNA testing for the following indications:
- Conditional HPV testing of women if they have a borderline abnormal PAP. This is appropriate for women undergoing screening in their 20’s. If the HPV is positive then further evaluation by her gynecologist is necessary.
- HPV testing should be used routinely in an addition to a PAP in women aged 30 years and older. Women who test negative for both HPV and PAP are then screened at an extended interval of no less than 3 years because it excludes cervical cancer with an accuracy of over 99%. If women test positive for HPV then they are either rescreened in one year, or if their PAP is also abnormal then they undergo further immediate evaluation—called Colposcopy.
- HPV testing at 12-month follow-up visits for women who had previous pre-cancerous cervical changes or recent abnormal screening.
Here is a summary of cervical cancer screening:
Confused? Just remember it is very important that you have a yearly gynecologic exam irregardless of how often your PAP test is performed. After all, there is more of you to care for than just your cervix.
Perimenopause, also called the menopausal transition is a vaguely defined phase when a woman’s body progresses from previous predictable cycles of ovulation and resulting menstruation that conludes with menopause—the complete absence of menstrual bleeding for 12 consecutive months.
While the average age of menopause is approximately 51, it can occur anytime in your 40’s and up to age 55. Likewise women start perimenopause months to years beforehand. Irregular periods are a hallmark of perimenopause, reflecting your ovaries waning ability to produce female hormones in an orderly seqeunce. Most of the time, this is normal and nothing to be concerned about. However you should see your doctor if bleeding is too heavy, too often, or too prolonged.
Women may also begin to experience menopause-like symptoms, such as hot flashes, sleep disturbances, and vaginal dryness. Inconsistent hormonal fluctuations of estrogen and progesterone are responsible for the changes during perimenopause:
- Menstrual irregularity: As ovulation becomes more erratic, the intervals between your periods may vary longer or shorter, flow may be scanty to profuse, and you may skip periods. Early perimenopause is defined as a change in menstrual cycle length of more than 7 days. Late perimenopause is characterized by two or more missed periods and longer intervals between periods.
- Hot flashes and sleep problems: About 75% of women experience hot flashes, most commonly during late perimenopause. The intensity, duration and frequency vary. Sleep problems are often due to hot flashes or night sweats, but sometimes sleep becomes erratic even without them.
- Mood changes: Some women experience mood swings, irritability or increased risk of depression during perimenopause. Sleep disruption from hot flashes may contribute to these symptoms. Conversely, perisistent daily mood changes may also be caused by factors unrelated to the hormonal changes.
- Vaginal and bladder problems: When estrogen levels diminish, vaginal tissues may lose lubrication, elasticity, and thickness making intercourse painful. Initially vaginal lubricants should be tried for sex, but if discomfort perists then vaginally applied estrogen can be restorative. Low estrogen levels may also increase vulnerability to bladder infections. Loss of bladder control may become more prevelent and can be successfully treated.
- Decreasing fertility: As ovulation becomes irregular, the ability to conceive decreases. However, as long as you are having periods, pregnancy remains a possibility. So to be safe contraception should be utilizeed until you have gone 12 months without a period.
- Changes in sexual function: During perimenopause, sexual arousal and desire may diminish. But for most women who had satisfactory sexual intimacy before menopause, this will continue through perimenopause and beyond.
Some women seek medical attention for their perimenopausal symptoms. Possible therapies include:
- Oral contraceptives: Birth control pills are often the most effective treatment to relieve perimenopausal symptoms because they use female hormones to create regularity—even if a women does not need them for birth control. Ultra low-dose pills can regulate periods, reduce hot flashes and vaginal dryness without weight gain.
- Progesterone therapy: If a women has irregular periods, but cannot use oral contraceptives, then cyclic progesterone therapy (10 to 14 days each month) usually regulates periods that occur afterwards. Some women with heavy bleeding during perimenopause prefer the convenience of a progesterone containing intrauterine device—Mirena® IUD—which lasts 5 years.
- Endometrial ablation: Endometrial ablation provides permanent relief from peristent heavy bleeding some women experience during perimenopause. During the procedure, the inside lining of the uterus is removed using a device that cauterizes it. It takes 90 seconds and can be conveniently performed during an office visit. It effectively reduces menstrual flow or ends it in over 90% of patients.
Finally, making healthy lifestyle choices may help ease some of the symptoms of perimenopause as well as promote good health as you age. These choices include:
- Good nutrition: Because the risk of osteoporosis and heart disease increase at this time, a healthy diet is more important than ever. In addition, remember to consume calcium-rich foods or take a calcium supplement (1200mg) that also supplies vitamin D (600 units). Be mindful that alcohol and caffeine may trigger hot flashes.
- Regular exercise: Regular physical activity helps prevent weight gain, improves sleep, strengthens bones, and elevates mood. Exercise for 30 minutes or more on most days of the week.
- Stress reduction: Practiced regularly, stress-reduction techniques, such as meditation or yoga, can be particularly helpful during the menopausal transition.
Many women find the perimenopause perplexing. Hopefully a little information goes a long way helping you understand and navigate this transition.
This week the government demolished it’s well-known food pyramid. Criticized as too complex to understand, it is replaced with a new, simpler image of a plate divided into basic food groups, called MyPlate. It was conceived as a crucial part of the first lady’s, Michelle Obama’s, campaign against obesity, designed to remind consumers about the basics of a healthful diet.
The plate is split into four sections, for fruit, vegetables, grains and protein. A smaller circle sits beside it for dairy products. The first part of the campaign will encourage people to make half their plate fruit and vegetables. Later phases will urge consumers to avoid oversize portions, enjoy their food but eat less of it, and drink water instead of sugary drinks.
The Agriculture Department has created a Web site, ChooseMyPlate.com, that elaborates on the guidance reflected in the plate’s design. It includes tip sheets with recommendations like eating fish twice a week and avoiding high-fat or salty foods. In addition, the website has many tools to help consumers; examples include a personalized meal plan, diet analysis, and a food lookup feature.
Conceptually this is a big step in the right direction for the government, simplifying instructions to help our nation eat healthier, combat obesity and its debilitating consequences.
PS: Want to get more out of your workouts in the same amount of time? Studies confirm that instead of exercising at the same rate inserting brief intervals of either increases in speed or intensity improves weight loss beyond the extra calories burned. Add strength training to build muscles, especially exercises that target multiple muscle groups like squats or lunges. Combined this helps you burn calories throughout the day by increasing your metabolic rate. click here for more information about HIIT (High Intensity Interval Training)
Based on review of approximately one thousand published clinical studies (who has time to read that much?) the Institute of Medicine recently updated their recommendations for daily intake of vitamin D and calcium for bone health. They specifically desire to counter the widespread hype about an “epidemic” of vitamin D deficiency. Included in their recommendations is that a vitamin D screening blood test should not be part of routine medical care unless special risk factors are present.
Regarding vitamin D intake, their conclusion is that 600 IU/day meets the needs of most children and adults ages 1 through 70, including pregnant and breastfeeding mothers. Over 70 this can be increased to 800 IU/day. This is irregardless of sun exposure, which stimulates vitamin D production in the skin, since this is too difficult to determine for a population and also concerns about skin cancer risk.
Regarding calcium adults ages 19-50 years old need 1000mg/day. Those over 50 should consume 1200mg/day. Each 8 ounce serving of dairy products contain approximately 300mg. Many people find they cannot consume enough calcium in their diets, so they take a supplement. These are better absorbed if taken twice a day. Chewable forms are often more appealing than pills and can be conveniently placed near one’s workspace as a reminder.
It is surprising that vitamin D requirements don’t vary as much by age as we previously thought and that more of either supplement is not better. Learn more about bone health and calculate your risk of breaking a bone.