Fix Heavy Periods at Single Office Visit

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.

Longer Intervals Recommended for PAP Smears

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
Hysterectomy

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.

Surgery-Free Permanent Birth Control Should be 1st Choice for Women Who Have Completed Their Families

Surprisingly despite all the available methods of contraception, over half the pregnancies conceived in the United States are unplanned, this includes women over the age of 40 who falsely believe they cannot get pregnant. Even when used correctly birth control pills fail 5% and condoms 15%, per year. Are you comfortable with this risk of having an unplanned pregnancy? If you or someone you know has completed their family and is considering a form of permanent birth control, such as tubal ligation or a partner’s vasectomy, we would like to educate you about Non-Surgical Permanent Birth Control.

  • Surgery-free—A simple procedure performed in your doctor’s office in less than 10 minutes
  • Hormone-free—Works with your body to create a natural barrier to prevent pregnancy
  • Anesthesia-free—No slowing down to recover, and return to normal activities in less than a day
  • Worry-free—Since 2002 over half a million women and their doctors have trusted Essure® as the most effective permanent birth control

Hysteroscopic Sterilization is different from the traditional method of surgery called tubal ligation. There is no cutting into the body. Instead, your doctor inserts a thin scope through your body’s natural pathway of the vagina and into the uterus, where the openings to the fallopian tubes can be seen. Micro-inserts are placed into your fallopian tubes blocking them. Since most women only report mild cramps, you have the choice of having the procedure performed without general anesthesia. In fact, most women choose to have their procedure performed in the convenience of our office. Some women experience mild cramps afterwards and all return to their regular activities in less than a day. The doctors at Women’s Health Specialists were the first to perform Essure® and Adiana® in our community, and serve as instructors for other doctors desiring to learn this revolutionary office-based procedure.

hysteroscopic-sterilization-catheter

hysteroscopic-sterilization-sperm-egg-blockage

During the first 3 months following Hysteroscopic Sterilization, your body and the micro-inserts work together to form a tissue barrier that permanently prevents sperm from reaching the egg.  During this time, you will need to use another form of birth control.  Then you will have a confirmation test to prove that your tubes are completely blocked and you can rely solely on Essure® or Adiana® for birth control.  Here’s what one of our patients says about her experience with Essure.

essure-effectiveness-comparison

Unlike birth control pills, patches, rings, injections, and some forms of IUDs, Hysteroscopic Sterilization does not contain hormones that interfere with your natural menstrual cycle.  Your periods should continue in their natural state.  Clinical studies have shown Essure® to be 99.85% effective at preventing an unplanned pregnancy, surpassing traditional tubal ligation, vasectomy, and IUDs.  Consequently, it is not surprising that Hysteroscopic Sterilization is quickly becoming the treatment of choice for women seeking permanent birth control.  Finally, these procedures are usually covered by your medical insurance.  So if your family is complete schedule an appointment to talk to your doctor about more effective contraceptive options.

Hysteroscopic Morcellation: Faster Removal of Fibroids and Polyps

The causes of abnormal uterine bleeding (prolonged or excessive bleeding, as well as bleeding between periods) vary and commonly includes endometrial polyps or fibroids.   Endometrial polyps are growths extending from the lining of the inside cavity of the uterus. Polyps can also cause spotting in menopause and in rare cases become cancerous, usually in women over the age of 50. Uterine fibroids (also called myomas or leiomyomas) arise from the muscular wall of the uterus. They vary in size, number, and location. It is estimated that 25% to 50% of women between ages 30 and 50 have fibroids. Fibroids are not typically associated with an increased risk of uterine cancer and almost never develop into cancer. Only fibroids that cause symptoms need to be treated.

fibroids-polyps

You don’t have to let abnormal bleeding interfere with your daily activities. While there is no medication to treat polyps and fibroids, there are procedures to remove them.  If there are numerous fibroids, large ones, or they are located in the middle or outer portion of the wall of the uterus then either myomectomy (removal of just the fibroids), or hysterectomy (removal of the uterus) is necessary.

However, if these growths project into the uterine cavity then they may be removed with a hysteroscope (the insertion of a small scope through the cervical opening into the uterine cavity). Dilation & Curettage (commonly known as a D&C) has been shown to miss removal of lesions. Hysteroscopy is the preferred method as it allows visualization and targeted removal: via grasper for small polyps, hot-wire cutting resection loop or morcellation for fibroids. Hysteroscopic Morcellation uses an instrument inserted through the hysteroscope that rapidly shaves away growths.  Since the system does not use heat it minimizes damage to the inner lining of the uterus, which helps preserve the chances of pregnancy in the future. This device also shortens operative time and enhances safety.

hysteroscopic-morcellation

Hysteroscopic procedures are performed on an outpatient basis. If you have completed your family then your doctor may give you the option of also having an Endometrial Ablation to further reduce or eliminate your menstrual bleeding. Your doctor will provide specific details regarding postoperative care, but most women return to their regular activities the following day.

At Women’s Health Specialists we are proud that we continue to lead in advancing minimally invasive surgical techniques for women of the San Francisco Bay Area.

PS: Check out Hysteroscopic Morcellation Videos & Brochures

Is Vaginal Mesh for Prolapse Repairs Safe?

vaginal-mesh-2

Ambulance chasing lawyers have found a new victims’ rights to champion. Not so fast…

The organs in your pelvic cavity—uterus, vagina, bladder and rectum—are held in place by a web of muscles and ligaments that act like a hammock. When these tissues become weakened or damaged (typically during childbirth, and/or after hysterectomy), one or more of the pelvic organs fall (prolapse) into the vagina. As a result, the organs may press against the vaginal wall and produce a hernia-like bulge causing discomfort, limiting sexual and physical activity, or impair bladder or bowel function.

Pelvic organ prolapse (POP) currently affects 1 in 11 women and Stress Urinary Incontinence (SUI) — urine leakage with coughing, exercise etc. — 1 in 6. Just as prolene mesh has replaced plication groin hernia repairs so has it revolutionized the urethral sling for SUI over 15 years ago and is similarly changing POP repairs.

While urethral mesh slings have rare complications and have become the gold standard, using larger pieces of mesh for POP corrective surgery has been controversial with setbacks. The good news is significant evolution has occurred over the past decade with lighter weight prolene mesh that has lowered the risk of exposure to less than 10% (which does require an outpatient, small revision of the mesh that fortunately doesn’t affect restored support). Contrast this with a 30 40% failure rate of non grafted cystocele (bladder prolapse) repairs, where these women require complete reoperation in a scarred field ripe for complications. After all these women have poor pelvic ligaments that tore during childbirth creating these vaginal hernias.  Hence, improved success (better than 90%) and longevity of a mesh-augmented repair for women with moderate to severe prolapse becomes a compelling choice.

We have been approached by numerous concerned patients who have been misled by these alarming ads that the FDA recalled mesh products. This is not true.  The FDA now requires surgeons to communicate about the risks to their patients contemplating POP surgery—with and without mesh augmentation; We have been doing so since we began using grafts years ago. The FDA has a list of 13 questions that patients should ask their doctor including their experience performing these complex procedures. It’s only fair that women suffering with prolpase recieve balanced information so they can make an educated decision about surgery, or alternatives such as a pessary. It’s unfair to have medicine dictated by greedy lawyers influencing these women into tolerating prolapse and its impact on bowel, bladder, and sexual function.

So you want birth control pills and have a medical illness. Is it OK?

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.

7 practical tips to improve contraceptive effectiveness

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:

  1. 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.
  2. 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).
  3. 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?).
  4. 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).
  5. 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)
  6. Emphasize non contraceptive benefits
    Hormonal contraception reduces acne, menstrual flow and cramps.  Counter false fears about weight gain or lingering effects on subsequent fertility.
  7. 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.

Well Intended Pregnancy Wives Tales are Often Misleading

grandmother-with-pregnant-womanOver 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.

Uterine Polyps Common & Usually Benign

endometrial-polyp.thumbnailWith 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.

PAP & HPV Testing: More is not Better

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:

  1. 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.
  2. 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.
  3. 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:

pap-hpv-testing

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.