Monday, July 21, 2014

Don't Skip Mammograms if YOu Have Progesterone IUD

It's very difficult to determine cancer risks as you have to study large group of women over long periods of time. Your gyno can estimate your personal risk when combining her knowledge of research studies and her knowledge of your personal risk factors and personal breast cancer protection factors. Of course your gyno is going to weigh other cancer risks when giving you contraceptive advice as described on the American Cancer Society stay healthy page.  A levonorgestrel-releasing intrauterine device (IUD) may protect users against cancers of the endometrium, ovary, pancreas, and lung, but increase their risk for breast cancer, according to a new study by Tuuli Soini, MD, from the Department of Obstetrics and Gynecology, Hyvink√§√§ Hospital, Finland, and colleagues write in an article (Obstet Gynecol. 2014;124:292-299) published in the August issue of Obstetrics & Gynecology.Using data from administrative registers in Finland, Dr. Soini and coauthors analyzed data on all Finnish women between 30 and 49 years of age who used the levonorgestrel-releasing IUD between 1994 and 2007 for the treatment of heavy menstrual bleeding also known as menorrhagia.  The cancer incidence among users of the hormone-releasing IUD was 7% higher than expected compared with women who did not use the IUD. Among women had received at least 2 IUDs, there was an excess risk of 20%. This research study looked Sorting your cancer risk with your gyno is a reason to get your annual gynecologic examination, even if it's not time for your annual pap smear.
at all cancer, not just gynecologic. Some cancers were lower than the non-using general population including uterine, ovarian, lung and pancreatic cancers, and breast cancers accounted for most of the excess risk of cancer cases.  Over 5 years of IUD use in this study significantly increased risk. Since these women specifically had disordered menstrual bleeding, it's possibly they have other risk factors that were not obvious from this study.

Thursday, July 17, 2014

Keep Pushing or Have Your Obstetrician Intervene?


Once a woman gets fully dilated in labor she has completed her first stage. Once she has her baby she has completed her second stage. The amount of time it takes to complete the second stage is dependent on many factors: the size of the pelvis and the size of the baby, the force of the contractions and the force of the pushing, the direction the baby is going (even a bit off of coming straight down the pelvis slows one down), and whether she has an epidural that is affecting any of the power of pushing. Whether the obstetrician shortens the second stage with a vacuum or forceps or c-section obviously affects that time sequence. And the delivery of the head can be accomplished more easily than the delivery of the shoulders which are a larger diameter than the head.  American College of Obstetricians and Gynecologists guidelines to define prolonged second stage for nulliparous women as greater than 3 hours with epidural or greater than 2 hours without epidural. For multiparous women, they defined prolonged second stage as greater than 2 hours with epidural or greater than 1 hour without epidural. . As your birth provider watches you there are clues beyond the stop watch. Specifically the amount of progress, with very little progress from the early pushes there is less hope of achieving a healthy vaginal birth.

S. Katherine Laughon, MD, Investigator, Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland, and colleagues published the results of their labor review study in the June issue of Obstetrics & Gynecology, showing that beyond 2 hours there are increased risks for both the mother and the child. They noted that labors are longer in these past few years than they were in the past.

The investigators reviewed electronic medical record data from 2002 to 2008, using a retrospective cohort from 19 hospitals at 12 US clinical centers. The researchers included 43,810 first time moms and 59,605 women who had had a child before who were at least 36 or more weeks of gestation, with head down (vertex) presentation and 10 cm of cervical dilation in the analysis, meaning they specifically studied the second stage.. Longer labors are common, about 10-15% in women who have epidurals, and about 3-5% of women who do not, and yet most women, about 80-90% will still accomplish the vaginal delivery even if they are moving slowly compared to normal standards.

The risks for mom of having that long second stage are infection and more significant tears to the pelvic floor, with baby also infection rates, and rates of having low oxygen increase, although they found no severe complications of that hypoxia, it is critical to note there was no increased rates of perinatal death. Experienced obstetricians can diagnose this lack of progress prior to two hours, and be able to predict whether normal or slowed progress is occurring, and whether it is healthy for you to keep pushing or have your obstetrician intervene.
Obstet Gynecol. 2014;124:57-67

Monday, July 14, 2014

You Have Been Exposed, but Will You Get HPV?

HPV exposure is almost universal, but even without vaccination, not everyone exposed tests positive and not everyone who tests positive will go on to develop abnormal pap smears or cancers. Other factors will determine whether you will test positive for HPV, and the list is mounting as to what these factors are. Smoking, menopause, poor immunity, frequent exposure to the HPV virus are just a few of the factors that have been associated with a positive HPV test.  Birth control pills have effects on the cervix and the uterus, and these effects have been well studied and discussed in many forums, they cause an enlargement of the sensitive t-zone area of the cervix that might make picking up an HPV infection easier. One group that has been particularly active in this research has been the International Agency for Reseach on Cancer . This group feels that taking birth control will increase your risk for cervical cancer by about double. But whether this directly is mediated through the effects on HPV or through the effects on some other aspect of our health, such as exposure to herbals, is still being debated. We like to test for HPV presence and rely on that test. But for a long time women have suspected there is something else that accounts for whether those tests are positive or negative besides just the fact that HPV is or is not present. And a new factor has just surfaced. Tests are more likely to be positive during certain times of the menstrual cycle. With tests reading slightly more positive later in the cycle in this recent study, although mid cycle peaks in detection have been previously reported. There is some biologic plausibility as to why this would occur. It has to do with the effects of hormones on various types of immunity which in turn would change how much HPV would be controlled or thriving. But don't worry about when to schedule your HPV test, the menstrual cycle won't affect whether it turns out positive. This is a very active area of research right now, there will be a lot more to read about.

Sunday, July 13, 2014

eCigarettes Going American But What Do They Contain And Does This Make Them Safer?

A large American company now will be making the first American made eCigarettes. Previously they have all been from China, but by being manufactured here does that mean they are safer? The Chinese made eCigarettes are not regulated in content, and thus the chemicals and percentages of nicotine varies greatly. A lot of the marketing says they're only harmless water vapor. The FDA has a definition of eCigarettes on line. Medscape points out that this is completely untrue and vaporized propylene glycol, nicotine, as well as flavoring agents that are vaporized by a heating element which is powered by a battery, and it delivers this aerosols using ultrafine particles. There are about 400 vapors, or vapes, per cartridge, and there's a poor concordance between labeled and actual nicotine content, although a typical vape puff will be about a fifth as potent as a cigarette's puff..For those who worry about second hand smoke, there's talk of turning marijuana reefers into eCigarettes, which poses a whole new set of risks. physicians are struggling with whether there is true therapeutic potential, verses just the potential for mind altering states. The NIH points out that adolescents may have special concerns, such as psychiatric risks with marijuana use, and no one knows what the effects of eCigarettes with marijuana in them may pose.
We have never been completely sure on a physiological level as to what about smoking raises the cancer risk, however we have many clues. Smoking and eCigarettes contain nanoparticles, that are so tiny they have ability to affect our cells, our stem cells, and the DNA within cells producing a wide variety of ways they can are or can transform into carcinogens. And for those who only use eCigarettes part time to decrease overall nicotine, it's questionable how that wide variety of different chemicals and particles will interact with each other to produce risk. Generally physicians know that less is more and certainly in pregnancy the safety of tobacco, alcohol, coffee, energy drinks, and marijuana are all not established!

Friday, July 11, 2014

Monday, July 7, 2014

Fibrocystic Breast Disease Fluid Evaluated

Women who have painful and lumpy breasts are most likely suffering from fibrocystic breast disease. It's been argued that it should be called a breast condition as almost 70% of women will have breast changes consistent with this diagnosis by the time they are in their 40s. The cause is not really known, but we do know that you are about 50% less likely to get FCBD if you have use birth control pills. Women know there are certain times of the month their breasts feel more painful, and seem to be more tender to the touch, and even physically larger. So it is no surprise to learn that on a microscopic level breasts do change during a cycle. During the menstrual cycle the breasts actually cycle, in sync with what the hormones of the ovaries are doing. So that in the early part of the cycle, the estrogen dominant part of the cycle, there is growth of the breast cells. And this is why after the menstrual cycle the breasts are less painful as the estrogen levels are the lowest, and during oral contraception use, the suppression of the estrogen cycle, with the suppression of ovulation, decreases breast pain. Whether you just need an exam, a mammogram, an ultrasound, or other test like a cystic aspiration, that will be up to your gyno. There are many ways to evaluate breast disease according to the American Family Physician.  For those who have developed the actual lumps, fluid begins to accumulate and if your gyno needles the fluid out of your breast it may look something like this.

Saturday, July 5, 2014

Understanding PCOS and Where To Find More Information

PCOS: The Syndrome of Hormones, Hair and Havoc of menstrual cycles
Polycystic Ovarian Syndrome (PCOS)

The doctors Stein and Leventhatal in 1935 discovered why some women had big cysts on their ovaries, extra hair growth and troubles getting pregnant. And though we recognize their work as the beginning, their name long left the condition of Polycystic Ovaries. After it was called Stein and Leventhal's disease this has been called a disease, a condition and now a syndrome, PCOS or Polycystic Ovarian Syndrome. The definition has been changed so that almost 1/10 women can meet the definition and in fact many women with perfectly regular menstrual periods are surprised to learn upon visiting their gynos that they are now diagnosed with an important condition that can have fertility and  life long health consequences. If you’ve got to shave your chin regularly, you may just have that sort of genetics, and on the other hand your ovaries may be producing too much testosterone, or one of the other boy hormones that emanate from the ovary or the adrenal gland. The most common symptom of PCOS is hyperandrogenism (too much boy hormone), chronic anovulation (skipped periods due to not popping an ovarian egg), many are overweight (7 out of 10) and finally either diabetic or pre-diabetic (again 7 out of 10), insulin resistance (you have it but it won’t work like it’s supposed to with your metabolism) and compensatory hperinsulinemia (the pancreas cranks out extra) are also features. And many have ovaries seen on ultrasound with a “string of pearls” look…little cysts all lined up around the edge as seen when looking with the ultrasound.

The insulin excess in a woman's body is probably in large part responsible  of the extra hair. The insulin stimulates the cells of the ovary to produce more male hormones. These extra male hormones right in the ovary mess up ovulation. Insulin can also suppress the liver substance SHBG (sex hormone binding globulin) which is supposed to bind male hormones and keep them inactive and there for in check. So the more deranged your metabolism is, the heavier you get, the worse your PCOS gets.

So how to fix: well to some extent there is no fix, it’s in your genes, but it can be controlled. Control anything and everything diet: lower bad LDL cholesterol, lower the blood fat triglyceride, exercise and increase good HDL cholesterol, and changing the biology of your blood fats so you change your cholesterol particle sizes and numbers of particles. Overall weight is related to how serious your PCOS is, slim by even 5%, control the sugar and use diabetic drugs like metformin if you need to. But watch for side effects of the medications used to control insulin and blood sugar. metformin can have its negative side, it can lower vitamin B12 levels (side effects of low B12 levels might include numbness, other odd neurologic symptoms such as memory loss and behavior changes). Oral contraceptives can suppress the boy hormones of the ovary, so that’s a good bet that it will be recommended as a possible solution by your gyno.

The fix for PCOS is not simple, and the more we learn, the more we know that we have to follow our PCOS patients closely, check their sugars, scan their gall bladders, check their hormone levels, discuss contraception carefully, help them control their weight, and help them when they want to get pregnant, there's a lot to gab about here!

Friday, July 4, 2014

Day Off Thoughts

On the fourth Americans celebrate the concept of freedom, gynecologists think about how to help their patients be free to feel empowered in their health care. So if you have a day off, and there is some quiet time to think about yourself it is a good time to take stock of the top questions on line regarding women's health. Always a good time to read them and think about what to ask your gyno at your next appointment, and make a list! For those who have inquiries about current Women's Health Practice news, be sure to go to our website and sign up for eblasts or follow on Facebook or Pinterest. Happy 4th of July gals!

Tuesday, July 1, 2014

Primary Care and Gynecologists Argue Over Pelvic Exam Necessity

Gynecologic scrimmages and even a bit of chaos has erupted over the confusion regarding pelvic exam necessity. As always, the risk benefit analysis of a particular test should be weighed by the patient and her physician. No patients are forced to do exams they do not want. Board Certified Gynecologists and Gynecologists who are members of ACOG feel strongly there is benefit. As soon as the reputable American College of Physicians issued a negative recommendation regarding routine pelvic exams then the American College of Obstetricians and Gynecologist issued their own statement confirming the benefits of routine pelvic exams. a key component of regular physicals for women, an influential medical group has now said. They protest there is no proof  that such pelvic exams are useful and plenty to suggest that the procedure provokes fear, anxiety and pain in many women, the American College of Physicians said in a new practice guideline for doctors. The college’s guideline was published in the Annals of Internal Medicine and was accompanied by an article reviewing the scientific evidence. The new recommendation contradicts guidelines from the American College of Obstetricians and Gynecologists, which immediately reiterated its support for yearly pelvic exams. Gynecologists agree that STD testing can be performed on urine instead of on a pelvic exam, but there is no doubt that visual inspection is the only way to diagnose warts, pelvic floor problems such as dropped bladder, or skin conditions such as precancerous changes of the external tissues, along with many other benefits. This new controversy will now be a talking point along with pap smear frequency.

Monday, June 30, 2014

STD Cure, STD Immunity, STD Reinfection? How Can You Be Sure

All STDs can be treated, but knowing if you are cured, if you are immune, or if you have become reinfected by your partner is an important consideration. If you had an STD treated the next step is to figure out if you were really cured. And each STD has both an incubation rate (before which you won't even know you need to be cured), and a time to cure if it's treated. HPV disease is odd, you can't cure it with treatment, but you can get over it. About 80-90% of women will eliminate their HPV infection within 8-24 months. Although some who we think are clear have just reduced their virus amount by about 90% to undetectable levels. The good news about reducing your viral amount to undetectable levels is that cervical cancer is often kept at bay by just having an immune system fight it off. Knowing whether you are then immune to getting reinfected with the same HPV virus is a very difficult concept.Although we do develop antibodies to HPV after being infected, they are not as strong as the protective antibodies we induce with vaccines, so they may not protect you against reinfection. CT and CT are both curable, but in neither case are you immune to reinfection. 10 to 15% of women will come back with positive tests again in the next year of a positive test for CT or GC . does that mean the antibiotics failed? Well, sometimes yes, but most times, probably you were re-exposed. Since the researchers can't honestly be sure who was re-exposed they have a tough time telling women who was just not treated. To be 'sure' of wheher you were cured, immune or reinfected you have to see your gyno. Post STD you should have gotten a Test of cure — Testing for Chlamida. trachomatis (CT) a few months down the line. Exceptions include women who have persisting symptoms or if you are actually pregnant, those patients are due to get retested right away. But be sure to stretch that test out at least more than three weeks or you might test positive for organisms that are there, but not really viable (dead). Guidelines issued by the CDC distinguish tests of cure from repeat screening, which should be considered within the first three to four months after therapy is complete. And also think about what other STDs you should be getting a test for. Once you test positive for one, you might have another. A good resource guide to STD testing and curing is on the ACOG site at their link.

Menstrual Migraines are not a Myth

Menstrual migraines are often listed under migraine myths, but they do occur.  Menstrual migraines do exist and are not a myth. Migraine sufferers have headaches, but often they will have warning symptoms as well. Some of the warning symptoms are vague and some are more typically recognized as migraines. These may be nausea, light adversity, odd sense of smell or even vomiting. These non-headache neurological symptoms that occur when the pain starts are known as auras. Recent studies have shown that it is actually more common to have migraines without warning than with warning auras. But other women might have migraine symptoms that precede the actual headache pain by a day or even several days. And these symptoms may be those that are commonly recognized to be associated with migraines: like spots before your eyes, vision changes or, fatigue. But it is also possible to get more obscure symptoms such as a condition known as facial congestion or swelling that can even be mistaken for a sinus infection. So make sure you think about when you are having those sinus “infection” symptoms. Migraine medication not an antibiotic is more likely to be the cure! Any of my Gals having these symptoms? Call!

Sunday, June 29, 2014

Get Tested To See if You Have HPV

Many women wonder if they have an HPV infection, and for more about the HPV virus you can check this site at the CDC. There are many options now in HPV testing that can check the cervix, the vagina or the rectal area. But few women get offered any testing other than testing of the cervix. We are following this subject closely as there are new developing tests of the activity of your infection, and tests of the specific type of HPV. If you wonder if you have HPV a few questions can predict the outcome of any test you may have. Firstly, have you been sexually active? About 30% of women will test positive for HPV after their first 2 years of having sex. Well, even if you say no, you haven't been sexually active this may not actually be protective against HPV infection. Non-sexual HPV transmission is possible. In fact we are getting away from calling HPV a "sexually transmitted disease" because it is transmitted in so many other ways, and perhaps is mostly transmitted non-sexually in some studies showing positive cultures on nails, and fingers, and in the mouth. Ultimately HPV transmission prevention probably would  mean that all contact from all people would be prohibited, without going into any detail at all. Infections that are very early, or infections that contain few viruses will not always be positive on HPV testing. The hc2 HPV test turns positive at about 5000 viral copies. Other  like the Cobas test are trying to be more sensitive, but it's not firmly established how many copies most women who are infected will carry. Low levels of virus carrier rates aren't always able to be detected. Research studies can test blood evidence of being HPV infected, and this is how we prove whether or not a woman has truly cleared HPV or is actually immune to HPV, but these tests are not available except through studies..So even if your prior positive tests have turned negative, it's tough to say you have really cleared the virus for all time. Have you been vaccinated? On time? With all three doses? Even then, there are HPV viruses you can contract that are not covered by these strains.  Many women have not completed their series. It is better to get one shot than no shots, but Gyno Gab Gal says get all the shots! So it's complex, and this post just touches on a couple of the important factors, talk to your gyno to have the best plan for pap and HPV testing. The goal: first is to prevent all cervical cancer, and that my friends, is not a bad, nor a completely unrealistic health goal for us!

Can Hot Flashes Be Completely Eliminated With Hormone Therapy?

Hot flashes come from low estrogen. Mostly women transitioning through menopause have hot flashes, but women who have low estrogen for other hormone imbalance reasons can have hot flashes as well. Most women will have only months to just a few years of significant hot flashes, but we know they occur over many years for some women.Yes, hot flashes can be completely eliminated by appropriate hormone therapy. Although not a 100% of women swill respond with a complete treatment response. Most all women will respond with enough effect to be satisfied? Using modest and low dose hormone therapy makes it take awhile to treat. It is possible to successfully treat mild to moderate hot flashes with non-hormonal methods as well, and there are many, but few treatments replace the gold standard t\of menopausal therapy which is estrogen treatment. We have recently discovered low levels of antidepressant medication can work but one of the largest hot flash studies unfortunately showed that exercise, although very health beneficial, doesn't treat hot flashes. Nor did yoga in this study actually treat hot flashes, but the patients did sleep better when they participated in yoga. The most popular oral therapy to date has been using conjugated equine estrogens,  and this has lately been replaced by bioidentical estradiol, is effective in the management of vasomotor symptoms of menopause. In an analysis of data from the Women’s Health Initiative (WHI) study use of estrogen therapy was associated with a 28% relative improvement in the relief of hot flashes compared with placebo and placebo cures hot flashes in about 20-30% of cases. The  key to successful therapy has been managing side effects and risk. This can be done by using lower dosing, dosing through the skin with either a patch or a topical application, and minimizing progesterone exposure. Other places to menopausal research include: the National Institute on Aging the National Institute on Complementary Medicine or the Office of Women's Health Research.

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Uterine Fibroid Study

If you are a female between the ages of 18 and 50 years old and are experiencing abnormal bleeding due to uterine fibroids, you may be able to take part in the VENUS research study, testing an investigational medicine. Qualified participants will receive study-related medical evaluations and care at no cost. If interested, please call 217-356-3736.

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