Saturday, May 18, 2013
Psychogenic dysmenorrhea is an actual diagnosis that is so obscure it appears in the billing codes, 306.52, but oddly doesn't appear in gynecologic text books. Psychogenic dysmenorrhea is apparently thinking you have menstrual cramps that you don't actually have. Dysmenorrhea, the actual disease, is a condition of painful menses. Like many conditions with pain as their major symptom your physician takes your word for it, and doesn't question the validity of 'did you really have a cramp.' We know that actual menstrual cramps exist. Researchers have documented physical contractions equivalent to the uterine contractions in labor, and know that blood flow is restricted to the uterine tissue during such a contraction. Ischemia to any body part is accompanied by pain. It has been postulated that the impetus for the contraction and cramping is due to the production of prostaglandins which are substances secreted in the lining tissue as it breaks down just prior to the actual bleeding of the menstrual period.
Friday, May 17, 2013
Getting an IUD placed is an important decision, and not to be taken lightly. So to is the decision to remove the IUD. Older guidelines, in part driven by the older types of IUDs and the strings they had at the time, recommended IUD removal for women with pelvic infections. Now the guidelines have changed and the CDC recommendation changed that guideline a while ago. It is no longer the recommendation to remove your IUD if you have chlamydia; and if a woman is diagnosed with Pelvic Inflammatory Disease (PID), it's is also recommended to treat the infection, and not immediately remove the IUD. If the infection is not able to be resolved, some women will have to have their IUD removed. In a recently poll it was found that over 60% of physicians were not following the PID guideline and recommending immediate IUD removal. So perhaps if you are being treated for a gynecologic condition while you have an IUD, if removal is recommended, maybe you actually need a second opinion before losing your effective long term contraception.
Thursday, May 16, 2013
In a five year study from the April Issue of Contraception looking at women who have used a NovaSure vs Women who had a Mirena IUD, more Brazilians ended up with hysterectomy in the NovaSure group. My first thought is that women with worse cases would select a NovaSure, but it was actually a randomized trial in that the authors took 84 women who had heavy bleeding that needed treatment and randomized them to either treatment with either endometrial ablation or the IUD with preogesterone which is approved for the treatment of heavy menstrual bleeding. They point out that hysterectomy is always 'the most effective' therapy for heavy periods, but that it is both more risky and less acceptable to women, and no longer the treatment of first choice for this condition. The study actually followed women out for 5 years. When physicians talk about success rates of treatments they often have only 6, 12, or 24 months of data and really couldn't give as many statistics after 5 years. Interestingly, there were no people in the IUD group that actually had worse bleeding at the end of their 5 years, and many with no periods at all. In their ablation group, there were some with worse bleeding, and none of the NovaSure patients still had no periods at all. There were other aspects to the cases, more Mirena users said they would do this again after 5 years, and yet both groups found their quality of life and satisfaction with the procedure about the same. Many women have bleeding right before they go into menopause, women entering menopause, and stopping menstrual periods naturally affects the outcome of a study like this one with relatively few patients. But be sure to gab with your gyno regarding alternatives when you have heavy menstrual bleeding.
Posted by Gyno Gab at 6:45 AM
Wednesday, May 15, 2013
After Three Decades of Being Withheld a Popular Nausea and Vomiting Medication Is Back For American Pregnant Women
10% of Women of Reproductive age Get Pregnant Each Year, and many will have morning sickness. It's been a huge dilemma for women and their physicians as to how to treat this nausea and vomiting that is so common, because until right now we have not had an approved medication. It's not that we don't like to use any medication. About two thirds of pregnant women are prescribed medications during pregnancy that are not their vitamins. If you want to know what you are taking is safe for a developing pregnancy, read the label, but it's probably confusing to both you and your gyno as often the label may contradict the science behind the medication safety. Some medicine is clearly not safe, but other mediation is safe but not labeled as such. . And the language it's written in and the research it's based on may be as confusing to your gyno as to you! And when you ask your gyno medication safety questions, the most important question to start with: what is your background risk of having a complication? About 2-3% of women have birth defects regardless of whether they have medical complications to their pregnancy.
Nausea and Vomiting of pregnancy currently is reported in about 85% of all women who are pregnant.Nausea and vomiting in pregnancy is more common in first pregnancies and it is most likely to be resolving by the third month. There's always been a popular wives belief that a "sick pregnancy" leads to an easy confinement. Since the nausea and vomiting more likely occur in the morning we have always called pregnancy nausea "morning sickness." We have long struggled with whether the medicines we use to treat nausea and vomiting in pregnancy, whether it causes an easier birth or not, but are the medicines used to treat this actually safe. We once had a drug in the US called Bendectin, and in 1983 it was removed from the us market for presumed safety questions with regards to birth defects. It was the combination of doxylamine and Vitamin B6. That very combination is still sold in Canada, by the company Duchesnay, without any undue reports of abnormalities. And the FDA has now announced that their medication containing 10 mg of the doxylamine and 10 mg of the vitamin B6 is approved for "the treatment of nausea and vomiting of pregnancy for women who do not respond to other therapy." It will probably be available by late May 2013.
In the USA we have an approved sleep medicine called Unisom, and it's actually doxylamine, so we used to be able to cobble together the old combination to use if we want to. More recently gynos have switched to using ondansetron. The use of this medicine grew rapidly because it was so effective, long before any safety studies were published. Then the safety studies were "look back" or what is called retrospective studies and they were often big!
As many as 5000 women, and the good news was that the look back studies showed that there were no reasons for the physicians to feel that this drug was not safe. There are lots of ways to track the safety of the medications that you are taking when you are pregnant.So do feel safe if it is still what you are using until the new medication gets back on the market. It's important to know if there are new alerts or new studies, so keep vigilant in watching the news and talking with your health care provider. Your physician might be using PubMed or the Web of Science to find answers to questions regarding exposures and risks, and you can check these sources as well, if you would like to.
About 20 mcg of synthetic progesterone, of the type called levonorgestrel, is released each day in the women who use a Mirena IUD. The hormone levonorgesterel released from the Mirena device helps to protect against infections and pregnancy because it thickens up the cervical mucus. This effect can therefor change the normal 500 ml of daily clear mucus at midcycle, to less and thicker mucus. And the mucus will remain thick with the use of these progesterone containing methods of contraception. The mucus changes are relatively rapid with the use of other progesterone contraception. For instance if you take progestin-only pills these changes occur within the first 24 hours, same with some studies of DMPA although other studies show that really thick mucus, that is impenetrable by sperm takes 7 days after DMPA injection. Implants of progesterone, probably take 48-72 hours to have effect on mucus of sperm. In a new study in the April 2012 issue of Contraception they looked at sperm penetration of mucus with MIrena IUD insertion. They found that all subjects had poor sperm penetration, meaning that the mucus had been successfully converted to thick, within 5 days after insertion. So the current WHO recommendation of using back up for the first 7 days is thought to be confirmed by this research since that would take women past the fertile time even if she had the device inserted in the fertile middle days of her cycle.
Tuesday, May 14, 2013
Is breast cancer inevitable? Is breast cancer preventable?WE have talked about the simple strategies such as breast feeding, eating low fat diet, and exercising.
It seems like it is inevitable, for now, 1/8 American women will have it before death. The best tests to determine if you are going to be that 1/8 are the genetic tests of the Gail Scale or the Claus Model. These scales can give you a prediction of whether you are at high risk or not. These two different genetic tests work differently depending upon your family history. You can catch up on statics by checking out the Am. Cancer Society’s Fact page:
other cancer facts may be at Oncolog stat
Right now we think that breast cancer is preventable in some cases: taking tamoxifen if you are at risk, or having breast removal, both work, but neither strategy is used very often. For the most part we actually 'prevent' breast cancer consequences more than preventing it altogether, as we are typically finding out about early disease and then treating the early disease. It's most important to follow mammogram guidelines and clinical breast exams with your gyno, but after that there may be other tests that would be useful. I highly recommend our patients with risk factors actually get the last test first, a Gail Scale analysis. I also recommend the Halo breast pap. For those with breast symptoms the ultrasound test is important. And you do not necessarily need a genetic counselor to get the breast cancer gene test, it is done by blood draw and the results come with a very clear pamphlet on what they may mean. However, it is important that you have a physician whom feels comfortable speaking about the genetic tests results with you. So here's a list so that you know there are tests out there beyond mammograms, which are most valuable, before you take any action such as breast removal.
1. Breast Ultrasound
2. Gail Scale Scoring, or scoring by the Claus Model to determine your own risk
3. BRCA 1/2 Gene Testing4. CellSearch ® Circulating Tumor Cell (CTC) Test from Veridex
6. The HALO™ Breast Pap Test
7. PreOvar (more specific for ovarian cancers)
8. Needle localization biopsy of an abnormal mass
9. Yearly breast exam by your gyno
And which ones are right for you? Keep reading!
Posted by Gyno Gab at 10:48 AM
In a provocative but little heralded study published in Contraception April 2013 researchers Nagy, Gyorffy, Nagy and Rigo from Budapest Hungary have discovered that use of contraceptive pills will result in fewer common fetal trisomies once a woman gets pregnant. They propound that the protection of the ovary from ovulating less frequently is the reason that this is biologically plausible. They go on to theorize that healthy cells of the ovary, with normal chromosomes, die off faster than the unhealthy ones, and that women who get pregnant after 35 have more Down's babies as they now have a greater % of these abnormal eggs that may ovulate. By protecting the ovulation of the healthy eggs, women can be protected against having a chromosomal abnormality like Down's Syndrome. They compared information from 119 affected pregnancies and 92 controls. The researchers haven't really studied the length of pill use, but it is a provocative concept. This has to be considered a preliminary study, and bears more studies. But it has always been thought by experts that having a chromosomal abnormal baby is due to many factors, some of which are genetic, some of which are environmental, and some of which may be acquired (such as infection); thus all would agree, the way to best have a healthy baby is to gab with your gyno before conception.
Sunday, May 12, 2013
Saturday, May 11, 2013
First you should know that a Vitamin is important for you to get in your diet as you body needs those chemicals, but cannot make them. Most of us have heard of the major vitamins that are recommended to be part of your daily diet. But there is a whole slew of chemicals cropping up in the chat rooms as substances you should get as extra vitamins. Most physicians don’t discuss these various chemicals because they are abundant in healthy diets and we never have to treat patients for diseases caused by their deficiencies. So they have been called “pseudovitamins.” Some of the pseudovitamins are lecithin, inositol, carnitine, lipoic acid, lutein, and zeaxanthin. All these substances are important for us to consume, and you may be getting them in your food. Some you may not be getting. Laboratory testing is tarting to be able to monitor some of these nutrients, and then after testing you can decide if this is something you really need in your diet. A few other substances, that you may see promoted around, but don’t even make pseudovitamin status as there is no medical proof they are important for health include laetrile, also called B17, pangamic acid , also called B15, and gerovital or Vitamin H3.
Pap test guidelines are changing rapidly, as we have said in many posts. Women who have had normal pap smears, and negative HPV may not need a test yearly. You should have a pap test when your gyno recommends that you have a pap test, because she knows your personal history; and remember, pap tests are separate from pelvic examinations. Pap tests themselves are an actual sampling of the cervix. It is designed to check for cervical cancers and not ovarian or uterine cancers. The pelvic examination checks you for conditions of the vagina, the vulva, the uterus and the ovaries. The pap smear can pick up abnormal ovarian and uterine lining cells, but that's not primarily what it is aimed to do. As for when to have the test: every year, every other year, every third year or every fifth year will depend on your age, your prior tests and whether you are getting an HPV test also. The guidelines as to when to have a pap do vary very slightly from one organization to the next and they have changed recently. So it's important if you are a mom of a young woman, ask your gyno what she currently recommends for your daughter, it's changed over what she recommended for you! The current guidelines can be summarized like this: get your first pap at age 21, and then begin getting every two years. Most studies say for those who pickup HPV, it takes about 5 years for abnormalities to be developed. So some physicians are going to recommend slightly earlier paps for those who began having sex prior to age 16. After thirty, if you are at low risk for cervical cancer, and have been getting normal pap smears, you can get pap smears even every 3 years, unless you have a negative HPV test as well, and some women can safely wait 5 years to get another pap. Although research has always said that there are cofactors to getting cervical cancer: smoking, estrogen levels, family history of cervical cancer, and possibly other infections like Herpes, none of these are factored into the current pap smear testing guidelines. Pelvic exams to screen for STDs, to check your uterus and ovaries are still done every year. By age 65 or 70, you may be low enough risk to stop pap smears. If you have had abnormal pap smears, if you have immune compromising conditions (cancer treatment for instance), or HIV, you need to keep getting pap tests every year. If you had prior CIS or high grade disease, you need a pap for another 20 years, every year. The FDA has approved adding HPV testing to your pap after the age of 30, and it is a separate test you may need to ask for as most labs are set up only to do that test reflexively if your pap test comes back ambiguous. It is now also approved to have type specific HPV testing: so not just a pap or pap plus HPV but a typing of the HPV virus to see if you have HPV 16 or 18. HPV 16 and 18 are responsible for a large percentage of cervical cancers. If you had the HPV vaccine you have been immunized against these viruses. If you had your vaccine after you had sex, you may have already picked one of these HPV types up. There is currently no specific cure for HPV although 80% resolves spontaneously, so it's important to have testing if you have had sex with a new partner in the past few years. Keep posted, as the guidelines do not yet say when to get pap tests if you have had the HPV vaccine, but we are assuming in the future they will recommend fewer pap smears if you were vaccinated.
Thursday, May 9, 2013
Women in menopause can take hormones for a short period of time to control their hot flashes, and once they have had no symptoms for over a year they can be tapered off hormones. Many women will not need hormone therapy and they can be treated by controlling their diet, their exercise, their weight, and the emotional responses to this. Women who use medication other than hormones for the control of hot flashes can have withdrawal side effects of the medications.
In ancient times they didn’t have antibiotics. Women rarely got infections and should someone actually contract an infection that became systemic it was fatal. Actually mostly the infections didn't become systemic, but were able to resolve on their own. Now it has become so common to treat complaints with antibiotics, as woman may get so many antibiotics for so may things. For a woman who receives so many antibiotics, it's more likely that your immune system cannot fight off infection, and thus common infections, such as a urinary tract infection (UTI) can recur. There are other reasons for UTI's to become chronic. Sex has always been one of the common causes of UTI, if your symptoms of the infection are more than 48 hours after sex, it probably wasn't the sex. It might be the partner you have picked, new sex is even more likely to be a cause of infection than having sex with that same guy (or gal). Spermicidal use is another modern cause of chronic urinary tract infections. And then here's an odd modern medicine cause of chronic infections: living long. More women living past the age of menopause, and getting bladder infections because they have low estrogen. If none of these are causing your chronic infections then other causes can be explored: holding your urine too long, dietary causes, pelvic anatomy causes. If you have bladder infections too frequently, see your gyno, it's probably time to gab about it.