Tuesday, June 21, 2016

Mirena IUD and Uterine Fbroids

Uterine fibroids and what method of contraception you choose are two separate gynecologic issues, but if you have both there are many pros and cons to discover. The IUD first has to be inserted and there are some cases of  uterine fibroids take up some space in the cavity of the uterus and it's possilbe that the IUD would be expelled after insertion. Typically we say that only about 2% of all IUDs are expelled in the first year after insertion. With uterine fibroids that expulsion rate could climb to over 10%. Your Mirena IUD can shrink your fibroids.It is known that the IUD can shrink the overall size of your uterus. Women who suffer from uterine fibroids need to get to their gyno and evaluate their reproductive plan. In a September 2010 issue of  Contraception it was reported from Jiangsu, China that they have discovered that the progestin component, the levonorgestrel, may actually both suppress the growth and cause death of uterine fibroid cells! WoW! It is important to control the growth of this common uterine tumor as they can grow quite large and produce symptoms of pain as well as symptoms of heavy bleeding. These researchers have been studying the fine points of fibroid growth. We know that it's probably a chromosome glitch in a single uterine muscle cell that gets that fibroid cell's growth unleashed and causes a tumor to grow. So they did a study of cells in culture from twenty women with fibroids who had hysterectomy. They point out that the growth, based on active DNA (ok, for the accurate scientists, actual mRNA phase of growth) was more active in the progesterone (luteal, second half) of the menstrual cycle, but paradoxically the growth of fibroids is somewhat restricted during phases of pregnancy when progesterone is very high. So they tested the levonorgesterel progesterone that is in Mirena IUD (for discussion group pop on here). There theory was that the 20 mcg/ml that is leaked each day from the Mirena (LGN-IUS to the fancy people and for info outside the USA go to the other Mirena) is about 1000 times what a normal circulating progesterone level would be, and that in their cultures after only 72 hours the growth of those cells was decreased by 24%. Wow! And furthermore, in order for a fibroid not to grow, that progenitor abnormal cell must die! And apparently that is what our hormones regulate as well. And in this research trial the physicians were able to use large doses of the levonorgesterel to induce the death of these fibroid (leiomyoma) cells. So there is a whole bunch of complex growth regulating factors, including the newest growth regulator on the block: "survivin" (I love that name, almost want to buy a cat just to use it!) and how they interact with the exact gene make up of the cells of one's uterus that ultimately determines the survive or die of a fibroid cell. And survival instincts must be pretty good since the newest estimates are that up to 50% of all women will have uterine fibroids before they die! The best news yet is that these researchers aren't done, they have all sorts of new proposals to look at how this might work. And if the use of the progesterone containing IUD doesn't suffice to shrink your fibroids successfully, it may be time to try other therapies. Call 217-356-3736 if you live within range of central Illinois and wish to have this therapy, wish to participate in a research study, or if you are done with having children, you may be interested in office same day NovaSure endometrial ablation therapy.

Pap Smears Are a Test For A Lot More than Just Cervical Cancer

Pap tests can test for uterine cancer as well as cervical cancer. When to have your first test, how often to test, whether to also test for the HPV virus, and what this test might show including abnormal changes of the uterine lining or infections are all decisions to be made as an individual in consultation with your own provider. Pap smear guidelines have evolved rapidly in the past decade, and those who have had HPV testing, vaccination, or a series of negative tests do not necessarily need a test yearly. You should have a pap test when your gyno recommends that you have a pap test, and remember, pap tests are different than pelvic examinations. Women need yearly pelvic examinations even though they may not need the additional testing of a pap smear.  Pap tests themselves are an actual swabbing of the cervix so in addition to the sampling of the cervix, it will pick up cells from the uterus.. 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 cells more rarely than it picks up uterine lining cells. In a young woman, or any woman who is tested on her period might have lining cells called endometrial cells on pap testing. A woman in menopause or near the age of perimenopause should not have endometrial cells very commonly and she should be checked for uterine cancer if these cells are found.

 As for when to have the test: every year, every other year, every third year (or every fifth year which I do not recommend) 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 medical society to the next. And you can have the discussion with your gyno as to which guideline applies best to you.  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. After thirty, if you are low risk, and have been getting normal pap smears, you can get pap smears even every 3 years.

Pelvic exams to screen for STDs, to check your uterus and ovaries are still done every year. Women under the age of 25 and women with new partners should have tests for gonorrhea and chlamydia at the time of the pap, and it can often be tested for on the same swab. For those too young for pap smears (under the age of 21) STD testing can be done on urine. If you are age 65 or 70, you may be low enough risk to stop pap smears; you would not want to stop getting pelvic examinations. If you have had abnormal pap smears, if you have immune compromising conditions, or HIV, you need to keep getting pap tests 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 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. It is also approved to have the activity of any HPV virus infection of the cervix tested which can tell you how likely it is that you have moderate or severe cervical dysplasia. 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 sexual contact or intercourse, you may have already picked one or more of  of these HPV types up. There is no specific cure, 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 anticipating that in the future they will recommend fewer pap smears if you were vaccinated.

Monday, June 20, 2016

Crowd Sourcing Contraceptive Advice?

When it comes to contraception we have a long history of asking girlfriends, sisters, hair dressers, and generally getting the broad strokes of over view of contraception alternatives from women's magazines. Now the social media savvy among us have all sorts of options for contraceptive advice from googling medical society guidelines, to reading published research, and getting the spin from the companies that produce contraceptives, themselves. We have had access to contraceptive specialists, gynecologic specialists, and even reproductive endocrinologists for many years now; all of whom have very detailed knowledge of the risks and benefits, and even costs and availability of contraception. When the morning after pill technology was no more than a special dosing way to take available oral contraceptive pills there was a special number to call for information and access to a physician. Although over the counter oral contraceptive prescriptions have been available in other countries for many years, they were not available in the US until recently, and now only in a very limited access in the states that allow this. But women have digital and social media access to the nation, and even the world at large, and this has allowed for a new phenomenon to take place: getting a contraceptive medical consultation and prescription via app as reported on the front page of the New York Times today. I think that Crowd Sourcing is excellent to raise some cash, but do you really want to make this a remote service. Like a remote hug, it may make you smile, but it's not a hug. Many of these contraception app services are available, and you may want to check with your physician, as many of them (Women's Health Practice included) will also offer medical visits by phone depending on condition and whether you are a new or established patient. I would caution women about getting care from a random service provider in various circumstances, here are just a few of the issues you should consider:
1. Have you had medical issues with contraception before?
2. Do you know what medications/contraception your plan covers, help make cost effective decisions
3. Are you aware of the non-contraceptive benefits of pills, often the focus is on contraception, but in truth there are a variety of gynecologic conditions to consider
4. What is your access to a provider you have spoken to before? If you cannot get the same provider, then each time you will be starting over with your medical history
5. Do you have a reproductive life plan? When are you having children? What are the fertility aspects of your contraception going to be?
6. Most gynecologists think that effectiveness and safety is enhanced with long acting contraceptive methods, and most of those (IUDs, injections like DMPA and Nexplanon) require an in person exam, consultation and administration of the method.
7. Are you on other medication? Contraceptives may interact with other medication, and often it's best to have your provider be able to access records, communicate with your primary physician, and or see you if there is adjustment to medications or an development in your medical issues, this also cannot be handled by remote access with just on line access.

Sunday, June 19, 2016

Understanding the Mystery of Uterine Fibroids: A Powerhouse of Estrogen

Uterine fibroids are non-cancerous muscle tumors of the womb, and in addition to symptoms due to size they are actually production plants for estrogen. Uterine fibroids actually arise from a single uterine muscle cell called a myocyte. If a woman has a number of uterine fibroids, and they have different characteristics they each has developed into a fibroid from a separate cell that evolved. The evolution of a fibroid actually stems from a gene defect.  Since 80% of women will have a uterine fibroid prior to menopause, most are not symptomatic in most people. Uterine fibroids do begin to develop in early reproductive life. Treatments depend on the size, the location, the goals of the patient, the amount of menstrual bleeding.

Uterine fibroids are hormone sensitive, and they literally are powerhouses of estrogen. . All uterine muscle cells have receptors for estrogen and progesterone. Thus a uterine cell s stimulated to grow by these hormones. A uterine fibroid tumor has a greater density of these receptors than in the case of most uterine cells.  In pregnancy this is a very effective strategy, hormones trigger growth as a pregnancy progresses. But in the case of uterine fibroid, the excessive growth is the source of many of the complications of fibroids.

The hormone sensitivity of uterine fibroids also produces a estrogen excessive environment. This is a situation where the uterine fibroids adhere (also known as binding) to the estrogen molecules. Thus there is more estrogen and this can be responsible for many of the associated symptoms.  Not only that but the fibroid cells are able to manufacture estrogen from other molecules. This also responsible for the powerhouse of estrogen. Obese women, or women with other high estrogen conditions like PCOS are more likely to have uterine fibroids.

Oddly women who smoke have lower risk of fibroids do to the fact that their estrogen levels are lower.

If your fibroid has grown or changed, it is important to get accurate ultrasound measurements measurements, to determine if this is true. It is equally important to know if you have other reasons for excess estrogen so that you can try to mitigate the side effects.. Generally the largest fibroid present in a uterus grows about 35% per year! It has never been shown that birth control pills or even other estrogen hormone treatments cause fibroids to grow. It is not clear why this would be so. It could be the types of hormones, the dosage, or the fact that local and genetic factors are so dominant that supplemental hormones don't have an effect. Since a uterine fibroid is a powerhouse of estrogen it is probably possible to alter that fact and help to shrink the fibroid. That is where all the new research is going.   Antiprogesterone and other new hormonal therapies do however help to shrink fibroids. If you are interested in participating in a clinical research study of uterine fibroids call Women's Health Practice, 217-356-3736.

Tuesday, June 14, 2016

Top Form Tuesday: Prevent LARC from being "SARC"

Long acting reversible contraception(LARC)  is effective and cost effective because women can use it for a long time, however side effects like bleeding can make a woman give up years before the contraceptive expires. LARC is a term that is applied to any method that is designed to be used for a long time: IUDs, DepoProvera, or the Nexplanon are what is usually (in the US) refered to as LARC. However, if you discontinue the LARC we may say you have now made it into "Short-acting reversible contraception or 'SARC." The Nexplanon implantable rod is designed to be used over 3 years. Patient contraindications for Nexplanon are similar to the contraindications for other progestin methods of contraception. Specifically you should not be pregnant, have a clot or clotting disease, have disease of the liver, or breast cancer. If a woman has irregular bleeding, it should be diagnosed and treated before getting the device. Those contraindications aside it is a terrific method for many women. The Nexplanon rod may cause irregular bleeding (usually light) that may not necessarily resolve over time. For women who like their rod, but get the bleeding, not many treatments have been effective. However recently there has been a study that looked at using the breast cancer treatment medication tamoxifen for 7 days to see if it would stop the bleeding. This study, done at many academic institutions looking at women who reported bleeding for an average of 23 days per month while on a Nexplanon. The women were able to reduce their bleeding while on Nexplanon with the Tamoxifen treatment to as little as an average of 6 days per months. The researchers lead by Dr. Katharine Simmons concluded that the medicine did in fact work very effectively to significantly reduce bleeding days. We do not yet know if women will be predisposed to continue their Nexplanon LARC, and prevent it from being SARC,  but it is an available alternative that may work for a particular woman, in consultation with her individual physician.

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Vaginal Contraceptive Ring

If you are a female between the ages of 18 and 35 you may be eligible for a contraceptive ring investigational contraceptive medication study. Qualified participants will receive study-related medical evaluations and care at no cost. If interested, please call 217-356-3736.

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