Thursday, March 26, 2015

Runny Noses in Pregnancy, Possibly Not Just an Upper Respiratory Infection

When you are pregnant every part of your body is dramatically effected by the physical changes that accommodate the developing baby. The uterus grows from 70 grams to 1000 grams, most women gain  at least a couple of stone, and your skin starts taking on pigments that may fade but never leave! We notice a our tastes changing, and our smell changing, and generally we ignore what seems minor. But what may seem minor, but often isn't in pregnancy, is the runny nose and altered hearing women report. The changes in the ear, nose and throat are primarily due to changes in the circulatory system, such as the extra fluid in our circulation and the extra fluid our heart pumps. We also have some presumed increased susceptibility to viral infections, as well as some pressure changes from the bulk pressure of the growing uterus. All of these can oddly lead to increased runny nose! This can range from the very minor changes such as an occasional sneeze or drips, or become ringing in the ears or tinnitus, facial palsies, and even cases of deafness. Since it is the pregnancy that caused it, it should be self limiting to pregnancy as well. As the levels of estrogen and progesterone rise without enough corresponding change in cortisol levels or immune enhancement there may also be heightened sensitivity to allergens may influence the engorgement of the nasal mucosa. More fragile nasal passage linings can in term cause epistaxis (bloody nose) and rhinitis. Most treatment regimens of these complaints do not differ from the treatment of these conditions in the non-pregnant state other than being aware of the effects of any selected medication on the fetus, as most advice relies on case reports or reports of case series. What did you notice during your pregnancy? Were there any treatments that helped you especially? Let me know!

Don't Just Sit There, Don't Just Stand There, Don't Just Lie There

Too much sitting, standing or lying in one place can have medical consequences. For instance, the habit of reading hone the toilet? That's too much sitting, and can contribute to too much straining and pelvic floor weakness. You are to get up and walk around a bit, and when you get the urge to finish, return at your leisure!Too much standing, especially locking your knees, that can contribute to fainting. So if moving around will not solve the problems of the pelvic floor, other solutions are possible. We begin with a pelvic floor evaluation and then some suggestions. 

Sunday, March 22, 2015

Preventing A Second Miscarriage

Low dose aspirin is the new way to prevent a second and third miscarriage is to begin aspirin before becoming pregnant has now been shown to be effective in a new study.They studied women of ages 18 to 40, who had had one or miscarriages, and those who miscarried at any point. Beginning low dose aspirin therapy before conception iincreased conception rates by 28% in women with a history of only one pregnancy loss of <20 a="" can="" cause="" check="" gestation="" important="" in="" is="" issues="" it="" medical="" preceding="" span="" still="" that="" the="" to="" weeks="" year.=""> second miscarriage such as checking the lining of that baby bed (the uterus) is ready including hormonal checks and infection checks February 2014 Fertility and Sterility Other tests including an endometrial biopsy and hormone measurements to check on the progesterone levels, and further more evaluating gynecologic problems like fibroids, or  medication use, lack of vitamins or other nutritional deficiencies, chromosomal problems, or perhaps problems with the male sperm count. And if problems are identified then treating them. Some women are ready physically but are not ready emotionally, which is of course critical as well.
But the trouble is that most women do not have anything that can be treated. So normalizing your nutrition, your rest, and beginning aspirin is the modern way to go when attempting pregnancy after a miscarriage.

Monday, March 16, 2015

Sleepless in...America

We just can't get to sleep, and the newest scientific study proves it. This is not good news as those with poor sleep have much poorer health and a shorter life span as well. To try to over come this we take sleeping pills! At any given time millions of adults in the United States — or 8.6 million — report taking prescription sleeping aids, according to a new report released by the Centers for Disease Control and Prevention (CDC). The rates are creeping towards 10% of those 80 and above taking sleep medicine, and it's mostly the women who are taking them. As a gyno I do not want the patients taking medication unless they need to, but what is more disturbing is that over 50% of adults report poor sleep, so we need to think about the things we can do to improve sleep. There is another culprit which is robbing us of sleep and that would be shift work. Those with shift that rotate or those that take night shifts have a lot worse sleep. Maybe its just living a in city that is the problem. Night time light exposure, even if you think it doesn't bother you, changes your body's melatonin production and gives us a distorted sleep cycle 9by the way it disrupts our eating patterns as well!).

Sunday, March 15, 2015

Mammogram Interpretation Extends To The Density of the Tissues

Mammographic breast density is also now graded along with the other characteristics of your breast reported on a mammogram.Women with dense breast tissue have 3-5 times greater risk of breast cancer than women with normal breasts, and hormone therapy can increase breast density in 30-50% of women who take it. Generally a physician can look at the mammogram and the amount of ‘black’ verses ‘white’ components of the x-ray. Very white means very dense. Since breast tissue is actually 3 dimensional the denseness of the breast also is based on the internal structures that the radiologist is seeing. The thought has been that too dense of a breast would then obscure the view of a cancer. In general the pictures are graded by the ‘percentage’ of density, and greater than or equal to 75% dense correlates with dense breasts and less ability to predict the presence of a very small cancer. For decades the individual reading a mammogram reported their interpretation of density, but now the CAD or Computer Aided Detection programs can very accurately reportthe percent of density. Women who are heavier tend to have more dense breasts, like other features of our breast the density is somewhat genetic. Your density on your mammograms will change. Having a baby decreases density, and having too much alcohol increases density. Aging and decreasing hormones will change your density the most dramatically and decrease its density. And the more your density decreases the less your risk for breast cancer over time.So next time you are discussing your mammogram report with your gyno, ask if your breasts are less or more dense than the last picture!

Saturday, March 14, 2015

Estrogen Treatment of the Vagina

Estrogen works to treat the vaginal changes that occur in menopause. For some women there are only minor symptoms, others have bladder symptoms, recurrent urinary tract infections, stress incontinence, painful sex, irritating dryness or itching. Women who have these symptoms in menopause, and now is more accurately called genitourinary syndrome of menopause.  It is commonly caused by the thinning of the vaginal walls due to menopausal changes. For the most part your gyno can tell by looking but are even pap tests to determine if this is the diagnosis, although your gyno can hear your complains and with the exam give you a diagnosis.

Generally gynos have recommended nonhormonal moisturizers such as coconut oil, or products such as Replens if you have mild symptoms, and estrogen therapy as the treatment of choice for this condition,  and now we have the new painful sex treatment ospemifene, or Osphena. Ospemifene is a  selective estrogen receptor modulator that makes vaginal tissue thicker and less fragile, resulting in a reduction in the amount of pain women experience with sexual intercourse. Osphena is also a systemic treatment that likely has positive effects on your bones as well as breast cancer prevention component. Although gynos estimate that virtually all women remaining sexually active into their post menopausal years will have this complaint if not treated by hormone therapy, over half never even bring it up at a medical visit. Of women with genitourinary syndrome in menopause so a great number of women stand to benefit by considering therapy.

Before therapy you need some evaluation: do you have an infection of the vagina, a bladder infection, or perhaps badder dysfunction that can be detected by urodynamics also known as cystometrics. .  Vaginal estrogen treatments are effective for all of the issues that occur with this syndrome. The doses of estrogen given do not cause estrogen blood levels to differ from women without the vaginal estrogen treatment. Women need to be treated for about 3 months for full effectiveness, and there have been rare cases of the medication can cause thickening of the lining of the uterus which would need to be evaluated. Women experiencing unusual vaginal discharge or bleeding need to see their gyno to see if they have this complication.

The boxed warning for ospemifene also states the incidence rates of thrombotic and hemorrhagic strokes (0.72 and 1.45 per 1000 women, respectively) and the incidence rate of deep vein thrombosis (1.45 per 1000 women)."These rates are considered to represent low risks in contrast to the increased risks of stroke and deep vein thrombosis seen with estrogen-alone therapy," the FDA said. Minor side effects can include hot flashes or vaginal discharge.

Making the decision as to whether to take a systemic therapy or to use estrogen therapy is a complex one. Most women will try simple therapies first and do have to consider risks and benefits of alternatives.  Recent web articles have focused on the negative aspects of this therapy, implying that this risk is greater than other therapies.. These articles not only focus on potential risks, but clearly doesn't list percentages of these risks, nor does it do a good job of addressing benefits and or does it do a good job of discussing alternatives and their risks and benefits. As first line in the discussion with your gyno figure out if you indeed need treatment at all. Most women who take therapy are sexually active, but if you aren't and you plan to be, you are still a candidate for treatment. Osphena as a SERM (selective Estrogen Receptor Modulator) has potential benefits on breast tissue and bones. Find out if you have a baseline risk for for blood clots.  All the clinical trials were done without a progesterone, and the risks were very low of lining changes to the uterus. Some physicians may decide to put you on progesterone therapy if you are on Osphena. Even off hormones entirely women have a baseline risk of endometrial cancer. Estrogen therapy used locally is thought to be safer than systemic therapy,for atrophic changes of the vagina and vulva, yet it does have the same package insert risks listed in terms of blood clots and lining changes of the uterus, and thus it's a decision as to which will be best for an individual woman.. 






Thursday, March 12, 2015

Did You Realize How Fast You Lose Muscle Mass With Aging?



Sarcopenia is muscle mass loss. Aging, illness, lack of exercise and poor nutrition produces muscle loss as much as bone loss. Muscle mass decreases about 3% per year after menopause and by age 80 you have lost about 50% of your muscles. Actually true muscle strength loss proceeds at half that rate. So we lose muscles faster than we lose overall muscle strength. We don’t know why this is it seems to be a scientific controversy that is not yet solved by may be related to various cardiovascular issues. It is also thought that immune system dysfunction, changes in our metabolism as we age, or changes in our nutrient intake cause this overall loss of strength due to muscle mass deterioration. Poor diet habits in women are a big contributor. Very rapid weight loss without exercise will burn muscle more preferentially than fat, which is why most nutrition experts shun those very rapid weight loss plans. Interestingly the same treatments, life style interventions, and nutritional strategies that preserve bone mass and bone health also preserve muscle mass and muscle health.

Wednesday, March 11, 2015

We Think You May Have Forgotten something

A new report has been released by the CDC that highlights a new disastrous trend in the US: women are not getting their routine pap smears.  Over 10% of women with insurance and about 24% of women without insurance did not get a pap smear in the past 5 years. It is common for women to tell their provider "oh, it's really been that long". Guidelines for pap testing have changed, but one thing is sure, cervical cancer screening for pap tests is very accurate and successful and screened women do not have to die from cervical cancer. HPV vaccination protects many individuals, but not all cervical cancers have been associated with positive HPV tests. The CDC tracks many screening tests and the current data released is from the 2012 Behavioral Risk Factor Surveillance System survey. Although screening decreased the death rates has remained stable and relatively low. But should this trend of women not getting regular testing continue the death rate will climb. Not only do women need to do better on screening, women with abnormal results are not always getting the follow up testing that can rule an actual invasive condition is present or not. The media has been replete with examples of why women can avoid ongoing care, but we urge women to stay in close contact with your gyno. There is so much to discuss each year and not enough time to cover every topic thoroughly every year, and you and your gyno need to get to know each other and how you want to approach your care. She can also keep you notified of new health care trends and whether there are new tests, treatments or strategies that may be an option for you. So check your health calendars, make sure your current email, phone number, address and contact information is in your medical record so that we can help you remember what you may have forgotten.

Tuesday, March 10, 2015

New Test For Those With Recurrent Miscarriage

With the advent of early pregnancy tests we now have found many women who have had repeat or recurrent miscarriages. Your gyno will check may aspects of your health to help you avoid repeat miscarriages, including treating uterine or cervical infections, giving hormonal therapies for those with lower placental progesterone production, correcting nutritional problems like diabetes, as well as searching for abnormalities of the uterus itself that can cause miscarriages. And if those don't reveal the problem, looking for abnormalities in the sperm can reveal the cause of the miscarriage. But now there is another test that is specifically for those who have had more than one miscarriage: looking for chromosome reasons in mom, dad, and the fetal tissue. The test is called Anora, miscarriage test, and it is done of the products of conception, which means placental tissue for most. If you have miscarried at home, saving the tissue in a clean jar and bringing it to your gyno can be sufficient to perform the test. Those having a D and C treatment for a miscarriage can have the tissue from the surgical procedure sent for evaluation. The chromosome tests are then compared to chromosomal tests of both mom and dad and a couple then has facts from which to make some decisions regarding future pregnancies.



Monday, March 9, 2015

Birth Defect Screening Has Shocking Benefit: Cancer Detection In Moms

Over the decades we have found birth defects in the developing fetus in many ways. In the early days we used physical exams and even x-rays, and then we moved to the very sophisticated testing through ultrasound, and finally it moved into looking at various blood factors. In the past few years blood tests for genetic tests have focused on looking for fetal DNA circulating in mom's circulation. Behind the test is actually some scrutiny of the mom's DNA to detect differences and shockingly the lab that produces the chromosome cell free DNA test MaterniT21, Sequenom, has now reported finding cancer in a mom when looking at her blood for birth defects. 

There are many ways at each stage of pregnancy to determine risks of maternal diseases. Getting a pelvic ultrasound is actually a check on the mom's ovaries and any signs of pelvic disease like of the uterus and the bowel (although early cancers cannot be found this way) as well as a genetic screening test. Ultrasound is not very sensitive for picking up chromosomal birth defects, however and it only picks up about 60% of the abnormalities in pregnancy, even if done after all the organs are both formed and large enough to visualize completely. It was discovered 30 years ago that certain birth defects are associated with abnormal blood levels of certain proteins and certain hormones. For many years now we have used this test, combined with more intense testing of older mom's to try to determine which babies have some of the most common serious birth defects.

But testing ultimately, for many women, meant invasive testing through sampling the amniotic fluid with a test called amniocentesis. Now we have NIPT by testing cfDNA! While this many not on the surface sound "simplified", this testing of mom's blood during early pregnancy can determine if your baby's chromosomes are normal. It stands for "None Invasive Prenatal Testing" and it's looking for cell-free fetal DNA circulating in mom's blood. This test does not pick up all abnormalities, and should not be done without early ultrasound tests of fetal health. This has the ability to revolutionize care, as currently about 80-90% of serious birth defects are not picked up until about 18-20 weeks of pregnancy due to the tests that are most frequently used. But it gives parents an option of knowing the health of the baby in a much safer way than amniocentesis. Several companies are now doing this test, and in fact, one option is to find out the sex of your baby, very reliably, and much earlier than ever before!

And this test can show the DNA associated iwth cancers like colon cancer or lymphomas!

Sunday, March 8, 2015

If You Slip


Winter in the north means slush and ice and occasional slips do happen. The primary components of self care for any injury: PRICE:
1. P for protect the injured area, do not let it get re injured.
2. R for rest the area, at least reasonable rest, and not to over do the muscles of the area
3. I for ice, heat does help soothe, but ice reduces swelling
4. C for compress the area with a bandage: if swelling has begun this is less effective, but compression both feels well and helps swelling
5. Elevation, this particularly works for legs as dangling them can make the swelling much worse.

And if you are pregnant, please get your birthing provider check the baby to make sure there has been no injury. But in most cases of simple slips and falls, the baby's natural water environment is highly protective. 

Saturday, March 7, 2015

Situps, Weight Loss and Medications

There are many strategies to reduce breast cancer risk, and weight loss and exercise are our front line strategy. And as a side not new studies show that even with the more serious estrogen receptor and progesterone receptor cancers exercise and weight loss will prolong survival! Too few women however realize that there are medical ways of improving breast cancer survival. Fuse medication to lower your breast cancer risk. The American Society of Clinical Oncology (ASCO) has changed the tenor of its recommendations in its clinical practice guideline on the use of chemoprevention for breast cancer, and they now are including the medications of raloxifene, and exemestane in the medications not just tamoxifen, and the organization is wanting more people to seriously consider these medication. Their point is that they are not seeing more people use these very effective therapies, and so awareness is not increasing, and more women and their gynos need to take note. Here is what you need to know
or women who are high risk there is a way to
  • Breast cancers,  that is due to cancers that have estrogen receptors, rate can be reduced by half by medicine use
  • Every woman should know whether they are at increased risk by getting Gail Model Score or National Cancer Institute's Breast Cancer Risk Assessment Tool, a modified version of the well-established Gail model
  • You can be evaluated for these medications as young as age 35
  • The medications used are not all the same, and have some risks, which includes the risks of blood clots, and benefits beyond breast cancer prevention, which may include osteoporosis prevention in the case of raloxifene
  • Mammogram findings do not directly impact the decision to take these medications, but Halo breast pap tests can influence decision
  • For more information go to ASCO’s  Web site.
 It is the best step to first figure out your risk, in a new study presented by Dr. Jonathan Herman at a presscast in advance of the 2013 Breast Cancer Symposium, which will be held in San Francisco. The presscast was organized by the American Society of Clinical Oncology (ASCO), he noted only 1/10 women accurately know their breast cancer risk.

Tuesday, March 3, 2015

Contraception News: The Best and the Newest

Long acting contraceptive (LARC) methods are staying in the news, and both the best and now, the e newest, contraception available for women. The CDC states that Nexplanon contraceptive is the best contraceptive with the fewest failures. The Newest contraceptive is an IUD which was approved yesterday  by U.S. Food and Drug Administration. The new IUD is called Liletta, it is a levonorgestrel-releasing IUD (as are Mirena and Skyla). The approval was based on the data in the largest hormonal IUD trial, ACCESS IUS, conducted in the U.S. with 1,751 enrolled women receiving the device. It, like Skyla is a 3 year device, Mirena IUD is approved for 5 years of use in the US and 7 in Europe. There are no restrictions based on body weight. Although Liletta IUD is already approved, it is not available in the US quite yet, and may take a couple months to get to your gyno. We suggest seeing your gyno for a reproductive life plan, and deciding what method is best for you to use during your plan!

Monday, March 2, 2015

Are We Talking About The Same Body Part? Clitorial-Vaginal Confusion

Sex is still a fascinating, expressed very much individually, and the subject of lots of discussion. Sexual arousal and orgasm disorders have been given new names, and the never ending G spot discussion had a new 8 women study to prove it exists (although it's off to the side more than we thought in some of us). We've had more sexual discussion in the past weeks about our clitoris than in the many generations before us. The Huffington post editors have admonished us as a society, and us as the medical practitioners as being in need of some serious clitoris education, specifically they are saying we need more clitoracy. Although I graduated medical school, well, lets just say a very long time before this date, it has been said that whatever I thought I dissected in all the anatomy and cadaver classes prior to 1998, was wrong, because it wasn't before 1998 that the true anatomy of the clitoris was accurately revealed. With this newer description all types of new terms and locations of the clitoris have apparently been unleashed in the media to great consternation of the some sex experts. These authors have cautioned that all sorts of new terms have gotten hold in the media that have no scientific basis in medical physiology study. Although it is true, the clitoris is left out of much sexual discussion. Most often you hear gynos and patients asking: do you have any sexual concerns, or how is your bladder, or any problems with uterine cramps. Rarely does a gyno come right out with the, how is the function of your clitoris? Kind of makes one think that question might be met with a jaw dropping, 'excuse me' for a response. So we do need to discuss these issues, so we call can truly be more open and be able to discuss what ever body part we want to discuss together. In fairness, all medical visits do have to have a prioritized list of discussion topics, especially since women are being encouraged to retreat from routine care. The anatomy of the clitoris is described in human anatomy textbooks, and it's an organ with several parts, but relatively small, and surrounded by other organs. Now apparently the female anatomy has become a place newly redefined by all sorts of could be and would be anatomistsThese Italian authors emphasized that various terms, increasingly popularized by the lay media, including " The clitoral/vaginal/uterine orgasm, G/A/C/U spot orgasm, and female ejaculation", are unsubstantiated by scientific study terms that are not validated in enough well done scientific research so should not be used by sexologists, women, and mass media. Clitoral bulbs, clitoral or clitoris-urethrovaginal complex, urethrovaginal space, periurethral glans, Halban's fascia erogenous zone, vaginal anterior fornix erogenous zone, genitosensory component of the vagus nerve, and G-spot, are terms used by some sexologists, but they are not accepted or shared by experts in human anatomy."It is true that an actual scientific study of an 83 year old cadaver claimed to prove the G spot is really a spot. And in a full 8 cadavers in the newest attempt to define this tangle of nerves and blood vessels at the front of the vaginal under the bladder. So discussion continues.

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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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