March, 2014

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What Is Endometrial Ablation?

Monday, March 31st, 2014

Endometrial ablation is a procedure in which a layer of the uterine lining is permanently removed in order to reduce or stop abnormal bleeding. The procedure is performed only on women who do not wish to have any more children. In some cases, it is performed in place of a hysterectomy.

The techniques used to perform endometrial ablation vary and include electrocautery, radiofrequency, cryoablation, and hydrothermal procedures, among others. The procedure is performed on women who are experiencing abnormal bleeding (bleeding between periods) or menorrhagia (prolonged or extremely heavy periods). Abnormal bleeding can be so severe in some cases that daily life is interrupted and some women may even develop anemia.

Reasons for abnormal bleeding and menorrhagia include hormone disorders or imbalances, fibroid tumors, polyps, or endometrial cancer. However, as stated earlier, the lining of the uterus is destroyed during ablation and is no longer able to function normally; therefore, bleeding is significantly lessened or even stopped entirely, and it is important to know that the woman also will no longer be able to become pregnant.

Endometrial ablation carries the same risks as any surgical procedure, including infection, bleeding, perforation of the uterine wall, or complications due to medication sensitivities the patient is not aware of (or neglects to inform the doctor of). In addition, women with certain medical conditions should not have this procedure, and these include vaginal infections, cervical infections, pelvic inflammatory disease, weakness of the uterine muscle, abnormal shape or structure of the uterus, and having an IUD in place, among others. In my health book, “Inside Information for Women”, I discuss this technique under “Resectoscopy”.  Endometrial ablation with cautery via a resectoscope or any other modality is a little tricky if the patient ultimately is found to have uterine cancer.  Why?  Because all the evidence regarding the extent of the disease (cancer) is burned away and the physician will have difficulty in staging the cancer, which is important in formulating the best management for a patient with uterine cancer. 

If your doctor and you decide that endometrial ablation may be right for you, your doctor should explain the procedure to you thoroughly and give you a chance to ask any questions you have. If you are to have a procedure that requires general anesthesia, you will be asked not to eat or drink before the procedure, most likely for at least eight hours or after midnight the night before. Be sure to tell your doctor if you may be pregnant, are allergic to any medications, or are taking any prescription drugs or herbal supplements.

Your procedure may take place in a hospital or in your doctor’s office on an outpatient basis. Recovery will depend on the type of anesthesia and the type of ablation used. In general, you can expect to need to wear a sanitary pad for a few days after the procedure, as bleeding during this time is normal. Also for the first few days, you may experience cramping, frequent urination, nausea, and/or vomiting.

Your doctor will probably instruct you not to use tampons, douche, or have sex for at least a few days. Usually restrictions on other activities are also necessary, such as heavy lifting and strenuous exercise. Let your doctor know if you experience fever, chills, severe pain, difficulty urinating, excessive bleeding, or foul-smelling discharge.

This information applies in general to most ablation procedures, but because each woman and situation is unique, the most important thing to remember is to follow your doctor’s specific instructions, and ask any questions you may have.

– Yvonne S. Thornton, M. D., M. P. H.

Posted in Women's health issues, Women's health news | No Responses »
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Dealing with Painful Intercourse

Thursday, March 27th, 2014

Pain felt during sex is known as dyspareunia, and it can cause a number of problems for you and your relationship. Besides the physical discomfort, painful intercourse can have emotional side effects as well, so this problem should be dealt with as soon as you become aware of it.

Causes of Painful Intercourse

Sometimes the reason for pain during intercourse is as simple as insufficient vaginal lubrication. Taking more time with foreplay or using a water-based lubricant will often solve the problem. However, sometimes there is a condition responsible for the discomfort that needs to be addressed. Conditions that may cause dyspareunia include:

  • Vaginal infections, such as a yeast infection or bacterial vaginosis
  • Menopause, which can cause a significant reduction in natural lubrication, as well as thinning of the vaginal tissues which can lead to discomfort
  • Vaginal dryness not caused by menopause – this can also be triggered by breastfeeding and certain medications
  • Injury to the vagina or vulva, such as a tear or episiotomy from childbirth, or
  • A sexually transmitted infection (STI)
  • Vaginismus, a condition in which the vaginal muscles contract involuntarily
  • Endometriosis, in which the tissues that normally line the inside of the uterus grow elsewhere
  • Problems involving the uterus, such as myoma (fibroid tumors)
  • Problems involving the ovaries, such as cysts
  • Problems involving the cervix, such as infection
  • Ectopic pregnancy

Treatment for Painful Intercourse

If you aren’t sure why you are experiencing pain during intercourse, a visit to your gynecologist is in order. For example, in the case of dryness caused by menopause, your doctor can prescribe estrogen creams or other medications. Most infections and endometriosis can be treated by your doctor as well.

When no apparent cause is found, therapy might be helpful. Sexual activity is deeply intertwined with emotion; therefore any type of negative emotion such as anxiety, depression, fear, or feelings of low self-esteem can play a role in painful intercourse. Issues such as guilt, negative emotions regarding past abuse, or conflicting feelings about sex can also cause physical reactions that make sex unpleasant. It can be difficult to tell whether pain has psychological or physical causes (or a combination), so a conversation with your doctor about all possible issues is the best course of action.

When you see your doctor, be sure to mention additional symptoms that you may be having in addition to pain, such as bleeding, irregular periods, genital lesions, unusual discharge, or involuntary contractions of the vaginal muscles, that may give him or her the clues needed to diagnose and treat your problem effectively.

– Yvonne S. Thornton, M. D., M. P. H

Posted in Menopause, Women's health issues | No Responses »
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What Is a Pap Test Used For?

Thursday, March 20th, 2014

The term  “Pap test” or “Pap smear” is known by almost every woman in the United States.  However, over the past few years, its annual frequency has been questioned and the actual manner in which it is performed has been enhanced in many gynecologists’ offices. One of the components of a gynecologic exam that you have undoubtedly undergone is the Pap test (or Pap smear).  As stated in my health book for women and many times before on this blog, A Pap smear is NOT a pelvic exam.  The purpose of a pelvic (gynecologic exam) is to check all of your reproductive organs, which includes uterus, ovaries, vagina and vulva.  The Pap test is only to check for cellular changes in your cervix (the mouth of the womb) that may signal cancer or precancer. This is why regular appointments with your gynecologist are so important – because a precancerous condition can be treated before it becomes invasive cervical cancer, but the only way to detect a condition like this is with a Pap test.

Make no mistake – a Pap test can save your life. The chances of treating cervical cancer successfully are far, far higher when it is caught in its early stages. In most cases, precancerous cell changes can be treated before they ever become cancer at all. If you are wondering why you need a Pap test, or have been putting off making an appointment for your annual visit to the gynecologist, remember: a Pap smear is the absolute best way to prevent cervical cancer.

With that said, a Pap test is not recommended for women less than 21 years of age.  However, between the ages of 21 and 65, most women need an annual Pap test. Even though the American Cancer Society recommends Pap tests every three years, the American College of Obstetricians and Gynecologists recommends this screening test every year, because three years is a long time for cancer to grow and spread. Why wait three years when your cervical cancer could have been caught in its precancerous stage two years earlier?

Even if a woman has had a hysterectomy, she still needs a Pap test if her cervix is still in place, which is the case with certain types of hysterectomies (known as subtotal or supracervical hysterectomies). Either way, she still needs an annual pelvic exam; you can find more information on this in my book, Inside Information for Women.

To help ensure accurate Pap test results, you should not douche for a couple of days beforehand. That was a trick question, you should not be douching in the first place!!). Also avoid sex, vaginal creams or suppositories, deodorant sprays or powders in the vaginal area before a pelvic exam and Pap test.  Although some gynecologists prefer that the patient is not menstruating, a Pap test can be performed during your menses and they are not mutually exclusive.  If there are cancer cells present, they will be present whether you are menstruating or not.

What Does a Pap Test Involve?

The Pap test is done as part of the pelvic exam, and is very quick. The doctor places a bi-valved instrument called a speculum (hopefully warmed) in the patient’s vagina, which allows the cervix to be visualized.  The word “speculum” comes from the Latin “to see”. The doctor then uses a special brush (cytobrush) or swab (similar to a Q-tip) to collect cells from the cervix. These cells are placed on a slide and examined in the lab under a microscope. That is the traditional Pap smear.  Recently, liquid-based Pap tests have essentially replaced the conventional Pap smear.  In this test, after the cytobrush or the Q-tip has collected the cells from the cervix, it is submerged into a small vial of liquid preservative for transport to the laboratory, where it is then processed and smeared on the slide.  The presence of Human Papilloma Virus (HPV) can also be tested with this technology.  Some spotting is not unusual after a Pap test, but the test does not hurt. If the test shows a potential problem, your doctor will let you know that further testing is needed. Although this can be scary, remember that abnormal test results do not necessarily mean you have cancer.

Most insurance plans cover Pap tests as part of the gynecologic visit. However, if you are uninsured and not participating in the coverage afforded by the Patient Protection and Affordable Care Act, there are facilities that offer free or low-cost Pap tests. 

– Yvonne S. Thornton, M. D., M. P. H.

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Trying to Conceive? Read This

Monday, March 17th, 2014

Making the decision to have a baby can be overwhelming and frightening, but it can also be extremely exciting. Most people are able to conceive without difficulty. For some women, it happens very quickly, but for others it can take longer. Around 30% of women trying to conceive will do so within one month; 75% will succeed within six months. For some women, it can take as long as a year.

The first thing you should do is schedule an appointment with your gynecologist and inform him or her that you are planning to become pregnant. Talk to your doctor about any medical conditions you may have and how they may affect your pregnancy, such as diabetes, high blood pressure, heart problems, or a family history of any hereditary conditions such as sickle cell anemia.

Be sure to discuss any medications you are taking with your doctor, and do not stop taking them without talking to your doctor first, particularly if you are taking them for a medical condition. Obviously, you should not be taking any recreational drugs if you are trying to get pregnant; you should also avoid alcohol and tobacco, as should your partner.

Once you stop using contraception, your fertility will return to normal, as will your periods. There may be a short delay in ovulation after you stop hormonal contraception, but after this, your fertility will not be affected by these methods of birth control. It’s also fine if you get pregnant very quickly after stopping a hormonal method of birth control. This is not dangerous to your baby.

You can improve your chances of getting pregnant by making healthy lifestyle choices – both you and your partner.  I have found in my practice that if a woman is having difficulty conceiving and she is obese, the first order of business is to lose weight and to attain a normal body mass index (BMI = 18.5–24.9;kg/m2 ) before she pursues pregnancy.  One of the most important things you can do is to make sure you are eating a healthy, balanced diet. Eat a wide variety of fresh, whole foods to help ensure that you get all the vitamins, minerals, and other compounds you need. You should also have a pre-conceptional visit with your gynecologist and most likely (s)he will recommend you start taking folic acid (0.4 mg per day) – and not just an all-purpose multivitamin.

Some patients want to know when they can expect to be fertile. I personally believe that this is a recipe for disaster, i.e., trying to calculate when you are fertile rather than enjoying your partner and having intercourse at least three times a week.  My dictum is, “A watched ovary never ovulates.” Nonetheless, you may want to be familiar with your menstrual cycle. The “average” length of the menstrual cycle is 28 days, but this can vary pretty significantly from woman to woman and still stay within the realm of perfectly normal. The key is to know your individual cycle. Count the first day of your period as day one. If you haven’t already, start keeping track of this on a calendar (a menstrual calendar). After a few months’ worth of counting, you will get an idea of the timing of your menstrual cycle..

This is important, because ovulation will occur somewhere around 14 days before your next period starts, so this can give you an idea of when you will be most fertile. I am not a fan of patients sticking their fingers into their vaginas in order to assess their cervical mucus.  But, some are compelled to do so.  The character of the cervical mucus  changes with the timing of ovulation: around the time of ovulation, it becomes clear, slippery, and stretchy (Spinnbarkeit). At other times it may be creamier and thicker.  Whether thick or thin mucus, a patient should engage in sexual intercourse frequently throughout the month if she wants to conceive.

If patients want to get the Cadillac of tests detecting ovulation, they purchase an ovulation kit. These kits are used to test the urine for the luteinizing hormone, which will increase a day or so before you ovulate. If your partner feels forced into intercourse based on these ovulation kits (“performance anxiety”), then there needs to be a serious discussion about the ovulation kit’s effect on the dynamic of the relationship.  Many women find that these kits are unnecessary and that getting to know their own bodies and menstrual cycles is enough.

Despite their best efforts, many women aren’t able to get pregnant within the first few months of trying. Several factors can affect whether or not you conceive, including whether or not you ovulate (see your doctor if you think you might not be ovulating), whether implantation takes place successfully, your weight (obesity is a deterrent to conception, as is severe anorexia), your age (women over 35 may find that it takes longer to conceive), and the quality or quantity of your partner’s sperm.

If it seems to be taking too long for you to conceive (a year for most couples, six months or so if you are over 35), talk to your doctor about the possibility of fertility testing (for both you and your partner) to determine whether there is a physical problem that may need to be addressed. Finally, if you do conceive but have a miscarriage, the odds of you having a successful pregnancy in the near future are still very good.

– Yvonne S. Thornton, M. D., M. P. H.

Posted in Contraception (birth control), Fertility & Infertility | No Responses »
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Supplements No Substitute for Healthy Diet

Thursday, March 13th, 2014

Bad news for vitamin-lovers: it appears they are not helping you prevent cardiovascular disease (CVD). A study carried out by the American Heart Association concluded that “the scientific data [does] not justify the use of antioxidant vitamin supplements for CVD risk reduction,” and that there is no consistent evidence which suggests that consuming micronutrients in higher amounts than those found in a balanced, healthy diet is beneficial in regards to CVD risk reduction.

What’s more, your vitamin supplements aren’t helping you prevent cancer, either, as outlined here by the American Cancer Society. Other organizations such as the Academy of Nutrition and Dietetics and the American Academy of Family Physicians have reported similar findings. 

In most cases, vitamin supplements are not harmful, and the results of the latest research do not mean that supplements offer no benefits whatsoever. But if you are taking them to lower your risk of CVD or cancer, the newest evidence suggests that you are wasting your money.

There is currently no official recommendation on either taking or avoiding vitamin supplements for healthy individuals, with a couple of exceptions. One such exception involves beta carotene, which studies such as this one show can actually increase a smoker’s risk of lung cancer when taken in the high doses found in many supplements. This is in direct opposition to the previously popular belief that high doses of beta carotene were beneficial in cancer prevention.

What has been shown to have a beneficial effect on CVD and cancer risk is nutrition – a diet consisting of mostly vegetables, fruits, whole grains, low-fat dairy, and lean meats, particularly seafood. A diet like this offers plenty of fiber, antioxidants, and Omega-3 fatty acids. These nutrients offer a number of health benefits, including weight control, blood pressure control, and heart disease and cancer prevention. What the new studies show is that if you are hoping that your vitamin supplements allow you a bit more leeway in your diet, you’re shortchanging yourself.

What about Prenatal Vitamins?

It’s important to note that these studies do not mean that women who are pregnant or planning to become pregnant should toss all of their supplements. Folic acid should be taken to help prevent neural tube defects; the prenatal multivitamins prescribed by a woman’s doctor should be taken as directed. Also make sure your doctor knows about any vitamin supplements you are taking, because some can be harmful. High levels of vitamin A, for example, may be linked to birth defects.

And again, just because you are taking a prenatal vitamin – which you should if you are pregnant – does not mean your diet is not important. Healthy, natural foods contain many compounds not found in supplements, so a combination of prenatal vitamins and a healthy diet will help protect your baby as he or she develops.

– Yvonne S. Thornton, M. D., M. P. H.

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About Endometriosis

Monday, March 10th, 2014

Over five million women in the United States suffer from endometriosis. Most common in women in their 30s and 40s, it can occur in any woman who menstruates, and is one of the most common health problems experienced by women.

The word “endometriosis” comes from the word “endometrium,” the name for the lining of the uterus. Endometriosis is the condition in which this tissue is found growing in locations outside the uterus, such as the outside of the uterus, the ovaries, the fallopian tubes, or elsewhere.

Endometriosis Symptoms

Endometriosis often causes lower abdominal or pelvic pain, or lower back pain, mostly during the menstrual period. The amount of pain the woman experiences is not necessarily linked to the extent of the endometriosis; some women experience a lot of pain with just a few small growths, and other women may experience little to no pain even though large areas of their bodies are affected.

Other symptoms can include painful sexual intercourse, painful urination or bowel movements, bleeding between periods, infertility, fatigue, and gastrointestinal disturbances.

Endometriosis is not cancerous, but it can still present a number of problems. Growths can expand month by month, causing increasing symptoms. Untreated, endometriosis can cause scar tissue, inflammation, and increasing pain. It can block the fallopian tubes; it can grow into the ovaries. Cysts can form as a result of blood trapped in the ovaries. Adhesions, tissue that can bind organs together, can form as a result of scar tissue.

Risk Factors for Endometriosis

Women who have never had children, have longer than normal periods, shorter than normal cycles, a family history of the disease, and cellular damage caused by a previous pelvic infection are at higher risk for developing endometriosis.

The cause of endometriosis isn’t well understood, but theories include:

  • Genetics
  • Immune system disorders
  • Endocrine system disorders
  • Unintended relocation of uterine tissue during surgery
  • Exposure to certain chemicals
  • Reflux of endometrial tissue into the abdomen during a woman’s period

Diagnosis and Treatment of Endometriosis

Be sure to talk to your gynecologist if you have symptoms of endometriosis. Your doctor will most likely want to perform certain tests, such as a pelvic exam, an ultrasound, and/or exploratory surgery.

If endometriosis is found, there is no cure, but a number of treatments are available that can help with symptoms such as pain and infertility. Your doctor should inform you of your options and help you select the ones that best suit your individual condition.

Pain medications, hormone treatments such as birth control pills or GnRH agonists and antagonists, which reduce estrogen, and surgery (best for severe cases) are all possible treatment options. Surgery may involve the removal of growths and scar tissue, or it may involve removing the uterus altogether (hysterectomy).

Endometriosis can be difficult to cope with on an emotional level. Talking with other women who have endometriosis can help. http://endometriosis.org/support/support-groups/ is a good resource for information and support. Above all, talk to your doctor about your symptoms and your options; learn as much as you can, and follow your doctor’s recommendations for treatment. Many women with endometriosis are able to find significant relief.

You can find more information on endometriosis in my book, Inside Information for Women.

– Yvonne S. Thornton, M. D., M. P. H.

Posted in Menstruation, Women's health issues | No Responses »
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VBAC vs Repeat Cesarean Delivery

Thursday, March 6th, 2014

Not so long ago, a vaginal birth after a cesarean delivery (VBAC) was unheard of. Because the uterus was cut in such a way that weakened it and made it vulnerable to rupture in subsequent pregnancies, women were often scheduled for cesareans before they could even go into labor if they had had a cesarean delivery in the past.

Now, with improved surgical techniques, VBAC is a choice that many women get to make, depending on the reason for the original cesarean. For example, if the first cesarean was performed because of a too-large baby and a too-small pelvis, that reason will in most cases still exist in subsequent pregnancies. On the other hand, if an isolated event such as breech presentation mandated the first cesarean, the event does not reoccur, and the correct surgical procedure was used the first time, then attempting a VBAC is usually safe.

Benefits of VBAC

This is important for a number of reasons. The most important reasons involve the safety of both mother and baby. A vaginal birth is safer than a cesarean delivery. Although the risk of infection or hemorrhage is relatively low with a cesarean, it is still several times greater than with a vaginal delivery. Therefore, a cesarean should be a last resort whenever possible.

Another reason VBAC safety matters is because many women prefer the natural experience of childbirth. This, of course, should not be a reason to put her life or the life of her fetus in jeopardy, but when it’s feasible, childbirth is a nicer experience when it fulfills the mother’s wishes.

Other benefits of VBAC include avoiding an additional scar on your uterus, which is important if a future pregnancy is desired. The more scars on the uterus, the more likely the uterus is to rupture.  Also, the placenta is more likely to be more adherent to the scarred uterus and not separate naturally, causing a life-threatening condition known as placenta accreta and resulting in massive hemorrhaging which may lead to maternal death.

Vaginal birth also comes with an easier recovery period, less pain afterward, a shorter hospital stay, and a more active role for you and your partner in the birth of your baby.

Risks of VBAC

The possibility (however remote) still exists for the uterus to rupture at the site of the previous cesarean scar, and this is one of the main fears when attempting VBAC. If the uterus ruptures, an emergency cesarean and possibly hysterectomy will be required to prevent severe injury to both baby and mother. That is why it is so important to be delivered in a hospital or medical center that has 24-hour anesthesia and in-house obstetrical coverage with a good blood bank.   With that the said, the risk of uterine rupture after a VBAC is 0.2% compared to 0.1% in those patients who had scheduled another cesarean.  Both figures mean that in 99.8% to 99.9% of the cases, a VBAC does not result in uterine rupture.

If you are hoping to have VBAC, you should clearly discuss this with your doctor to see if it is a good fit for your individual situation. In addition, you will need to deliver in a facility that has the equipment and staff capable of handling any emergency that might arise.

If you and your doctor decide that VBAC may be safe for you, you will be able to have a “trial of labor,” or TOLAC (trial of labor after cesarean). This means that you will go into labor naturally with the goal of delivering vaginally. However, there are no guarantees. Some women who attempt VBAC end up with necessary cesareans anyway. A trial of labor is a safe choice as long as the conditions that necessitated the first cesarean no longer exist and the baby is monitored closely for signs of distress. For more information on this and other women’s health issues, see my book, Inside Information for Women.

– Yvonne S. Thornton, M. D., M. P. H.

Posted in Childbirth & delivery, Pregnancy | No Responses »
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Pros and Cons of Robotic Surgery

Monday, March 3rd, 2014

If you need surgery, you are likely to be presented with the option of robotic surgery. This means that instead of the surgeon working on you directly with his hands, he or she will manipulate a set of robotic arms with surgical instruments attached from a console. Should you go along with this, or should you question the practice?

It would be understandable if you were hesitant. Thanks to the media’s love of a good horror story, most people have heard of instances where patients were accidentally injured – or worse – during robotic surgery. Even the American College of Obstetricians and Gynecologists maintains that robotic surgery is neither the best nor the most cost-effective approach to hysterectomy.

Does this mean that you should flatly reject robotic surgery? Not necessarily. Like any surgical instrument, a robot is as good as the surgeon using it. Furthermore, every patient profile is different. There are a number of considerations for anyone making a choice about robotic surgery.

In 2000, there were (worldwide) only 1,000 robotic surgeries. Last year, there were 450,000. Proponents of the practice say its benefits are responsible for its rising popularity. Less blood loss, less need for pain medication post-surgery, and shorter hospital stays are among these benefits, along with smaller scars (which is also a benefit of laparoscopic surgery). Robotic procedures are less taxing for surgeons, who don’t need to bend over an operating table, but instead, can sit at a console viewing the surgical field on a screen.

But some feel that robotic surgery does not offer significant benefits beyond those of laparoscopic or other types of surgery, and that the “wow” factor is one of the real reasons robotic surgery is catching on. In our love affair with new technology, it’s possible we have a tendency to move ahead too fast without enough standardized evaluation. To be sure, any new medical technology requires proper patient selection as well as a full explanation of all options and their risks and benefits for informed decision making.

What Does All of this Mean for You?

The wisest approach for a patient who needs surgery is to make sure to get an explanation from the surgeon about possible procedures, including what to expect in the postoperative period. The surgeon should also explain why he or she feels that a particular method is the best option in an individual patient’s case. There is no one-size-fits-all when it comes to surgery.

Another consideration is the cost of the surgery. Robotic procedures tend to cost more, but the patient may end up spending less overall. The need for longer hospital stays and pain medications is potentially lower with robotic surgery, and patients might have a lower chance of being readmitted for complications, all things which can lower a patient’s total costs.

For now, robotic surgery appears safe and effective, but it remains just one of the options available to patients. Ask your surgeon about his or her experience with any procedure he or she wants to use, and about complications that have arisen in the past. Remember that the right choice will be different for different people, so talk to your doctor, and let his or her expertise and experience guide you to make the right informed choice for your unique situation.

– Yvonne S. Thornton, M. D., M. P. H.

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