LAVH--laparoscopically assisted vaginal hysterectomy) is now the benchmark
Are annual Pap smears necessary?
Hormone replacement after menopause--what is right for you?
New surgical techniques to repair vaginal laxity (rectoceles and cystoceles)
Heart Disease Prevention--HDL's, LDL's, and what about aspirin?
Osteoporosis--Prevention is much easier than building new bone
Yearly Exams--more than just Paps (much more)
IUD's--more popular than ever with something new to offer
What's new in birth control options: new pills, patches, vaginal rings, and coming soon, IMPLANTON.
3-D Ultrasound
How important is it?
3-D ultrasound is a technology that has come about over the last few years that is very popular with our OB patients. While it does have some use in evaluating certain things, for the most part it is used for “cosmetic ultrasound”—taking pictures just for recreation. 2-D ultrasound is still the standard for screening the baby for birth defects.
All OB caretakers do things a little different when it comes to ultrasound. It is our policy to routinely do 3 ultrasounds during pregnancy. The patient is only billed for one (the full screening ultrasound done at about 22-23 weeks), barring any unforeseen complications. We do two others in 3-D just for fun at 16 and at 34 weeks. We have our patients bring in their own tapes and, if baby cooperates, we take some footage that will be a keepsake for years to come (again, at no charge to our patients). Click here to see some of our favorite 3-D pictures.
Too Many Episiotomies?
You Do Have a Say In It!
There are some times when an episiotomy is the only option. However, I believe that they are mostly unnecessary and can cause significant harm. I have found no reliable data anywhere that shows that it prevents future problems with bowel and bladder, and rarely is an episiotomy needed to expedite delivery. Episiotomies are painful to heal, and can extend down into the rectum. Several major studies done on episiotomies show that the risk of tearing down into the rectum or through the anal sphincter muscle is 16 times greater with an episiotomy. It is like tearing paper. Take a piece of paper and hold it between you thumb and forefinger of each hand and pull your hands apart. It will eventually tear, but it takes some force. Now put a little tear in the paper between your hands and pull it apart again. It easily tears now. A woman’s tissues do the same thing.
Tearing into the rectum can result in fistulae—a connecting track between the rectum and vagina. These are no fun at all. Also, tearing the anal sphincter--the circular muscle the controls the exit to the rectum--can damage it. This is a very important little muscle. A doctor named Goligher one wrote a little ode to the anal sphincter, and it goes something like this:
You can damage, deform, ruin, remove, abuse, amputate, maim, or mutilate every structure in and around the anus except one. That structure is the anal sphincter. There is not a muscle or structure in the body that has a more keenly developed sense of alertness and ability to accommodate itself to varying situations.
They say that man has succeeded where the animals fail because of the clever use of his hands, yet when compared to the hands, the anal sphincter is far superior. If you place into your cupped hands a mixture of fluid, solid, and gas, and then through an opening at the bottom try to let only the gas escape, you will fail. Yet the anal sphincter can do it! The sphincter apparently can differentiate between solid, fluid, and gas. It apparently can tell whether its owner is alone or with someone; whether standing up or sitting down; whether its owner has his or her pants on or off. No other muscle in the body is such a protector of the dignity of man, yet so ready to come to his relief. A muscle like this is worth protecting.
Talk about episiotomies—the when’s and why’s—with your doctor before delivery. It’s worth your time. It is your body.
An episiotomy is when the delivering nurse or doctor makes an incision with scissors to enlarge the entrance of the vagina to allow passage of the infant. The rationale behind it is that it speeds up delivery and prevents other tears into the urethra and labia. Some feel that by expediting delivery it prevents damage to the connective tissues that support the bowel and bladder. Some caregivers do episiotomies on almost all their patients. Some don’t. Who is right?
Unlike the “walking epidural”, where a single shot is delivered and no catheter is left in place, the epidurals of 2005 offer a unique approach. In this approach, a tiny catheter is left in place and taped to the patient’s back and the catheter is attached to an electronic pump. The patient is given a handheld button attached to the pump to allow her to dose the epidural to her needs. There is a very constant level of anesthesia and can be used from the very onset of labor. In other words, it won’t “run out” or quit working. Onset is slower than it is with the “walking epidural” but is able to work much longer. Many women express concern that there is a risk of paralysis or injury. The epidural catheter does not enter the covering of the spinal cord, and even if it accidentally did, the spinal cord ends several inches above the site of insertion and so no damage would be done to it.
Spinals
Spinal anesthesia is used when a very dense block is needed, like for a C-section or some other operative procedures. Medication is directly injected into the fluid that surrounds the spinal cord. It causes both sensory and motor block, and lasts about 2 hours. It is seldom a good choice for labor, but is an excellent option for surgery.
Does anesthesia increase the risk of C-section or slow down labor?
This is a difficult question to answer since all the studies ever done on it have significant flaws. A recent analysis of 14 major studies between 1980 and 2001 showed that epidural anesthesia did NOT increase the number of C-sections or vacuum/forceps deliveries. It did slow the second stage of labor (the pushing stage) by an average of 15 minutes, but this did not take into account the newer medications used that do not block motor ability like those used in the 1980’s. It may also have to do with the level of pain being so high in women without anesthesia that they simply pushed harder and faster than women with pain relief. My experience concurs with these findings. Having delivered over 1000 patients here in Nampa, with the excellent anesthetic services that are offered, I cannot name a single case where I attributed a C-section to an inability to push, and I have seen labor sped up as often as I have seen it slowed down with epidural anesthesia. Patients with back pain 3 weeks after delivery are very rare, and in those few that do, half had not even had an epidural in labor.
The Intrathecal, or the "Walking Epidural"
This term is a bit of a misnomer, since very few women are up and walking after they receive this—mainly because they prefer to rest in bed. Using this technique allows the woman to maintain strength in her legs, to walk to the restroom as needed, and to push and better position herself. This technique uses a narcotic and a different class of local anesthetic that, in combination, require much less volume of medication with the same pain-relieving effects. This results in less motor block, and hence better ability to move. This is injected directly into the spinal fluid with a very tiny needle, and is a single injection that is usually good for around 2-3 hours of pain relief. For women who know they go fairly quickly and are progressing well, this is often an excellent option, with very low risk to the mother, and perfectly safe for baby. Onset is very rapid and pain relief is very uniform.
Now that aside, let's look at VBAC from a practical sense. About two-thirds of women who attempt a VBAC are successful. The risk of catastrophic uterine rupture is around 1 in 2000. And there are risks of c-sections of bleeding, infection, and damage to internal organs. These are also rare. The risk of a VBAC is mainly a risk to the fetus. The risk of a c-section is mainly a risk to the mother.
You will read a great deal on the internet about different views. Some are very extreme. It has been my experience that women who choose repeat c-sections have very good experiences, are out of the hospital many times by the next day, and recover very quickly. I have also had a great many successful VBAC's. I have also had one uterine rupture and the baby almost died. So it can and does happen, albeit rarely.
It is my policy to perform VBAC's under the following conditions:
That epidural anesthesia be initiated from the beginning of labor
That the mother sign a consent acknowledging the potential risk of uterine rupture and of fetal death.
The baby has to be normal sized.
No augmentation of labor with pitocin is allowed
If the woman has had more than one c-section, I recommend a repeat c-section
So it is possible, and for those women motivated to have a vaginal birth who understand the risks and benefits. It is unfortunate our medico-legal climate is the way it is, and it is unlikely to change anytime soon.
This is one of the major controversies in obstetrics right now. Unfortunately, most of it is medico-legal, and that is too bad, because fear of litigation leads to more c-sections. It is highly uncommon for physicians to be sued for doing an "unnecessary" c-section, but it is more and more commont to be sued for millions for attempting a VBAC and having the mother experience a catastrophic uterine rupture. Given that picture in society today, what would you do if you were a physician?
On the flip side, though, those women you see with happy, healthy pregnancies often work very hard to maintain their physiques. They eat carefully. And they exercise. A lot. I realize that that is not always practical, but today we are going to talk about a few things you can do that don’t require a personal trainer or 3 hours a day in the gym. Be sure you check with your OB care provider before undertaking any of the following:
1. Eat right. Steer clear of junk food, all fast foods, and eat desserts and fried foods in great moderation. Pregnancy is not a green light to indulge for two of you. You only need an extra 300 calories a day while you are pregnant. That is one slice of white bread. Indulge, and you will be left with more of you than you started with. You need to keep your weight gain in the target range given to you by your doctor and keep your metabolism as high as possible with exercise.
2. Start slow. Start with walking a mile or two a day, light weight lifting (5-8 lb) for your upper body, and stay limber. Spend lots of time stretching. Try to exercise at least every other day, and build up to 5 days a week. Start at 20 minutes a day and build up to 40 minutes. All of us are busy, but we can all squeeze an hour in per day to keep fit.
3. Build up endurance. When you are able to walk briskly for 40 minutes three times a week, start a new activity. Swimming and stationary biking are great aerobic exercises while you are pregnant. Keep well hydrated and keep your heart rate under 140 beats per minute. Jogging, stair master, and aerobics are also great exercises for pregnancy and postpartum. All of these build your endurance and strength and increase your metabolism as well as burn calories.
4. Lift weights. I believe weight lifting is essential, because it builds muscle mass which increases your metabolism, it helps your posture, and it increases your endurance. Your weight program should be low weight with a high number of repetitions. This can be started from the very beginning. The earlier the better.
5. Stay flexible. This is often overlooked and is vitally important, too. Yoga is a great pregnancy exercise. You can get some tapes and do it at home. It will increase your core strength and flexibility, and will greatly decrease back pain and other common aches of pregnancy. Of all the exercise you do while you are pregnant, this can be one of the most beneficial.
6. Vary your workout schedule. It is tedious for me to do the same work out every day. Walk one day. Lift weights the next. Do yoga the next. Do aerobics the next. Take at least 2 days off per week. You are in this for the long haul. Don’t burn out. If you don’t have a pass to a fitness club, go walk the mall. Walk the greenbelt. Walk around the high school track. Just do it.
7. Warning signs. If any of these things happen, you need to stop and don’t start exercising again until you contact your physician: shortness of breath, chest pain, vaginal bleeding, regular contractions, heart palpitations, pain, or decreased fetal movement. Don’t get overheated.
Being fit isn’t being model thin. Being fit is having the strength, flexibility, and endurance to do any activity you want. A goal to be fit is a very attainable one and one that we can all do with a little effort. Being pregnant taxes your body and saps your strength. No one may come knocking on your door for you to be the next pregnant swimsuit model, but you will sleep better, have more energy, have a better and possibly faster labor, and regain your pre-pregnancy body much faster, and maybe even improve on that, with a little work. Good luck.
Exercise in Pregnancy
I sometimes feel bad for my pregnant patients reading magazines in the waiting room. I see many of them read the pregnancy magazines I subscribe to, which are chock full of airbrushed, waif-like pregnancy models with perfect skin and no stretch marks who do not seem to have to waddle when they walk and are happy and smiling. When your back aches, you feet are swollen, you skin is stretched to within an inch of its life, and you haven’t had a good night’s sleep for 6 weeks, it’s hard to look or feel particularly perky and pretty, and looking at these models doesn’t do much for your self-esteem. If I was a pregnant woman, I’d be throwing darts at or sticking voodoo pins in those pregnancy models’ pictures.
Following a short recovery, the patient goes home the same day. There is some soreness and cramping that last a couple of days. There are no incisions, no stitches, and she can return to her normal activities almost immediately. Blood loss is minimal. The cost is significantly less, as are the risks of infection, damage to bowel and bladder, and no hormone replacement is necessary. Sexual function and desire are unaffected. Sterilization is considered permanent, but the ablation is NOT considered a form of contraception, so many women choose to have a tubal ligation done at the same time
Is it successful?
Current data in regard to the success rates are as follows:
No further bleeding--50%
Minimal spotting-----40%
Persistent bleeding---10%
This last 10% usually end up needing a hysterectomy.
Who is an acceptable candidate for this procedure?
The ideal patient for this procedure is a woman that is done with childbearing that is experiencing persistent spotting or heavy periods. Women that undergo ablation typically are either is not good candidates for hysterectomy (due to weight, medical condition, or other factors) or simply desire a less invasive procedure. Pregnancy, cancer, and abnormal uterine growths must be ruled out prior to surgery.
What are the risks?
As I previously mentioned, in 10% this procedure will fail and in 30% some bleeding may persist. The risks of infection, bleeding, damage to internal organs, and of reaction to anesthesia are significantly smaller than with hysterectomy.
I should point out that by and large, hysterectomy is a relatively safe procedure and is certainly an effective cure of life-altering uterine bleeding. But it is more invasive, and the recovery period is from 3-6 weeks (depending on whether or not the surgery could be done vaginally or abdominally) and the pain and discomfort following a hysterectomy is significantly greater than with an ablation.
I would recommend the following site if you want more information. There are a number of different types of ablation systems available now. The one I use is the Novasure System. It is simple, safe, and very effective. Click HERE for information on in-office ablation.
What is an endometrial ablation?
Endometrial ablation is an outpatient procedure that is done in the operating room under spinal or general anesthesia. It is done for women with heavy cycles. At the time of surgery, a small scope is inserted through the cervix into the uterus and the uterine lining is cauterized (burned) with electric current. This destroys the glands responsible for the bleeding and cramping that bother so many women.
Stress incontinence, on the other hand, is leaking small amounts with any activity that increases pressure upon the bladder, like coughing, sneezing, lifting, standing, etc. It is an anatomic defect, usually caused by age or childbirth. The usual anatomic mechanisms the prevent urine from leaking are damaged and lax. Kegel exercises can help this, but often it is insufficient to prevent future leaking. This is a situation where surgery can help.
The latest in a long line of ever-improving techniques is called the "transobturator urethropexy". It can now be done as an outpatient with two small incisions in the inner thigh and a one inch vaginal incision. A catheter is left in overnight. Bladder spasms and problems urinating are extremely uncommon with this procedure. Having performed hundreds of bladder suspension procedures, I truly like this one. It is simple, quick. and very effective. Complications are extraordinarily rare and the success rate is very good. For more information on the one that I personally prefer, see the following LINK.
While it is a very safe surgery, I must point out that it still entails the risks of bleeding, infection, and damage to internal organs, and there are failures in perfectly performed surgeries. I would not recommend you undergo any sort of bladder repair procedure without a thorough work up, bladder testing, and thorough counseling. For those women, though, who have life-altering urine loss with activity, it can change your life.
The two most common bladder control problems are urge incontinence and stress incontinence, or a mix of the two. Urge incontinence has to do with the innervation to the bladder. In a sense, it is faulty wiring. The bladder is sending the message to the brain and spinal cord that it would like to be emptied now…RIGHT NOW…whether it needs it or not, or whether you are ready or not. This is NOT a condition improved by surgery. On the contrary; surgery can make it worse.
LAVH--Better in almost every way than abdominal hysterectomy
It is unfortunate to note that in women’s health care, a field that prides itself as the originator of laparoscopic surgery, that over 70% of all hysterectomies are still done through a large abdominal incision. I personally do about 90% of the hysterectomies I do vaginally, or with laparoscopic assistance. The difference in recovery between an abdominal and vaginal or laparoscopically-assisted vaginal hysterectomy (LAVH) is enormous. A talented laparoscopic surgeon should be able to remove large ovaries, fibroid tumors, and even a very large uterus with laparoscopic assistance.
The hospital stay is usually overnight, and within 4 days women can walk, climb stairs, lift, drive, and function in just about any capacity. Most women are back to work, if they so desire, in two weeks. Sexual activity can resume 4 weeks after surgery.
Though gynecologists pioneered laparoscopy and other minimally invasive techniques, other surgical specialties have picked up on this idea and have also excelled at it. Arthroscopic knee surgery, laparoscopic bowel resections, and laparoscopically assisted hysterectomies are just a few of the many procedures now done. These used to be done through large open incisions. This has greatly improved recovery time, reduced post-op pain, and leave almost imperceptible scars.
Fixing Vaginal Laxity--It's Like Patching your Favorite jeans...
The damaged connective tissue is like having a hole in the knee of your jeans. If you have such a hole, if you try to patch it by sewing the bad cloth back together, in no time it will fall apart. That is how it has been done for years, with less than perfect results. Thirty percent of repairs were failing because the torn and damaged tissue that were sewn back together just fell apart again.
The best way to fix a pair of jeans it to patch the knee, right? So a new method--one which I have performed hundreds of time with excellent results--uses a tissue "patch". It is made of bovine pericardial fascia--the leathery sack around a cow's heart, and is called Veritas Fascia (see www.synovissurgical.com). The tissue is sewn into place to support and replace the damaged tissue, restoring the vaginal vault to its former well-supported self. Over time your body vascularizes the tissue and makes it your own. The resulting vaginal tissue is soft and supple and having placed hundreds of these, I have never seen one get rejected or infected. I have, however, seen this procedure fail, though at a much lower average than is seen nationally. I would estimate less than 10% of the time. A good source for more information on the topic is found at www.webmd.com. Type in "cystocele" or "rectocele" as the search word.
The female pelvis is supported by strands of tough and elastic connective tissues. This support tissue can be damaged by time, by smoking, by your genetics, and especially by having babies. If the underlying support tissues are damaged and torn, the uterus can sag down and the vagina can sag over the bladder (a cystocele) or over the rectum (a rectocele).
×Current general guidelines recommend that women have a Pap test at least once every 2 years, beginning about 3 years after they begin to have sexual intercourse, but no later than age 21. Experts recommend waiting about 3 years after the start of sexual activity to avoid overtreatment for common, temporary abnormal changes. It is safe to wait 3 years, because cervical cancer usually develops slowly. Cervical cancer is extremely rare in women under age 25.
×Women ages 65 to 70 who have had at least three normal Pap tests and no abnormal Pap tests in the last 10 years may decide, after talking with their clinician, to stop having Pap tests. Women who have had a hysterectomy (surgery to remove the uterus and cervix) do not need to have a Pap test, unless the surgery was done as a treatment for pre-cancer or cancer.
×We now believe that most cervical cancers are caused by HPV—the human papilloma virus. It is transmitted sexually. That is why women in stable monogamous relationships or who have never been sexually active are at low risk for cervical cancer. Most HPV infections go away on their own. Some persist and cause precancerous changes. Low risk HPV infections can cause genital warts.
In spite of these recommendations, women are still sent yearly Pap cards by their providers and many will not refill contraception or other meds without a yearly Pap. National recommendations do not back this up for low risk women. The American Cancer Society says women can have a pap smear every other year if they’re over thirty and have had three normal pap smears in a row. There is a great study in the New England Journal of Medicine that looked at over 900,000 women which concluded that it was perfectly safe to space Pap smears out for 2 and maybe even 3 years. There is NO DATA showing that, in healthy women between 25 and 50, that yearly clinical exams decreased mortality in this low risk population, when compared with exams every other year. The argument arises from some physicians that there are other things that are discussed at yearly exams that make it worth while to have a woman in every year. Doing yearly Paps get women into the office to discuss these things. All I can say to that is that there is no data to back that up.
I use the following outline to counsel the women under my care:
1.In higher risk women, yearly pelvic exams and Paps are mandatory. Women on other medications or with medical problems that need monitoring need yearly visits, too.
2.In lower risk, healthy women, exams are spaced out to up to two years until age 50. After age 40, mammograms are done every 1-2 years so that women get a breast exam at least yearly. Cholesterol and diabetes testing should start by 40 also. I personally refill contraception for up to 2 years in carefully selected low risk women. The classic example here is a 28 year old married woman with all normal Paps who needs birth control. I believe it is a waste of health care dollars to perform a “yearly exam” on this group of patients.
×The Pap test (sometimes called a Pap smear) is a way to examine cells collected from the cervix. The main purpose of the Pap test is to find abnormal cell changes that may arise from cervical cancer or before cancer develops. It does not effectively detect uterine or ovarian cancers. A woman’s lifetime risk for cervical cancer is 1 in 120 (versus 1 in 8 for breast cancer or 1 in 27 for colon cancer).
Heart Disease--
The #1 killer of
women over age 50
•Heart attacks alone kills 6 times more American women than does breast cancer
•13% of all women over the age of 45 have had a heart attack
•Women who smoke have heart attacks 20 years earlier than women who don’t.
•Women with diabetes have 2-3 times the risk of heart attack
•40% of women die within one year of having their first heart attack.
Of those that survive, 50% will be legally disabled within 6 years
I think those number make it frightfully clear how important heart disease prevention is. There are some risks that you can do nothing about, such as your family history, age, or other chronic health problems. Let’s talk about what you can do. There are basically six modifiable risk factors.
1.Smoking. This one goes without saying. Stop smoking! It is the greatest modifiable risk factor of all.
2.Obesity. Obesity is epidemic in our society. The more excess body weight you carry, the harder your heart has to work, the higher your blood pressure is, and it is often accompanied by abnormal cholesterols (see below). This added strain makes the likelihood of damage to the heart muscle and its blood vessels much greater.
3.Serum lipids (cholesterol). You should have your cholesterol checked at least every 5 years after age 35. Just getting a total cholesterol count done is not adequate. We now divide up the cholesterols into different fractions. It is important to have all of these. You can have a normal total cholesterol and be at risk. You can have a high total cholesterol and be OK. LDL is the “bad cholesterol”. It is deposited under blood vessels and causes “hardening” of arteries, narrowing of arteries, and if these plaques of cholesterol rupture, can cause clots that can cause a sudden heart attack or stroke, or can flip off clots that will do the same. HDL cholesterol is the “good cholesterol”. It carries away LDL’s and is preventative of heart disease. Triglycerides are also checked and can be a problem if they are too high. Total cholesterol is the total of all the good and bad, and is an important number. We look at your risk factors, the ratio of the HDL to the total cholesterol, and the level of the LDL as we evaluate how aggressive to be. The more risk factors, the greater the risk. If your lipids are abnormal, often exercise and dietary changes can help. If not, medications exist which can also lower your cholesterol, and presumably lower your risk.
4.Diabetes. You should be screened for diabetes at least every 5 years, and more frequently if at high risk (family history, overweight). Diabetics, for a number of reasons, are at much greater risk to die from heart disease. Treating or preventing the diabetes greatly lowers your risks.
5.Sedentary life style. A lot of these factors overlap. Lack of cardiovascular health contributes to obesity, high cholesterol, diabetes, and hypertension. Get active. If you have been sedentary for a long time, consult your doctor before starting an exercise regimen.
6.Hypertension (high blood pressure). High blood pressure puts tremendous pressure on the heart muscle and on the blood vessels in the heart and brain, and the risk to damaging or breaking one is much greater when the pressure is too high. Testing yearly with your exams is, for most women, adequate screening.
Interestingly, a recent very large study was done on the protective effects of aspirin in women in preventing heart attacks. It has been shown to be very helpful in men. It unfortunately did not have any protective effects against heart attacks. And taking aspirin has its own risks, such as intestinal bleeding. So if you are on it, you may need to evaluate things again based on new data as it comes in.
Here are some facts to mull over while we have you thinking about heart disease:
•One of three women who die in the U.S., dies of heart disease . More women than men now die of heart disease each year. Women are twice as likely to die from bypass surgery than men
Yearly Exams--More than just a Pap and a breast exam
Pap smears: This is a screen for cervical cancer. That is all it screens for. Women who have never been sexually active are at lowest risk for cervical cancer. Women who have had multiple partners, who have had STD’s, who have had an abnormal Pap in the past, and who have genital warts are at higher risk. Yearly screening is usually sufficient, unless otherwise specified by your doctor.
Birth Control: Make sure you discuss this if it is an issue. Along those lines, questions about STD’s and problems or concerns about sexual issues should be brought up. Most of the time, your physician won’t ask you.
Breast Cancer Screening: Yearly breast exams after age 30, and mammograms every 1-2 years from 40-50, and yearly after age 50.
Heart Disease Prevention: This, in my opinion, is the most important thing to discuss after age 40. It is far and away the number one cause of death in women over age 50. Issues to discuss are:
High blood pressure. This increases risks of heart attack and stroke.
Cholesterol screening. This should be done every 5 years in women over the age of 40 at a minimum. Levels under 200 are the goal.
Smoking cessation.
Weight control.
Bone density/osteoporosis: This should be discussed in all women over the age of 50. Not all women need to be tested for their bone density, but your risks of osteoporosis should be discussed.
Colon cancer screening: Colon cancer, in non-smokers, is more common that ovarian, uterine, and cervical cancers combined. It is only second to breast cancer in its frequency. All women over the age of 50 should have stool occult blood testing done yearly (a simple test that checks for small amounts of blood in the stool) and sigmoidoscopy every 5-10 years after age 50.
Thyroid screening: This is recommended every 3-5 years on women over the age of 60. Thyroid disease is very common in women over the age of 50.
Diabetes screening: This should be done every 3-5 years in women at high risk after the age of 45.
Skin cancer check: All moles should be checked yearly.
Periods and Menopause: Problems or questions about menopause should be discussed BEFORE you go through it. It is up to you to decide on how and if to use hormone replacement. It is a whole other discussion in and of itself.
Tests not to ask for routinely: Liver functions tests, electrolytes, blood counts. These should only be ordered to investigate specific problems, not as screening tests.
Ideally, my mechanic will check all the important things in my car, since he or she knows more about it than I do. Now I no longer assume that this is happening unless I ask for it. The same applies with your health care. You need to go in with a list, and if time is not being taken to address your questions, you need a new mechanic.
When I take my car to the mechanic for an oil change, I assume that will be done. I take it for granted that other fluid levels will be checked. The last time I went (one of those discount deals—a lube and oil change and a free carwash for $16.99 or something like that), a few days after I noticed some transmission fluid leaking. I called the garage, who informed me that they didn’t look at that since we didn’t ask them to. It wasn’t part of the deal, apparently. I learned my lesson—don’t assume.
Don’t assume your physician will discuss all the other important issues. I know for a fact many, if not most, don’t. I am a believer in self-empowerment. The more you know, the more you can manage you own health care. You need to know, going in, what needs to be done and ask for it. Don’t assume a physician that orders every test under the sun is doing you any favors, either. This is expensive and much of the time, worthless. The purpose of the following discussion is to inform you exactly what you need to ask for.
In the U.S. today, 10 million individuals are estimated to already have the disease and almost 34 million more are estimated to have low bone mass, placing them at increased risk for osteoporosis. 80% are women.One in two women over age 50 will have an osteoporosis-related fracture in their remaining lifetime.
Symptoms
Osteoporosis is often called a "silent disease" because bone loss occurs without symptoms. People may not know that they have osteoporosis until their bones become so weak that a sudden strain, bump or fall causes a fracture or a vertebra to collapse. Collapsed vertebrae may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as stooped posture.
Risk Factors
Current low bone mass
Being female
Being thin and/or having a small frame
Advanced age
A family history of osteoporosis
Estrogen deficiency as a result of menopause, especially early or surgically induced
Abnormal absence of menstrual periods (amenorrhea)
Anorexia nervosa
Low lifetime calcium intake
Vitamin D deficiency
Use of certain medications (corticosteroids, chemotherapy, anticonvulsants and others)
Presence of certain chronic medical conditions
An inactive lifestyle
Current cigarette smoking
Excessive use of alcohol
Detection
Specialized tests called bone mineral density (BMD) tests can measure bone density in various sites of the body. This name of this test is a DEXA scan. It looks at bone density in your arm, back, and hip.
Prevention
A balanced diet rich in calcium and vitamin D
Weight-bearing and resistance-training exercises
A healthy lifestyle with no smoking or excessive alcohol intake
Talking to one’s healthcare professional about bone health
Bone density testing and medication when appropriate
Some scary statistics
An average of 24 percent of hip fracture patients aged 50 and over die in the year following their fracture.
One in five of those who were ambulatory before their hip fracture requires long-term care afterward.
At six months after a hip fracture, only 15 percent of hip fracture patients can walk across a room unaided.
Not just hip fractures, but vertebral fractures are also linked with an increased risk of death.
One in five hip fracture patients ends up in a nursing home, a situation that participants in one study described as less desirable than death.
Medications
Although there is no cure for osteoporosis, many medications are approved by the FDA for postmenopausal women to prevent and/or treat osteoporosis. Some are taken daily. Some are taken weekly. Now there are medications that can be taken MONTHLY.
It is much easier to prevent bone loss than to build new bone and heal old broken ones. Take charge of your health. Make sure you do all you can, and then make sure your risks are carefully evaluated and proper screening is done.
Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures, especially of the hip, spine and wrist, although any bone can be affected.
improvements have been made. First, the string is now a single filament and poses no threat of causing infection. Secondly, there are no systemic hormones to affect moods, weight gain, or that pose any increased risk of heart attack or stroke (as many hormonal forms of birth control do). The IUD of 2005 also is as effective as birth control pills (1% failure rate per year). The other new twist is that the IUD emits small amounts of progesterone to the lining of the uterus, making cycles very light. IUD's work by inhibiting fertilization. No study ever done has ever shown the
IUD works as an abortifacent. There do not appear to be any fertilizations in the studies done on it. For more information on the type of IUD we recommend, please click on the following LINK
IUD's have changed a great deal of the last several decades. They have been made in all shapes and sizes. In the 1960's they fell out of favor because the braided string attached to it served as a "wick" for infections to move up. Since that time, a number of
What's New in Contraception?
Permanent Contraception:
New Birth Control Pill Strategies
The procedure for female sterilization is now done through 2 half inch incisions and a device called a Filshie Clip is placed on each tube. No cutting or burning are necessary. I place 2 on each side and close the small abdominal incisions with skin glue. You can realistically be up and about your normal activities within 24 hours.
There is a type of birth control pill marketed as "SEASONALE" which lets women go for 12 continuous weeks without menstruating. It is as effective as regular birth control pills. There is more break through bleeding on these, which is a nuisance but does not reduce the effectiveness.
Weekly Contraceptive Patch
These patches are less effective in overweight women, and can leave a bit of a rash on sensitive skin. Smokers over age 35 should not use the patches (called ORTHO EVRA). One big advantage to them is that they do last a week, are as effective as pills, and can be used continuously from 4-12 weeks at a time.
Vaginal Contraceptive Ring
The NUVARING has estrogen and progesterone and works in the same way pills or the patch do. It is inserted the first Sunday after a cycle starts and left in for 3 weeks. A European study of several thousand women showed that 98% liked the ring and would continue using it.
The MIRENA IUD
The pro's and con's of the MIRENA are described above. Clink in this LINK to read more about it.
IMPLANON--The Implanted Rod
This single flexible rod is inserted beneath the skin of the arm is left in up to three years. Already approved, it will probably be ready for use in the US in 2006. Its predecessor, NORPLANT, was taken off of the market for a number of reasons. IMPLANON is not only as effective as NORPLANT, but has the advantage of very low hormone levels, great effectiveness, and easy insertion and removal. LINK for more info.
Hormone Replacement--What we think we know as of now
benefits far outweighed the risks overall. What the newest data shows is that there is no protection against heart disease and stroke, and in fact it may increase the risk. So where does that leave you?
For women that have no post-menopausal symptoms, or who can control them with over-the-counter medications, then we would recommend you continue to do so, while watching for osteoporosis and working on prevention. For women who feel miserable, then estrogen should be considered. Your individual risk taking HRT is actually very small. As a baseline, a woman's yearly risk over the age of 60 of breast cancer is 2/1000 per year. Using HRT increases that risk to 3/1000 per year. So there is an increase, but it is relatively small. The same is true of heart disease and stroke. For some women, feeling good is worth the added risk. It comes down to quality of life.
So what about "bioidentical hormones"? Bioidentical hormones are manufactured to have the same molecular structure as the hormones made by your own body. By contrast, synthetic hormones are intentionally different. Drug companies can’t patent a bioidentical structure, so they invent synthetic hormones that are patentable (Premarin, Prempro and Provera being the most widely used examples). So isn't natural better? Aren't there women who swear it is better?
We are believers in evidence-based medicine. It is not sound medically to prescribe therapies based solely on a handful of individual experiences. The experience with traditional HRT shows us that it takes years of study and tens of thousands of women to reassure the effectiveness and safety of HRT.
The North American Menopause Society's executive director Wulf Utian, MD, PhD, says there is no evidence that testing hormone levels during menopause or tailoring hormone therapy is beneficial, or safe long-term. "Women have been sold a bill of goods by people who have conveyed these products as better and safer. The fact is these are the same hormones in different combinations and permutations, and they are therefore subject to the same risks and benefits."
The custom compounded formulations are supposedly tailored to an individual woman's hormone needs, which are determined through hormone testing. Because they are considered natural formulations, bioidentical hormones are not regulated by the FDA the way traditional hormone therapy is. We certainly see women who swear that they feel good now and didn't in the past. We suppose as long as they realize that they are taking an unknown risk, it is not unreasonable. We certainly do not oppose it. We simply can't endorse it, either. If that changes, we will change along with it.
So much has been said in the press regarding hormone replacement therapy, and it is not always very clear. It is actually pretty simple, at least based on the information we have:
We used to believe that hormone replacement therapy (HRT) prevented heart attack and stroke, the number one killers of
women over age 50. It has always been known that HRT may increase the risk of breast cancer, but it was felt the
Renee is a certified family nurse practitioner with over 28 years of medical experience. She holds a Master's degree in Nursing and has worked as a Nurse Practitioner since 1987. Renee is also certified in Advanced Cardiac Life Support and is a Certified Trauma Nurse. Renee offers general medical care for women--much in the same way a family physician or internist would. She takes care of acute problems such as injuries, colds, GI problems, infections, etc, as well as yearly exams and chronic problems such as high blood pressure, diabetes, asthma, acne, depression, headaches, and virtually any other problem imaginable.
