What Women Want to Know

How old should my daughter be before I get her immunized for HPV?

This is an excellent question and we commend you for you for keeping up on this important topic.  HPV, human papilloma virus, is the virus responsible for all abnormal Pap smears and most cases of cervical cancer, as well as cancers of the vagina, vulva. It is a sexually transmitted infection for which there is no cure and is not completely preventable even with condoms. Every year about 12,000 women are diagnosed with cervical cancer in the U.S. and about 4,000 women die from it. (CDC). Fortunately, with regular Pap testing and treatment most women who are exposed to the virus (the majority of women) will not develop cervical cancer.

There are over 100 different strains of HPV some of which are considered high risk for cancer. Of the current approved HPV vaccinations, Gardasil helps to protect against 4 important strains of HPV and has been widely used and studied.  This vaccination immunizes women against 2 high risk strains of HPV that cause 70% of cervical cancers and 2 strains that cause 90% of genital warts.  Warts do not develop into cancer and are completely benign, but they are bothersome and this is why the vaccine includes protection from some strains.  The vaccine is highly effective, but doesn’t protect against all strains of HPV or completely prevent cancer.

The HPV vaccine is currently approved for use in women age 9-26.  (Studies are being done on the benefits of vaccinating men to minimize HPV in the population and whether women over 26 years old can benefit.)  The key is to get immunized before contact with the virus, as is the case with all other immunizations.  Typically around age 11-12 is a good time to think about immunizing your daughter, [click to continue…]

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I have 2 children 2 years and 5 years and I feel that my PMS depression is getting worse since they were born. I suffer from very angry bouts on certain days in the middle of my periods and more recently I suffer from these during the time I have my period. It is uncontrollable anger and sadness and I just feel like crying. I can’t explain how angry I feel and I feel now that it’s affecting my life and my children. I feel very down a lot, have lost my self confidence. I went to a doctor to get a medical check and the only thing she found was under-active thyroid which can also cause depression, I am on tablets now but I don’t notice any change in my moods. A friend of mine said she had PMDD which affected her life badly and now she is on medication Prozac and it’s much better but it makes her sleepy. Please I would like some advice.

First I want to commend you for being so proactive about your health and well-being by taking the time to see your doctor and write in to us. I know this is not easy to do amidst your busy parenting schedule and the difficult symptoms you’re having. Many of the symptoms you are describing can also be present in thyroid disease, so I am glad you were evaluated for that and are on the proper medications.

I wrote a lot about PMS (premenstrual syndrome)/PMDD (premenstrual dysphoric disorder) in a prior PMS article. These disorders include many of the symptoms you describe, occur anytime up to about a week or two before your period starts, and the symptoms are usually gone by the fourth day of your period. Common symptoms include: fatigue, irritability, bloating, anxiety/tension, breast tenderness, bad mood, depression, change in appetite, acne, oversensitivity, swelling, anger, crying easily, feeling of isolation, headache, forgetfulness, gastrointestinal symptoms, poor concentration, and uncommonly hot flashes and heart palpitations. Also, I’m not sure of your age, but perimenopause can often present with irritability, mood changes, depression and agitation. Of course we cannot make a diagnosis from your question without a full evaluation in person, but you may be suffering from PMDD and/or depression from the symptoms you describe.

It can be debilitating and can make it tough to perform everyday activities, let alone taking care of the kids and work duties. I will defer to my prior PMS article for you to review an extensive list of options for treatment for this. Certainly at this point I recommend seeing a health care professional who is well versed in treating depression and PMDD. For PMDD your Ob/Gyn can care for you and write a prescription for medications. A good psychiatrist or psychologist is best for depression, but many Ob/Gyn’s and Primary Care doctors are well versed at evaluating for the common symptoms of depression and starting a prescription while you are looking for the right person to see for counseling and care.

For depression, [click to continue…]

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Recently, we answered readers’ questions on the CA 125 test for detecting ovarian cancer. Today we will follow up with a discussion on the early symptoms of ovarian cancer and some of the risk factors and protective factors. Ovarian cancer is the most common cause of death among the gynecological cancers. The most common type of ovarian cancer usually is diagnosed when a woman is in her 50’s. Typically, ovarian cancer does not present with obvious symptoms until a late stage of the disease, when the prognosis is poor. Fortunately, it has been recently discovered that there may be early symptoms of ovarian cancer that if recognized, could hopefully detect it at an earlier stage and improve survival.

Early symptoms can include: bloating, pelvic or abdominal pain, difficulty eating or feeling full, and urinary symptoms (urgency or frequency). If these symptoms are new, persistent, a change from your normal body, worse than expected, or if you have more than one symptom, it is worth seeing a gynecologist for a closer history and physical especially if the symptoms have been present daily for more than a few weeks.(1) Your gynecologist will take a close history, perform a full pelvic and abdominal examination, and may consider an ultrasound and CA 125 test depending on the findings. The good news is that most patients who present with one of these common symptoms do not have ovarian cancer.

Some of the main risk factors for ovarian cancer include: [click to continue…]

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What happens when you don’t take the prenatal vitamins? What happens to the child?

This is a great women’s health and pregnancy question as many women don’t know they are pregnant in the first trimester, or are so nauseated it makes it hard to take prenatal vitamins.

One of the most important components in a prenatal vitamin is folic acid. This vitamin help prevent malformations of the spine (neural tube defects like spina bifida), skull, and brain and 800 mcg  is the minimum recommended pregnancy dosage. The tricky part is that the neural tube closes about 2-4 weeks after conception, so often you don’t even know you are pregnant and may not have started a prenatal vitamin. We recommend that all women of childbearing age take a multivitamin or prenatal vitamin daily, since 50% of pregnancies are unplanned. If you have not been taking folic acid and just found out you are pregnant, the good news is that most of the time it is okay and the overall risk of neural tube defects is low. Folic acid has also been shown to reduce other congenital abnormalities and may decrease the risk of abruption (the placenta separating from its attachment to the uterus). If you are having significant nausea and cannot tolerate prenatals in the first trimester, a folic acid supplement can be taken alone and is usually well tolerated. Foods that are naturally rich in folic acid include: leafy green vegetables (like spinach and turnip greens), asparagus, broccoli, peas, fruits (like citrus fruits and juices), dried beans, and liver.(1) Folic acid is also added to breakfast cereals, breads, flours, pasta and rice.

Another important ingredient in prenatal vitamins is iron, which often is deficient during pregnancy and is the leading cause of pregnancy anemia (decreased oxygen in the red blood cells). Iron is important for fetal and placental development and to help with boosting maternal red blood cells. The recommended intake is 30 mg per day during pregnancy which is in most prenatal vitamins. (2) The most common symptom of mild anemia is fatigue. [click to continue…]

How long should you be off of the birth control pill before starting to try to get pregnant?

Good for you for planning ahead for a healthy pregnancy. We used to recommend stopping the pill and waiting for at least three periods to start trying to conceive. The thought was that this will give your body time to start ovulating and for you to start charting when your last menstrual period occurs. The first date of your last menstrual period (LMP) is an important date for calculating the baby’s due date, and before the advent of good ultrasound machines, this was all that was used for dating the pregnancy. Nowadays, we still ask for the LMP, but we perform an early first trimester ultrasound to compare it to the period date to determine the most accurate due date.

Fortunately, the pill has been well studied and there are no known dangerous risks to the developing fetus if you were taking it when you became pregnant or just stopped the pill and became pregnant. In answer to your question, you can safely take the last pill, have a period, and then start trying to conceive without any increased risks. Some patients conceive right away, and for others it may take months to start having regular cycles and ovulating again. Ultimately, time frame for stopping birth control pills also depends on your medical and social situation.

Some people want to try to do their best to conceive during a certain time of year (e.g. many teachers try to have summer babies), and thus may want more time off the pill to start charting their ovulation and cycle length. Medically, if you have a history of: irregular periods before you began the pill, difficulty conceiving in the past, endometriosis, or are over 35, it may take longer to conceive and thus you might want to factor this in as to when you want to stop the pill. Also, remember to start a prenatal vitamin, schedule a preconception visit with your doctor, avoid alcohol, tobacco and drugs, and be mindful of what prescription and over the counter medications you take before conception. Best wishes for a wonderful pregnancy!

I keep getting that email that talks about the CA 125 test for ovarian cancer and to ask your doctor. I did ask my doctor and she said it really wasn’t a good test, but we didn’t have time to discuss. What are your thoughts on it? I know ovarian cancer is an awful cancer.

I get asked this excellent question by patients all the time, and I too have received that email about the CA 125 test too many times to count. The interest in diagnosing ovarian cancer early on is valid, given that it has the highest death rate of all the gynecological cancers and can be very hard to diagnose at an early stage. Fortunately, this type of cancer is not very common; the lifetime chance of developing ovarian cancer is just less than 2%.

CA 125 is a tumor marker that is found to be elevated on a blood test in many of the ovarian cancers. Unfortunately, in patients at low risk for ovarian cancer and who are premenopausal this is not a good screening test. The problem with it is that it is elevated in a lot of normal conditions including: fibroids, various times in the menstrual cycle, endometriosis, pelvic inflammatory disease, pregnancy, ovarian cysts, as well as about 20 other nongynecological conditions including heart disease, diabetes, lung disease and liver disease. About 1% of normal women have an elevated CA 125 (1). The other problem with the test is it can be normal in some patients who actually have ovarian cancer, since not all ovarian cancers make this tumor marker.

If it was a good test to do on everyone, we would check it once a year like a Pap smear and I would make sure all my family members also got it checked. Unfortunately it is not. It would cause a lot of unnecessary surgery in healthy women, including the concerning risks related to the surgery if we screened everyone. If my patients have no risk factors but absolutely want the test done, [click to continue…]

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Since I receive so many questions on birth control, I have decided to do a series on the various birth control options available. In this issue I thought I would start with listing the different methods and then will discuss the birth control pill.

Fortunately, we are very lucky to have so many great methods available to us, compared to just 10-15 years ago. Currently in the U.S. the options include: barrier methods (such as condoms, diaphragms, cervical caps and sponges), combined oral contraceptives, the progesterone only pill (mini-pill), the emergency pill, the Ortho-Evra patch (a birth control skin patch), The Nuvaring (a vaginal ring), Intrauterine devices (IUD’s) including the Mirena and Paraguard devices, injectable contraception like Depo-Provera, Implanon (a rod that is inserted in your arm), and sterilization. One study ranked what they found as the most popular methods of contraception in the U.S (listed in order of highest popularity): birth control pills, sterilization, condoms, injectables and implants and patches (all tied), and lastly all other forms of contraception. (1)

In terms of ease of use, effectiveness and low side effects, I often recommend some of the newer low dose oral contraceptives (birth control pills) like Yaz, Yasmin, Orthotricyclen and Orthotryclen Lo, the Nuvaring, and the Mirena IUD. (By the way I have no affiliations with any pharmaceutical or other device companies, so my picks have to do with what patients do well on). However, there is not one option that is best for everyone and each person has their own preferences and issues to consider. Some factors to keep in mind when selecting contraception include, whether you want it permanent or reversible, whether you like taking a pill/patch/ring daily or weekly or not thinking about it for years, and how rapidly reversible you would like it. For instance if you are planning to have a baby, what is the horizon for when you want to conceive? Also, some people prefer to take a pill when they are taking their vitamins or brushing their teeth once a day, others cannot remember or dislike pills, and may prefer weekly patches, monthly rings, and implanted devices like Implanon or the IUD. Some women are minimally sexually active, or either prefer not to or cannot take any hormones and choose the barrier methods instead. Also, an important question to consider is what are the risks, side effects and benefits of each form of contraception.

The birth control pill is the most widely used contraception in the U.S. and is comprised of a daily pill consisting of [click to continue…]

I am moving out of state and am wondering if you have any recommendations on how to find a doctor?

It can be very difficult to find a good doctor. You might first check with your current physician, as sometimes they have colleagues in the town you’re moving to. Also, asking trusted neighbors, moms, and coworkers can often give you a good starting point if you have just moved to a new city. However, even if you get a recommendation, I would suggest doing a little more research at this point. It is good to make sure the physician is board certified, and, if possible, to talk to any nurses or physicians that you know to see if they have any recommendations of physicians or hospitals to avoid. If you can manage to find an excellent primary care physician or ob/gyn, they can be invaluable in helping to guide you to specialists and help to manage your care if you have multiple medical conditions. When you do find a doctor with all of the qualifications, the next step is to make sure they also have a good bedside manner and really listen to you. If not, I suggest finding another doctor. This is not always possible, but for those in major metropolitan areas there are usually many good physicians to choose from, so there is no need to put up with someone who is not caring or empathetic.

It is also important to find out [click to continue…]

Many women struggle with menopausal symptoms and opt to take hormone replacement during this time. Hormone replacement consists of estrogen and progesterone and it can be taken orally, via patches, and as creams and gels. There are always many questions regarding hormones, given how difficult the perimenopause and menopause can be, and with the various risks and benefits of hormone therapy. The Women’s Health Initiative was a large study that found that women using Premarin 0.625mg and Provera 2.5mg of hormone replacement treatment had higher rates of breast cancer (26% increased risk) than those who did not use any hormones. After this study was released many women stopped hormone therapy in the U.S., and breast cancer rates have decreased nationally since the study in 2002. In this follow-up study, the same patients who were in the Women’s Health Initiative were followed and found to have their breast cancer risk drop to the same level as women who did not take hormones 2 years after stopping treatment. One cannot prove a cause and effect relationship, but it is compelling. This study only looked at one type of hormone replacement therapy, and so it is unknown how the other types of estrogen and progesterone on the market affect the risk of breast cancer.

The Women’s Health Initiative was a study of older postmenopausal women, who have stopped having periods for 1 year or more and on average were 63 years old (ranging from 50-79 years). These same risks have not been found in younger and premenopausal women taking birth control pills and hormones, nor has it been found in the vaginal estrogens, or in women who have had hysterectomies who are taking estrogen only. (Progesterone is given to women with a uterus in combination with estrogen to protect the uterus from cancer while on estrogen). Currently we counsel patients about these risks and warn that any estrogen and progesterone combination including the “bio-identical” hormones postmenopausally (especially over age 60) could potentially pose these risks. However, many women cannot function during menopause without at least short term use of hormones and these are still the most effective treatment for menopausal symptoms. We try to use the lowest dose possible to control symptoms for the shortest amount of time needed, if possible. If you taking hormones, discuss with your doctor the various options and dosages, remember to perform monthly self breast exams, and see your physician for annual examinations and mammogram screening.

Chlebowski RT, et al “Breast cancer after use of estrogen plus progestin in postmenopausal women”. New England Journal of Medicine 2009.

Menopausal Reading Resources:
1. NIH Hormone Treatment Facts
2. Up To Date Patient Information on Menopause