Preterm Births – Ways to Prevent This Large Problem

Preterm births continue to be a large problem in the United States, leading to many problems for these children.  It is the leading cause of infant mortality in our country.  Prevention is always the goal, and today, measuring the cervical length with a transvaginal sonogram may help identify patients who are at a higher risk for preterm births.Stethoscope on Pregnant Belly

Once identified, these patients may benefit from close follow-up plus the progesterone treatments and cervical surgery that are available.  Here are some more details:

  • The cervix may begin to shorten long before preterm labor or before the preterm rupture of membranes occur.
  • The cervical length usually can be measured with the use of a transvaginal sonogram.
  • A shortened cervix found before 20 weeks of pregnancy markedly increases the risk of preterm birth.  Progesterone treatments and cervical surgery, called a cerclage, may reduce the risk significantly.
  • Women with a history of a preterm birth, multiple gestations, or a previous cervical surgery are at a higher risk of early delivery and so may benefit from cervical length measurements.

As always, a dialogue with your health care provider is the first step in receiving the best medical care.  For the prevention of a preterm birth, taking the measurement of the cervical length may be part of that discussion.

For more information, check out: Preterm Births – Information You Should Be Aware Of

-Dr. P

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Are You Concerned About the Morning Sickness Associated with Pregnancy?

Waking Up Morning Sickness M.O.…..Morning sickness is a common problem affecting many women during early pregnancy.  To try to help with the symptoms, most medical professionals will advise eating several small meals during the day, eating low fat, bland foods, and trying to avoid smells that seem to increase the nausea.  Over my many years in practice, I often also advised popcorn, the insides of Italian bread, and ginger pops.

…..If this conservative management does not help, there is a recent FDA (U.S. Food and Drug Administration) approved treatment that may be of help.  Diclegis is the first medicine approved for this problem in over 25 years.  This combination of two substances was marketed many years ago as Bendectin, and it was removed from the market after a safety scare that was proved to be a false alarm.  However, the manufacturer stopped producing it because defending it in court was too costly.

…..Diclegis is a combination of two active ingredients, doxylamine and vitamin B6, and the FDA has granted  Diclegis a Pregnancy Category A status, meaning that controlled studies have not shown an increased risk to an unborn baby during pregnancy.  For the past few years, the American College of Obstetricians and Gynecologists has recommended this combination as a first-line treatment for morning sickness.

…..There is a set protocol on how to start and use Diclegis.  Drowsiness and sleepiness are the most common adverse effects reported by users.  These symptoms can be severe, so great caution is necessary.  As with all medications, you must have a thorough discussion with your health care provider before entertaining the use of this or any medication.

-Dr. P

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Cervical Cancer Update – Including When and How Often You Should Screen

…..CCervical Cancer Updateervical cancer in the United States has been dramatically reduced over the past 30 years due to the widespread testing of cervical cells with the use of the Pap smear.  The cervical screening program is constantly evolving as more studies mature the guidelines.  The American College of Obstetrics and Gynecology (ACOG) in November of 2012 issued a new Practice Bulletin, which gives new guidelines to improve cervical cancer screening, based on the latest studies.  This will be a short summary of these guidelines:

  • The cervical cancer screening program begins at age 21 regardless of the onset of sexual activity.
  • With women 30 to 65 years of age, cervical cancer screenings should not be performed as often as annually.  Annual well woman exams are still recommended and extremely important!
  • For women ages 21 to 29, Pap smears should be done every 3 years.
  • For women ages 30 to 65, Pap smears should also be done every 3 years.
  • Co-testing (Pap smears and HPV testing) should not be performed with women 21 to 29 years of age.
  • Co-testing should occur every 5 years with women 30 to 65 years of age.
  • With adequate screening history, cervical screening can be stopped after age 65.
  • After a hysterectomy in which the cervix has been removed, screening can be stopped.
  • Any woman who has received the HPV vaccine should be screened by the same guidelines.

…..As always, all of this information should be discussed with your health care provider who will establish an individual plan for you.  Remember all recommendations may be modified based on the individual’s personal history.

-Dr. P

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A New Medication to Help a Painful Menopausal Symptom

.
MH900370730In February 2013, the FDA (Food and Drug Administration) of the US approved a new drug for the treatment of dyspareunia (painful sexual relations), caused by the thinning of the vulva and vaginal tissues in the menopausal time of life.

The drug is called Osphena (ospemifene), and it acts as a tissue selective estrogen protagonist and antagonist.  This means that in some tissues, like the uterine lining and the vulva/vagina tissues, the ospemifene stimulates the tissue like estrogen, and in other tissues it acts like an anti-estrogen.

  • This is a medication in the same family as tamoxifen, which is used in breast cancer treatment and prevention protocols.
  • Dyspareunia is decreased because ospemifene has been shown to stimulate the vaginal mucosal tissue.
  • Osphena is an oral tablet which is taken daily.
  • It is contraindicated in patients with estrogen dependent cancers, a history of stroke or blood clots, or a cardiac history.
  • With this medication, there has been a reported increase in hot flushes.
  • This new medication may appeal to women who are not interested in using estrogen vaginal treatments or systemic hormone replacement therapy.

If you are suffering with this menopausal problem, speak to your health care professional because help is available, and this new medication may be an answer for you.

-Dr. P

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Crucial Tdap Vaccination Recommendations for Pregnant Women

…..Let us now summarize the Tdap vaccination recommendations as advisCDC_09[1]ed by the CDC (Centers for Disease Control and Prevention) and the American College of Obstetricians and Gynecologists:

  • Pregnant women should receive the Tdap vaccine with each pregnancy, and the ideal timing is during 27 to 36 weeks of the pregnancy.
  • With the preceding plan, there is an increased likelihood of optimal protection against pertussis for the pregnant woman and her infant during the first few months of the baby’s life.
  • All women during each pregnancy should receive the vaccine whether or not she has received the vaccine in the past.
  • If the pregnant woman has not received the vaccine during the pregnancy, it should be administered immediately after delivery.
  • To date there is no data to suggest increased fetal, maternal, or pregnancy risks with the vaccine, but the safety should be closely monitored under the direction of the Food and Drug Administration.
  • Although not part of the new immunization schedule recommendations, experts are advising vaccinations for the new baby’s father, siblings, and other caretakers.  This is part of the cocooning strategy.  Even grandma and grandpa should consider vaccination.

…..As always, discuss all your concerns with your caring medical professional so you can obtain the best care possible for you and your family!

-Dr. P

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The New Outbreak of Pertussis in Babies


Little Baby M.O.
Over the past decade, there has been a large increase in the incidence of pertussis (whooping cough) in the United States, with over 40,000 cases being reported in 2012.  What is of great concern is the large number of infants being affected.

The CDC (Centers for Disease Control and Prevention) reports that most pertussis hospitalizations and deaths occurred among children under 3 months old.  Babies do not receive their first pertussis vaccine until two months of age, and they are not fully protected until after their third shot, which comes at about six months.  Over the first six months of life our babies are at a high risk of getting very sick if they develop this bacterial infection.

In order to combat this new outbreak of pertussis, in January 2013, the CDC released a new immunization schedule.  This recommended that a dose of Tdap vaccine be given to all women during each pregnancy whether or not she had received the vaccine previously.  This was a change from their previous recommendations which suggested that the vaccine be given only to pregnant women who had never received this vaccine.

-Dr. P

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Are You at a High Risk for Lung Cancer?

Last week, I spent the day attending a conference at the Icahn School of Medicine at Mount Sinai in New York City.  It was called Lung Cancer Screening: A Paradigm Shift in Primary Care.  The main focus was on the changing thoughts and new protocols for screening for lung cancer in high risk patients.  Of course I looked at the course through my OB/GYN glasses, and here are some of the points I took home:lungs brown and pink

  • Lung cancer is the #1 cancer killer in the United States, and it is now found as often in women as it is in men.
  • Therefore, for women in the United States, lung cancer is the #1 cancer killer, and its numbers are greater than breast, ovarian, and uterine cancer combined.
  • Smoking and exposure to passive smoke are the main causes of lung cancer.
  • Finding lung cancer at an early stage and having it removed can give an overall cure rate of 80% at the Stage 1 level.
  • Low-dose lung screening CAT scans can pick up these early cancers, and the radiation exposure can be low, thus decreasing the radiation exposure risks.
  • With the new thoracic laparoscopic surgical techniques, post-op pain and recovery time have been greatly reduced.

The questions that need to be resolved are many.  When do you start the screening process?  In the high risk patient, do you screen yearly?  How do you define who is the high risk patient?  How are the scans paid for?

I left the conference more determined than ever to try to help my patients stop smoking and to help the younger ones not to start.  If you do smoke and have been smoking for a while, please speak to your health care providers to see if these new developments may be of help for you.  The lung cancer screening protocols are evolving so keep your eyes and ears open!

-Dr. P

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Postmenopausal Women – Preventing Your Urinary Tract Infections


…..
Postmenopausal women are at an increased risk for urinary tract infections (UTIs) because of a decrease in their estrogen levels.  This lower hormone state is associated with specific physical and physiologic changes that increase this risk:Postmenopausal Women – Preventing Your Urinary Tract Infections

  • Thinning of the mucosa of the vulva (vaginal tissue)
  • Changing of the normal bacteria that usually inhabit the vagina, especially a decrease in lactobacillus colonization
  • An increase in the pH of the vagina
  • Vaginal colonization of E. coli.

…..There have been multiple studies which have found a decrease in these UTIs with the use of estrogen intravaginal creams.  There are many variations on the types of estrogen used and many commercial products available.

…..If you are in the menopausal time of your life and suffer from recurrent UTIs, ask your medical professional about the possible use of a vaginal estrogen preparation.

-Dr. P

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Another Way to Reduce Your Risk of Developing Breast Cancer

Pink Breast Cancer RibbonSome women at a high risk for breast cancer may reduce their chance of developing invasive breast cancer with the use of the medication called tamoxifen.  Chemoprevention is the use of a medication to reduce cancer, and it may be considered in a patient who is at high risk of developing breast cancer.

In a high risk population, the risk reduction with the use of tamoxifen has been reported to be 49%, and this has resulted in the FDA approving tamoxifen as the first drug for breast cancer prevention.  In addition, studies have also found that another medication, called raloxifene, to be of benefit in menopausal women.  Of course there can be serious side effects with these medications, so their use may be limited.

If you are at a high risk of developing breast cancer, start a discussion with your medical team about the possible use of chemoprophylaxis!

-Dr. P

Read more about tamoxifen in my post: How Does Tamoxifen Treat Breast Cancer?

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Some Points You May Not Know About HPV

Let us continue our HPV informational journey with a few essential points:

  • HPV infections are almost exclusively acquired from sexual exposure.Some Points You May Not Know About HPV
  • The virus has been detected in multiple sites on both the male and female genital areas.
  • The cervix is the most common site for the infection.
  • Transmission between the mother and infant has been documented, with exposure during the delivery being suggested as the most common cause of the fetal infection.  This is considered a vertical form of transmission.  Some studies suggest a vertical transmission rate of about 25% with almost all neonatal infections cleared by the first year of life.

-Dr. P

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What Other Issues Can HPV Cause?

It was not until the early 1980s that the association HPV Researchbetween the human papillomavirus (HPV) and genital tract infections became apparent.  A German research physician had isolated the HPV 16 and implicated its role in the development of cervical cancer, so a new scientific journey had begun.

We now know that the persistence of an HPV infection is necessary for the development of cervical cancers, and it is implicated in the majority of other genital tract infections in both men and women.  It is time to start our journey to a better understanding of a virus that affects so many of us!

Click here to continue to: Some Points You May Not Know About HPV

-Dr. P

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Two Reasons Why You Should Not Drink Alcohol During Pregnancy

Water Pouring from Bottle…..Alcohol is a teratogen!  A teratogen is a drug or any other substance that can affect the development of an embryo and can lead to birth defects or other developmental problems.  Fetal alcohol syndrome (FAS) is a constellation of physical, behavioral, and cognitive abnormalities in children resulting from a mother drinking alcohol during a pregnancy.

…..The Centers for Disease Control and Prevention report that the rates for FAS in the United States range from 0.2 to 2 cases per 1000 live births.  A less severe form of this problem, called fetal alcohol spectrum disorders (FASD), might be 3 times this rate.

…..There is always the question about how much alcohol will cause a problem.  Will low levels of alcohol consumption during pregnancy cause harm?  What do low levels of alcohol mean?  Will a small amount be OK?

…..It is important to remind ourselves that FAS and FASD are entirely preventable.  These syndromes are not seen if a pregnant woman does not drink alcohol during her pregnancy.  It is for this reason that the Surgeon General of the U.S. and the American College of Obstetricians and Gynecologists direct health care clinicians to advise patients to abstain from alcohol completely during pregnancy.

-Dr. P

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Exercising During Pregnancy – Is it Safe?

…..Obstetrical health professionals have always told their patients that regular, moderate exercise during pregnancy is beneficial and safe for both the mother and fetus.  It is generally agreed that exercise can reduce the common discomforts of pregnancy.  Exercise may even help decrease the risks of gestational diabetes and even preeclampsia.

…..young woman exercising in a parkThe Department of Health and Human Services recommends 2 1/2 hours of moderate aerobic exercise per week.  I have always suggested walking a 1/2 hour daily while trying not to get overheated or out of breath.  If you are able to carry on a regular conversation during your walk, then you are probably not overdoing it.  The problem is not knowing how much is overdoing it, and the guidelines are vague.

…..Should elite athletes continue vigorous programs during their pregnancy?  Should overweight or inactive women begin some exercise regime during their pregnancy?  Once again, relating to these questions, the problem is that detailed studies with direct answers are scarce.

…..However, new studies are now being undertaken at the Johns Hopkins Bayview Medical Center that may give some direct answers.  Recently, two articles were published from their program which showed that even inactive healthy women can exercise moderately during their pregnancy without problems.  They also showed that athletes may continue vigorous exercise safely.  Their very scientific research continues, and finally, we may have the answers for our patients.

…..Lastly, common sense should always be used: pregnancy is not the time to begin activities that may increase your risk of injury.  That means no kickboxing!

-Dr. P

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Preterm Births – Information You Should Be Aware Of

Baby Looking UpWhen a pregnant woman “breaks her water” usually it is the start of an exciting time of her pregnancy because labor has started or is about to begin.  This is fine if the pregnancy is near the due date, but if the water breaks and the pregnancy is not near the due date, then there is a problem.  Preterm premature rupture of membranes (PPROM) is a bad problem and is a leading factor in premature births.

  • About 12% of births in the US are preterm
  • Most pregnancies last about 40 weeks
  • Babies born between 32 and 37 weeks are considered preterm, and babies born before 32 weeks are considered early preterm
  • About 5% of births in the US are complicated by PPROM

Since the most common outcome of PPROM is delivery of the baby within 1 week of the water breaking, information about this potential complication must be available to everyone.

-Dr. P

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How Does Tamoxifen Treat Breast Cancer?

…..Science HealthTamoxifen is a common endocrine treatment for both early and advanced breast cancer in pre- and post-menopausal women.  Some breast cancer cells are stimulated to grow in the presence of the estrogen hormone.  The estrogens bind to special areas in the cancer cells called estrogen receptors, and once the estrogens are attached, the cancer cells’ growth is enhanced.  These breast cancers are called estrogen receptor positive.

 …..Tamoxifen breaks down in the body into a compound that also binds to the estrogen receptor in the cancer cell, but it does not stimulate the cancer cell to grow.  Since the binding site is filled, any available estrogen cannot attach to the cancer cell and stimulate its growth.

…..After the diagnosis and treatment of a breast cancer that was estrogen receptor positive, many patients would be placed on 5 years of tamoxifen treatment, and this would reduce the recurrence of the disease.  New studies may cause oncologists to change the protocol to 10 years of tamoxifen treatment due to the findings of better long-term outcomes.  There are currently ongoing studies which should shed more light on the possibility of modifying the protocols.

…..I would like to touch upon two other points.  As with all medications, tamoxifen can have side effects.  Endometrial cancer is increased with the use of tamoxifen, and so oncologists follow patients closely for this potential problem.  Lastly, another group of medications, called aromatase inhibitors, is now being used more frequently with these patients, but worldwide tamoxifen remains widely used.

-Dr. P

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Hysterectomies in This Day and Age

.Surgery….A hysterectomy is the surgical removal of the uterus.  There are many reasons to have this surgical procedure, and the decision to undergo a hysterectomy must never be made lightly.  Today, the decisions are becoming more complicated as the surgical techniques change and more options are available.

…..The first laparoscopic hysterectomy was performed about 25 years ago, and this changed gynecological surgery forever.  The instruments used were very basic, the technique was new, and acceptance was gradual.

…..In 2008, only about 20% of hysterectomies performed in the USA were being performed with a laparoscopic technique, but by 2012 the number had risen to about 40%.  This minimally invasive route includes the robotic and the conventional laparoscopic procedures.  The refinement of instruments and robotic technology continues the march to an even larger percentage of hysterectomies being performed by the minimally invasive approaches.

…..Remember, before undergoing any surgery, do your research into the indication for the surgery and the type of procedure.  Check into the surgeon’s experience and background, and always ask many questions before any decisions are made!

-Dr. P

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Should You Take Depression Medications During Pregnancy?

MH900390528…..The decision to use any medication during a pregnancy is always made with great care after thorough evaluation by the patient and her health care providers.  Selective serotonin reuptake inhibitor (SSRI) use during pregnancy has always been controversial and now even more so due to recent articles on the subject.  Here are some important points:

  • Depression and anxiety are common in women of childbearing age, and many of these women are being treated successfully with medications, especially the SSRIs.
  • Stopping any antidepressant medication before or during a pregnancy can bring about a depressive relapse, especially in women with a history of severe depression.
  • Fetal and maternal well-being is paramount in balancing the risks and benefits of antidepressant treatment in pregnancies.
  • SSRIs seem to work by boosting serotonin levels in the brain, resulting in mood regulation.
  • Prozac (fluoxetine) was the first SSRI antidepressant approved by the FDA, hitting the market in 1988.  It quickly became one of the most prescribed medications in the United States.
  • Prozac, Celexa (citalopram), and Zoloft (sertraline) are three SSRIs that have been used in pregnancies.

-Dr. P

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Is Egg Freezing for You?

…..There is a recent report from the American Society of Reproductive Medicine which states that oocyte cryopreservation is now an officially sanctioned option for young women with special fertility needs.  Sperm and embryo freezing have been available and used successfully by infertility specialists for many years, but the techniques for egg freezing/warming is now a viable option in special conditions.  The latest studies reveal an equal IVF (in vitro fertilization) successful pregnancy rate with the use of fresh eggs or frozen eggs.

…..Egg freezing can be considered to help women with the following conditions, which may endanger their fertility:

  • A young woman about to undergo chemotherapy for a cancer; the medications can be toxic to her eggs
  • A young woman with any condition that points towards early ovarian failure
  • An IVF cycle where eggs are available but sufficient sperm is not available
  • Some couples involved with IVF treatment do not want to freeze extra embryos

…..There is a new controversy arising from this available technique.  As we are all aware, childbearing in our society is being delayed to later in a woman’s life for many individual reasons.  Should egg freezing be considered to help ensure fertility success for some time later in a woman’s life?

-Dr. P

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A Way to Help Determine the Status of Your Weight

Weight control is a major concern for most of us.  As menopause approaches, many women experience an increase in their weight, with about 70% being overweight.  Body mass index (BMI) is a commonly used calculation that quantifies where our weight is, and when using this classification, about 50% of perimenopausal and menopausal women are considered obese.

Using a person’s height and weight, body mass index can be calculated, giving us a guide to where we stand with regards to our weight.  A BMI of 24 to 29 is considered overweight, and over 30 is obese.  Let us look at where some weights fall:

  • At 5 ft. 1 in. a BMI of 24 to 29 corresponds to a weight of 130 to 150 lbs.
  • At 5 ft. 1 in. a BMI of 30 corresponds to a weight of 160 lbs.
  • At 5 ft. 6 in. a BMI of 24 to 29 corresponds to 155 to 180 lbs.
  • At 5 ft. 6 in. a BMI of 30 corresponds to a weight of 185 lbs.

Remember that this BMI number is not an exact measurement of body fat but it alerts us to where our weight status lies and gives us an indication of our risks for developing the complications of obesity.  These include diabetes, hypertension, heart disease, and many other medical conditions.

BMI Chart Larger

-Dr. P

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Treatment for Lichen Sclerosus

To finish up our review of lichen sclerosus, I want to leave you with some important points:

  • woman smiling in the parkPruritus is the most common symptom, occurring in 99% of women, vulvar irritation occurs in 60%, and vulvar burning and painful sex in 30%
  • High potency corticosteroids are the treatment of choice with 80% experiencing complete remission
  • Clobetasol 0.05% ointment is the medication most often prescribed
  • Ointments are used instead of lotions because of less irritation, and there are rarely any adverse effects with long-term use
  • The treatment protocol usually entails a few months of daily use, followed by a gradual decease, then followed by use as needed

Find about more about lichen sclerosus in: Could You Have Lichen Sclerosus?

-Dr. P

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Could You Have Lichen Sclerosus?

Business DiscussionAt the recent Female Sexuality conference I attended, much attention was spent discussing vaginal pain.  Lichen sclerosus, a long-term skin condition which mainly affects the vulva, was a condition thoroughly discussed.  I knew it was a common problem, affecting 1 in 70 women, and over my career there have been many patients who I cared for with this condition.

In women, the genital and anal areas are mostly affected but it can appear on the upper body and breasts.  Females of any age can develop lichen sclerosus, but it is most common in post-menopausal women with the median age of onset at 51.

Early in the condition, it presents as small shiny smooth white spots or depigmented areas, which can be tender and very itchy.  It is often misdiagnosed as a yeast infection, herpes, or vitiligo.  With time, the spots can progress to bigger patches, and the skin can become thick and crinkled.  The skin can tear easily as the disease progresses.  When severe scarring has developed, the lips of the vagina can shrink, the vaginal opening can become narrowed, and the clitoris may be covered with scar tissue.

Continued in: Treatment for Lichen Sclerosus

-Dr. P

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This Past Stormy Month and a Conference

I cannot believe a month has passed since I wrote my last blog; it has been an interesting month.  First, I hope all of my friends in the New York area are getting back to normal after Sandy.  On Long Island where I live, the damage along the coast has been devastating, and the strength of my neighbors has been heroic.  Mary Ann and I just returned to our home after 2 weeks when the electric came back on.  We were very lucky with only tree damage, so no complaints in our home.This Past Stormy Month and a Conference

We participated in a wonderful conference in Atlanta concerning Female Sexuality.  It concentrated on many aspects of the sexual experience with a major focus on vulva, vaginal, and pelvic pain.  We must become more open about these problems, and it is my hope to help relieve these concerns with many of my patients in the future.

-Dr. P

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One Possible Way to Decrease Your Chance of Developing Alzheimer’s Disease

One Possible Way Decrease Alzheimer’s Smaller BlogI recently came upon an article which touched upon a walking program that could decrease the chance of developing Alzheimer’s disease.  Some studies have suggested that by walking about a mile each day, you can dramatically decrease your risk.

It seems that this decreases the mental losses by improving Reduce Alzheimer's Diseasethe blood flow to the brain and therefore keeping the brain cells healthier.  So one of the easiest exercises available to all, again shows great benefit.

Let us then begin a review of this exercise!

  • There are very few medical conditions that prevent us from walking.  Of course, always check with your medical professional before starting a new program.  Beginning at a slow pace in a safe area is a perfect way to start.
  • Good walking footwear is important, and replacement every 6 months or when the cushion of the heal wears is a must.
  • You should start with a few minutes of a mild warm-up with mild stretching.

-Dr. P

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Breast Cancer – Early Detection Can Save Your Life

…..October is Breast Cancer Awareness Month, and hopefully we are all aware of the high risk of breast cancer that surrounds us.  We know that 1 in 8 women will develop breast cancer in their lifetime, and all of us have someone close who has suffered with this cancer.  In my own family, we lost Mary Ann’s mom, who was my wife’s mother, to this terrible disease.

…..Early detection saves lives, and it is all of our responsibility to encourage the special women whom we love to practice good breast health, which should include:

  • Monthly self breast examsBreast Cancer Pink Ribbon Patch
  • At a minimum of once a year, breast exams from your health care provider
  • Yearly mammograms starting at age 40
  • Special follow-up programs if there is a strong family history of breast cancer

…..As a gynecologist, breast health has been a daily and major part of my professional life.  I encourage all of my patients to be their own best advocates when it comes to breast health.  Do your self-exams.  Do the recommended breast studies.  Once the studies are done, get the results and understand what the results are.  Do the follow-up studies and follow-up consults that are advised.  If there is a problem, see the breast specialists.  Get second opinions if there is ever a doubt.  Let us all work together to defeat this foe!

-Dr. P

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Gonorrhea – A Condition Which Often Lacks Symptoms

…..teenage depression - teen woman sitting thinkingNext in my series about sexually transmitted infections in adolescents, we will be discussing gonorrhea.

…..Gonorrhea is a common STI in the adolescent and young adult population (15 to 25).  There are about 750,000 cases each year, with women having a slightly higher rate than men.  We should use the same targeted screening that is used for chlamydial infections (with all women under 25 being tested).  The same risk factors are associated with gonorrhea and chlamydia, and with both, more than 50% of women are asymptotic.

…..When there are symptoms, they may include vaginal discharge, pelvic pain, or pain with urination.  Again, if there is a delay in diagnosing and implementing the treatment of an infection, severe pelvic problems can develop.

…..There are specific antibiotic protocols for treatment that are available.  These days, consideration must be made for antibiotic resistance, which has been developing.  Lastly, with all persons found to have gonorrhea, there should be testing for HIV, syphilis, and chlamydia.

-Dr. P

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Urgent Facts About Chlamydia, a Common STI

…..Sexually transmitted infections in adolescents continued…

…..CChlamydia Infohlamydia is one of the most common infectious diseases in the United States, with somewhere between 1 to 3 million cases each year among women ages 15 to 45. The most affected group is between ages 15 and 19, followed by 20 to 25 as the second most affected group.

…..One problem in finding this infection is that less than half of the most affected women are screened for Chlamydia trachomatis. The Center for Disease Control (CDC) guidelines suggest a yearly screening for chlamydia on all sexually active women who are 25 and younger, and testing should be performed for women over 25 if they have a new sexual partner or multiple partners. Women should also seek testing if they experience abdominal or pelvic pain, vaginal discharge, painful intercourse, pain with urination, or irregular bleeding.

…..Testing usually entails a speculum exam with a Q-tip swab of the cervix. If the speculum exam is a problem for the adolescent, then a vaginal swab can be performed. The patient can even collect a vaginal swab test privately if necessary.

…..After a woman is treated, reinfection is common, and having a treated infection does not provide immune protection against future infections. It is therefore advised that a repeat test be performed a few months after a treated infection.

…..If there is a delay in treatment of this infection, then there is an increased chance of developing an infection of the pelvis, called pelvic inflammatory disease (PID), which can lead to infertility. Some studies suggest that PID can develop in up to 30% of women with their first chlamydial infection.

…..There are many antibiotic treatment plans suggested by the CDC, and they all are very successful. The adolescent and her partner should avoid intercourse for 7 days after both partners have been treated.  Ideally, the patient should refer for testing any sexual partner that she encountered within the last 1-2 months.

-Dr. P

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What Factors Place Adolescents at an Increased Risk of Developing STIs?

Young women are at a high risk of acquiring STIs (sexually transmitted infections) and of developing the serious complications of untreated chlamydial and gonococcal infections.  Almost half of all STIs occur in teenagers and young adults between the ages of 15 and 25.  Physical and behavioral factors place the sexually active teenager at an increased risk to develop these infections.

Physically, the cervix is more vulnerable to these infections because it has not fully developed, exposing more susceptible cells to the infections.  Since the young woman may be coming into contact with these infectious agents for the first time, her immune defenses are not strong.

Behavioral risk factors include having multiple new sexual partners and not using condoms or not using condoms properly.  The U.S. Department of Health and Human Services has a goal to increase the simultaneous use of both condoms and hormonal contraception (birth control pills).  This combination of methods is highly effective in preventing a pregnancy and preventing the acquisition of STIs.  Yet currently, some studies reveal that only about 5% of adolescent females are using this practice.

-Dr. P

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Some Points You Should Know About Bleeding in Early Pregnancy

…..Let us end our review of vaginal bleeding in early pregnancy with a few points:

  • Early pregnancy bleeding often stops on its own, and the Some Points You Should Know About Bleeding in Early Pregnancycause is not always determined.
  • Vaginal bleeding is a common problem, and observing vaginal sonograms and hCG blood levels is helpful to determine the cause of the bleeding and to assess the chance of a successful pregnancy.
  • If the bleeding continues past the third month of the pregnancy, there is an increased chance of problems later on in the pregnancy, such as early rupture of the membranes and preterm (early) delivery.
  • This type of bleeding is a cause of great fear and anxiety for a couple, and emotional support from the medical team, family, and friends is imperative!

-Dr. P

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How a Sonogram Can Determine if Your Pregnancy Is Normal or Abnormal

…..OHow a Sonogram Can Determine if Your Pregnancy is Normal or Abnormalver the last 30 years, ultrasound has changed dramatically in how we evaluate early pregnancy.  Transvaginal sonography has allowed us to assess early gestation with better clarity.

…..The gestational sac is the first visible sign of a normal
intrauterine pregnancy.  This should be seen with the transvaginal sonogram by 5 weeks after the last menstrual period. The earliest embryonic structure is the yolk sac, and likewise, this can be seen as early as the end of the 5th week.  Evaluating the yolk sac is important because it can point to problems in a pregnancy. If it is not present at this early time, or if the shape is irregular or large, this can be the first sign of a nonviable pregnancy.

…..Near the 6th week from the last menstrual period, the embryo should be seen attached to the yolk sac, and fetal heart activity should be noted between the 6th and 7th week. When the gestational sac is approximately 2 cm, an embryo should be seen, and if it is not identified at this time, a blighted ovum is confirmed.

…..There are specific sonographic signs of a problem pregnancy:

  • A small gestational sac around the embryo
  • If the embryo does not increase in size by 1 mm per day
  • A fetal heart beat at a rate of less than 120 beats per minute after 7 weeks of gestation.

…..Let us end this review on a positive note. If a patient has no abnormal symptoms, normal fetal heart activity, and 7 weeks of gestation has been reached, then there is a 99% chance of a successful pregnancy.

-Dr. P

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Evaluating Your First Trimester of Pregnancy – The HCG Hormone’s Role

…..LEvaluating Your First Trimester of Pregnancy – The HCG Hormone’s Roleet us now start to review how early pregnancy (the first trimester) is evaluated, especially in the case of bleeding.

…..The embryo produces a hormone called hCG very early in the pregnancy, and later the placenta also produces this hormone.  Repeating or checking the levels of the hCG every 2 to 3 days is helpful when trying to assess the viability of an early pregnancy and to see if it is normal.  At a certain hCG level (between 1200 to 1500), a pregnancy should be visualized by a transvaginal sonographic exam.  When serial hormone levels are being followed, it is important to use the same laboratory or else there may be different test kits used at the specific lab, and so the results may not be accurate.

…..The hCG level should have a minimum rise of 50% every 2 days, and some practitioners consider a rise of 66% to better reflect a normal pregnancy.  I was taught that the levels should double every 3 days, and this is the formula I have always used.

…..All pregnancies are different, and there is some variability in the rise of hCG in normal pregnancies.  There are also some specific circumstances that affect this hormone’s levels:

  • If the woman is dehydrated when a test is taken, and on the repeat test she drinks more, the test can be affected
  • The level of hCG, which rises so dramatically early in the pregnancy, will begin to level off at about 8 weeks
  • In twins and other multiple pregnancies, the numbers can have great variability especially if there is a problem with one of the pregnancies

-Dr. P

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What Are Common Causes of Bleeding in the First Trimester of Pregnancy?

…..There are a few common causes of bleeding in the first trimester:What Are Common Causes of Bleeding in the First Trimester of Pregnancy

  • Spontaneous abortion
  • Ectopic pregnancy
  • Subchorionic hemorrhage
  • Gestational trophoblastic disease (less common)

…..When we speak about miscarriages (spontaneous abortions), there are a few terms which are frequently used.  An ultrasound and an examination will usually confirm the diagnosis:

  • Threatened abortion (when vaginal bleeding occurs before 20 weeks of gestation, there is a viable pregnancy, and the woman has a closed cervix)
  • Inevitable abortion (if there is a dilated cervix)
  • Incomplete abortion (when a portion of the pregnancy has passed)
  • Complete abortion (when all of the pregnancy tissue (products of conception) has passed)

…..Gestational trophoblastic disease is a much less common cause of vaginal bleeding early in a pregnancy.  Some signs of this condition would be a pregnancy size larger than would be expected (based on routine dates), very high levels in a blood pregnancy hormone test (hCG), and severe nausea and vomiting.  Here are some common terms that are encountered:

  • Complete hydatidiform mole: A partial mole is formed when a sperm fertilizes an egg that has no nucleus.  This is the most common type of this condition.  On a sonogram, there may be many ovarian cysts seen or many cysts within the uterus.
  • Partial mole: This arises when two sperm fertilize an egg.  On a sonogram, there may be a sac with a fetus.

-Dr. P

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You May Experience This Common Complication of Early Pregnancy

…..I would like to begin a review of one of the most common complications of early pregnancy, vaginal bleeding.  This is the number one reason patients will have an emergency visit in the first trimester, and it is a cause of great anxiety to patients and theirYou May Experience This Common Complication of Early Pregnancy families.  There are a few important facts you should be aware of:

  • About 15% of recognized pregnancies will end in miscarriage
  • 80% of miscarriages occur in the first trimester
  • Trauma, smoking, excessive alcohol use, and advanced maternal age increase the risk of first trimester bleeding
  • 25% of pregnant women will report first trimester bleeding or spotting
  • 8% of pregnant women report heavy vaginal bleeding
  • Of the patients who report bleeding, 75% will have 1 episode, 20% will have 2 episodes, and 10% will have 3 or greater episodes
  • The amount of bleeding is the most significant predictor of an impending miscarriage
  • Again, advanced maternal age is a significant risk factor for first trimester bleeding and subsequent miscarriage; 50% of pregnancies in women over 40 result in a miscarriage, with abnormal chromosomes in the fetus being a primary factor
  • For women under the age of 35, the rate of a spontaneous miscarriage is 2%.

-Dr. P

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The Concern of Getting the Flu Shot During Pregnancy – FAQs Answered

…..Let me give you some information to cover some of the questions that patients frequently ask.  This information is from the American College of Obstetrics and Gynecology, the American Medical Association, and the Society for Maternal-Fetal Medicine. It is from the form given to obstetricians to give to thSyringe for Flu Concern Patch Blog Post Paint3eir patients.

…..If you get vaccinated during your pregnancy, your unborn starts to get some protection during this period. This also gives the newborn a degree of protection in the first few months of life when their vaccinations have not been begun.

…..Safety, of course, is the main concern of all mothers. Flu vaccines have been given safely to millions of pregnant women for more than 50 years and are endorsed by the above medical societies.

…..The question of mercury in some of the vaccines is always a concern. Thimerosal, a type of mercury, is a type of preservative used in trace amounts in some vaccines and has not been shown to be harmful to a pregnant woman or her unborn child.  Also, it does not cause autism. Again, this is from the above mentioned medical societies. Remember, if you are still concerned about being given preservatives during your pregnancy, there are single-dose flu vaccines that are mercury-free, so speak to your medical professional.

…..Lastly, you must begin the discussion about the flu vaccine with your caregiver now. Ask all your questions, become informed, and let us all be protected… and you cannot get the flu from the flu vaccine!

-Dr. P

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Why Should You Get a Flu Shot Each Year?

…..The influenza vaccine comes in two types:

  • Inactivated, or killed vaccine, which is given by injection with a needle
  • Live, or attenuated (weakened) vaccine, which is sprayed into the nostril

…..The influenza viruses are always changing, and so each year scientists try to determine which viruses are going to cause the flu that year. In other words, a new vaccine is put together each year to prevent the flu for that season. It is for this reason that an annual vaccination is recommended.  After a person receives the vaccine injection, it takes about two weeks for the protection to develop, and the protection lasts for about a year.

Why Should You Get a Flu Shot Each Year

…..Some inactivated influenza vaccines contain a preservative called thimerosal while some vaccines are thimerosal-free. This has been a concern for many, but it has been shown not to be harmful to a pregnant woman or her baby, according to the American College of Obstetrics and Gynecology.

…..The U.S. Department of Health and Human Services recommends that all people 6 months of age and older should get the flu vaccine. Vaccination is especially important for people at a higher risk of severe influenza, including their close contacts.  Some of these close contacts can be healthcare workers and children younger than 6 months.

…..You should get the vaccine as soon as it is available for the new season. Even though most influenza occurs from October through May, the flu season can occasionally come earlier, so get the protection as early as possible.

-Dr. P

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All Pregnant Women Should Be Immunized for the Flu

…..A few days ago, the influenza vaccine for the 2012-2013 flu season arrived in myAll Pregnant Women Should Be Immunized for the Flu office.  In the United States, this season is considered to be October through May.  We have already begun to arrange the vaccination for all of our pregnant patients.  As a result, it seems to be the appropriate time to have our review of influenza immunization during pregnancy.

…..The American College of Obstetricians and Gynecologists recommends that every pregnant and non-pregnant woman receive an inactivated influenza vaccine.  It appears that the most effective way to increase the influenza immunization rates among pregnant women is for the physicians to directly recommend the flu shot to patients.  The live, attenuated influenza vaccine is contraindicated for pregnant women, but the inadvertent vaccination of a pregnant woman with the live vaccine has not been shown to be harmful.  Therefore it is not an indication for pregnancy termination.

…..Why should we get vaccinated? Influenza, the flu, is a contagious disease caused by the influenza virus, which can be spread by coughing, sneezing, or with nasal secretions.  Anyone can get the flu, but the rates of infection are highest among children.

…..The symptoms usually last only a few days and include fever, chills, cough, sore throat, headache, muscle aches, runny nose, and fatigue.  Young children, older people, pregnant women, and people with medical conditions that have them in a weakened state can become much sicker and need to be hospitalized.  So by taking the flu shot you can protect yourself and those around you.

-Dr. P

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What Is Most Likely to Happen if You Are Diagnosed with Lyme Disease?

…..When Lyme disease has been diagnosed because you have the “bull’s eye” rash from a tick bite or a positive blood test, your medical team will usually prescribe an antibiotic regimen.   Depending upon your history of allergies, two of the most common treatments are amoxicillin (500 mg three times a day for 14 to 21 days) or doxycycline (100 mg twice a day for 14 to 21 days).

Bull's Eye Rash (Tick)

…..Intravenous antibiotic treatments are not often needed, but they are needed when the Lyme infections are more serious. These would include infections around the brain and spinal cord (meningitis) or heart (carditis).

…..I would like to leave you with two interesting facts about Lyme disease. If for some reason you get the infection and do not obtain treatment with an antibiotic, you have about a 10-15% risk of developing Lyme arthritis, and this needs to be treated with a different antibiotic plan.

…..Even after treating Lyme disease and having no blood tests pointing to an active disease, about 10-20% of people will not feel well for months, having complaints of being exhausted and joint pain. Antibiotics do not seem to be the answer for this frustrating condition.  The passage of time is the ultimate treatment.

…..Enjoy the rest of your summer and always check your clothes and body for ticks after working or playing outdoors in a grassy area. Then take a shower, which removes the ticks off your body and prevents those troublesome bites!

-Dr. P

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You Found a Tick on Yourself – What Are the Next Steps?

Once you have discovered that a tick is on your body, you remove it with a tweezers.  Try to detach it at the base of the tick’s attachment.  If it is removed within 24 to 48 hours, it is unlikely that it has infected you with Lyme disease. Also, it is important to remember that only 1 in 20 people bitten with an infected tick will develop the disease.  Not every deer tick carries the Borrelia burgdorferi bacteria, with usually 1 in 5 being carriers in high risk areas.Tick Removal Display Image

The Infectious Disease Society of America does not recommend antibiotics for everyone who has been bitten by a tick. If the rash of Lyme disease develops, then antibiotics are advised.

The rash is the easily noticed circular “bull’s eye” target-like rash. This rash can begin anywhere from 1 to 4 weeks after the bite. It starts out being the size of a quarter and can widen to 6 to 9 inches as the bacteria spread out. If your anxiety of developing the disease is great, many doctors will treat you with doxycycline if you do not have an allergy to the medication.

Find out more in: What is Most Likely to Happen if You Are Diagnosed with Lyme Disease?

The blog post preceding this one: This Little Surprise in Your Garden Can Cause a Big Problem

-Dr. P

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This Little Surprise in Your Garden Can Cause a Big Problem

Two days after working in the garden, I was taking a shower, and on my shoulder I found a dark raised lump that looked like an apple seed. Of course I panicked, took a nail clipper, grasped the bottom of the “seed,” and then pulled it off. It was a tick! I put it down next to the sink and it started to walk. Again I panicked, crushed it, and flushed it down the toilet.Garden M.O. USENext, the ever-calm OB/GYN doctor quietly called his wife to let her know what happened and to check the rest of my body for ticks. Surely you know that is not the manner in which I spoke. Thank God I was smart enough many years ago to have found a calm and cool wife who then helped me check for any other ticks, and none were found.

The next morning, again while taking a shower, on my abdomen I found another dark spot. This time it was much smaller, black, and I did not notice it the morning before. It was another tick.

Later that day, I went to see my personal physician, who happens to be one of my dearest friends. He is an expert on Lyme disease and took care of me. This story has prompted me to write about this problem and get some basic information to my friends.

Over 30,000 new cases of Lyme disease are diagnosed each summer, and 90% occur in 10 states.  New York is one of those states. This disease is an infection caused by the bacteria called Borrelia burgdorferi, which enters the body from an infected deer tick’s bite.

While the tick is attached to us, it begins to suck blood from the victim, and at this time, it regurgitates the bacteria into the person’s system. Most of the infections in humans are caused from the bites of immature ticks called nymphs, which are the size of poppy seeds. The disease can also be transmitted from the bite of an adult deer tick, but because they are larger, they are more likely to be discovered before having time to transmit the disease.

Continue to: You Found a Tick on Yourself – What Are the Next Steps?

-Dr. P

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Four Reasons Why Your Hair Could Be Losing

…..Today we will close our discussion of hair loss in women with a few more causes.

Four Reasons Why Your Hair Could Be Losing…..Traction Alopecia is hair loss from excessive pulling at the hair roots over a prolonged period of time.  The loss occurs where the hair is pulled in one direction, for example, by a ponytail or a cornrow pattern of braids.  The treatment is usually just discontinuing the particular hairstyles, and in time, the problem resolves.

…..Tinea Capitis is caused by a fungal infection of the hair shaft.  It is most common in children.  However, it can be found in immunocompromised adults such as AIDS patients and patients receiving chemotherapy.  The presentation is usually a round patch of hair loss associated with pruritis and scaling.  The diagnosis is made with cultures and the examination of scrapings along the border of the lesion.  The usual treatment is oral antifungals.

…..Trichotillomania is classified as an impulse control disorder.  It involves compulsive and repetitive pulling or plucking of the hair, which leads to noticeable hair loss.  Patients have described feeling tension before pulling out the hair, and the tension is relieved after the hair is pulled out.  This condition is usually managed by a trained mental health professional.

…..Anagen Effluvium involves an acute loss of scalp and body hair when the growth phase of hair is disrupted.  This occurs mostly with patients on chemotherapy.  Because 80 to 90% of hair is in the growth phase, this hair loss is dramatic and diffuse.  The loss usually begins 1-3 weeks after the chemotherapy is started, and the hair returns typically 3-6 months after the treatment is finished.  The initial hair that returns may differ from the patient’s usual hair, but these changes are mostly temporary.  Permanent hair loss from this condition is usually rare.

…..I hope this information on hair loss in women has been enlightening and helpful.

-Dr. P

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Is the Stress in Your Mind Causing Stress on Your Hair?

…..Continuing our discussion on hair loss in women….

…..Remember how our mothers always told us that stress could cause so many problems and make us feel terrible?  As always, our mothers were right.  For women, a severe illness, psychological stress, or having a baby are inciting stressful events that can cause physical effects.  One of these effects is hair loss.Hair Loss  Patch Blog Post 2

…..Usually 90% of our hair is in the growth phase, with 10% in the resting phase.  Keep in mind that some hairs are always shedding in the resting phase, and it is usually a small and regular amount.

…..Telogen Effluvium (TE) is a condition of diffuse hair loss that is caused by an identifiable stressful life situation; three of those situations were stated above.  In TE, 70% of hairs are in the growth phase and 30% in the resting phase.  This results in about 3 times as many resting phase hairs being shed daily.  The hair loss is gradual and diffuse and may be similar in appearance to the loss associated with the female patterned hair loss called androgenic alopecia (AGA).

…..With TE, a woman usually is aware of shedding, but with AGA, the loss is gradual, and shedding is not usually a complaint that is presented.  Also with TE, the loss may not become apparent for several months after the stressful event.

…..To treat TE, you must first identify and resolve the stress the body has been subjected to.  With pregnancy or an acute illness, the hair loss is usually self-limiting with complete recovery within 6 months after having the baby or recovering from the illness.  When TE is caused from psychological stress, since the treatment and recovery can take some time, the hair recovery can also involve a prolonged period.

-Dr. P

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