It has become apparent over the years that there is a very close association between cervical cancer and the Human Papilloma Virus (HPV).  We now know that the HPV is a precursor of cervical cancer, a carcinogenic virus that over several years in some women can lead to cervical pre-cancer and cancer.  The screening paradigm has been shifting and now is clear.  We should have HPV screening with our Pap smears starting when we are 30 years old until 65 years old, and if positive an annual Pap Smear or possibly closer monitoring is recommended.  BUT for those who are HPV negative, a Pap smear is only needed every 3 – 5 years.  Do not confuse annual cervical cancer screening with an annual exam.  You still need to see your women’s health care provider EVERY YEAR for a pelvic exam to check the uterus, bladder, ovaries, and vagina as well as a breast exam.  STI (Sexually Transmitted Infection) screening is necessary for any women with more than 1 sexual partner or a new sexual partner.

Change is sometimes scary and hard. The more we know, the better we can make informed decisions for ourselves.  A recent consensus of opinion leaders in this area makes this simpler. There is now agreement between the National Taskforce for Cancer Screening and the American Cancer Society.  This is the wave of the future.  I have already made changes in what I recommend to women in my office.

The FDA is now requiring that all the companies manufacturing the mesh fund a registry of all patients who have this implanted.  They are also requiring more research on these products already on the market and are suggesting they be used only by specially trained pelvic surgeons with urogynecology experience and only in certain cases, perhaps after a prior failed prolapse surgery.

The complications noted were mild and severe.  The mild problems are mesh erosion with bleeding from the vagina, or extrusion that causes pain with intercourse.  Sometimes this heals with some estrogen cream and other times it must be removed surgically and another method of prolapse repair must be utilized.  Extra surgeries are not as successful as the first attempt.  Severe problems involve mesh erosion into other organs such as the bladder or rectum.  This requires major surgery with significant risk.

There are good studies that indicate that natural tissue repairs may not “look as tight” as those done with mesh but they are as functionally beneficial without the added mesh risk.  For the strongest longest lasting repair, mesh is used through the abdominal route, either through an incision, with a laparoscope or with the De Vinci Robot. The latter 2 choices get you out of the hospital in 24 hours with a 2 week recovery.  This option works well for those who need extra strong repairs and long lasting repairs with minimally invasive surgery.  I recommend seeing a surgeon who does all these types of repairs so you are getting what is best for you not just what the individual surgeon knows how to do.

I am trained and experienced in all techniques and therefore can discuss the risks and benefits of all approaches to best design a treatment plan for each individual woman.

It is always best to be armed with information.  The full FDA warning can be read on the www.FDA.gov website.

Listen here: KFI-11-13-11-7AM

There are many ways to easily accommodate larger women.  In my office I have a variety of specula, some are extra long and narrow, some are extra long and wide and I can see what I need to without any problem.  I have a couple of electrical tables and some mechanical tables all of which can accommodate most women.  If someone is not ambulatory or over 400 or 500 pounds, this is a different story but up to 350 pounds is manageable in my office.  We have extra long instruments for cervical biopsies and other office procedures.  Sometimes I will have the patient lift her knees to her chest to give better access to the perineum.  Our reception area has a very sturdy sofa without arms along three walls and several armchairs that are strong and can accommodate most sizes.  They were purchased with this in mind.

No patient should ever be sent away from a medical office for their size.  I find that our open attitude about this has encouraged many women to take better care of themselves, to start exercise programs to improve their fitness and to consider healthier eating patterns. They are certainly relieved that we are neither preachy nor judgmental.  They follow up better and are very loyal patients.  Doctors are here to treat all patients, not to cherry pick the “easy ones”.  Let’s get back to why we took that oath and chose medicine as a profession, to care for those who need us.

This blog entry was cross-posted on OBGYN.NET

Lo Loestrin 10 Fe is the lowest available dose birth control. Interestingly it is half the dose of the next lowest dose pill 10 mcg of estrogen. This is very good news for young women or small women especially if they have experienced the side effect of nausea from the birth control pill as this is a dose dependent side effect; lower dose, less nausea, less reduced libido, less irritability. There are some drugs that influence the effectiveness of all birth control pills, such as antibiotics and seizure medications. You should always inform your doctor of all medications, prescription and over the counter medications you may be taking.

Beyaz is another new low dose oral birth control pill. This one combines a 20 mcg estrogen dose with a unique progesterone (drosperidone) that has some diuretic action to reduce bloating, as well as reduce acne, excess hair and PMDD. The added advantage of this pill is the addition of Folate, a vitamin, into the pill. This vitamin is recommended for women of reproductive age to reduce the occurrence of certain birth defects in the babies of women with inadequate folate intake. Beyaz is closely related to Yaz (same hormones, same dose just no folate). The main increased risk with this class of birth control pill is an excess of potassium in the blood due to the diuretic action of the progesterone in this pill. This should be monitored by your doctor.

For the past several years I have been tracking the success of my patients on the long cycle pills Seasonique and LoSeasonique. For the most part women are very happy having fewer periods per year. These pills usually result in a period every 3 months which for most is preferable to a period every month and absolutely safe. On the downside, there can be considerable breakthrough bleeding in the first three to six months. Usually this resolves and gives a reasonable light, short, non-crampy period each season (hence the name!)

For women who cannot tolerate oral contraceptives there is the ring, Nuvaring, a combined estrogen progesterone birth control ring that is inserted into the vagina like a tampon and removed three weeks later. It is quite small and not felt by the woman or her partner and contraception is comparable to the oral pill with no first pass through the liver so it is a lower dose, the lowest circulating dose of hormone available. This is good for women with nausea on higher or all oral contraception and may be better for libido since the sex hormone binding globulins that bind to our own testosterone are made in the liver and stimulated to form by oral hormones that pass through our liver first before entering our blood stream.

The Mirena IUS (intrauterine system also called an IUD) is FDA approved both for birth control as well as for heavy menstrual bleeding. It is a very good choice for peri-menopausal patients who might be bleeding heavily because it will greatly reduce flow; some women do not bleed at all. If estrogen supplementation is required, the Mirena will cover the progesterone needs of the patient as it prevents uterine lining cancer as reported in several European journals. This remains an off label but very safe use of the Mirena at this time.

A discussion of birth control is not complete without mentioning Emergency Contraception (The morning after pill). Plan B has been available for several years as a pill of levonorgestral 75 mg. followed 12 hours later by another pill of the same. It is now available as Plan B 1 step. This is 1 pill of 150 mg of levonorgestral (double the prior pill amount) that is taken once and very effective in preventing pregnancy by delaying ovulation and changing the cervical mucous and uterine lining. It is very well tolerated and available over the counter to women over 18. If you are under 18, you should request this from your doctor and fill it to have it available if you are sexually active and not on hormonal birth control. Condoms can break or fall off. This is excellent back-up and effective within the first 3 days or 72 hours after intercourse. If it does not work, there are no increases in birth defects noted in the resultant pregnancy. It is good to be prepared and have this in advance because these mishaps invariably occur on weekends when it is difficult to find your doctor and get a prescription.

There is an entirely new medication for emergency contraception called Ulipristal or Ella. This pill is taken within 2 days or 120 hours of intercourse and is a progesterone blocker which results in blocked ovulation, a change in the mucous preventing fertilization, and a change in the uterine lining preventing implantation. It requires a prescription and of note is useful out to 5 days.

Any IUD can be used as an emergency contraceptive within 5 days of intercourse but this requires a visit to the doctor and insertion of this device.

With some advanced planning unplanned pregnancy is preventable and avoidable. All it takes is a good birth control plan and a back up plan.

There is a website www.NAFC.org which has a great depth of information, some of it furnished and written by me I am proud to say.  I highly recommend using this resource for information for patients as well as caregivers. It is very accessible and there is a great depth and breadth of information.  There is a question and answer patient forum as well as a quarterly newsletter online

Why would a urogynecologist be involved with a consumer advocacy group?  Because my mission is to educate and treat patients who are the consumer.  Any assistance I can find for my patients that improves their understanding of their problem and its treatment is an advantage for both me and the patient.  We do not live in a vacuum; we must use all the resources we have available.

The NAFC is an amazing group of urogynecologists, patients, urologists, nurses, physical therapists, and non medical leaders in public relations, law, and healthcare administration all dedicated to pelvic floor education and treatment.  Please check out the website and if you like what you see and are so inclined make a donation to continue the excellent work of this organization.

Stress incontinence is urinary leakage associated with “physical stress” or activity that is exercise, coughing, sneezing, changing position, jumping, running or the like.  It is related often to childbirth injury and tends to get worse over time for many reasons.  Gravity is the first issue.  Since we walk on 2 legs, our pelvic organs are just above our vagina.  If there is a disruption in the support structures of the vagina and uterus from childbirth we then have prolapse or “falling” of the bladder, uterus and possibly rectum.  This results in urinary loss, difficulty with bowel movements at times and sometimes an uncomfortable bulge at the vaginal opening. Although this bulge can be alarming, it is rarely dangerous.  If we were like man’s best friend, the dog, we would not have prolapse because animals that walk on four legs have a vagina that is horizontal and not affected by gravity.

The urinary leakage is also caused by the hormonal changes of menopause.  Less estrogen can result in weakening of the support structures and more urinary leakage.  And aging is a factor as well.

So when do you consider surgery?  If there is minimal or no prolapse, the TVT Sling procedures are outpatient procedures with minimal pain and short recovery times.  Most women are back to work in a week and pain medication is required for only a day or two.  There are no external stitches, just a few dissolving stitches in the vagina and most activities are manageable in a short time.  There is a limitation on strenuous exercise and heavy lifting for 2 months and no swimming or intercourse for 1 month.

When I counsel women I find that most put up with symptoms of urinary leakage far too long. When they get this corrected they invariable ask, “why did I wait this long? I didn’t have to suffer with pads and embarrassment as long as I did”.  Many younger patients note that their symptoms get worse with each subsequent delivery.

If you are finished having children, if you are limiting your activities because of your bladder, if you are wearing more than 1 mini-pad per day, if you are not playing sports, hiking, playing tennis or golf because you can’t find a bathroom every 30 minutes, it is time to consider surgery for stress incontinence.

The success rate of these nylon-like slings is 90% and the slings are permanent.  They act as a hammock to support the urethra (the tube that empties the bladder) when there is a cough, sneeze, or when exercise tightens the abdominal muscles.

Some women have heard that mesh is dangerous, and in large quantities this may be so, BUT these mesh ribbon slings have been implanted in women in the USA for the past 15 years and in Europe for another 5 years prior to that. There is a very long experience with them. I have been implanting them since they were first introduced in this country and have a 15 year experience with them.  They are very safe.

So, if you are bothered by your bladder, consider surgically correcting the incontinence (if it is stress incontinence).  You do not have to live with it, there is no benefit to putting off treatment, it is not likely it will be necessary to treat it again.  You can reclaim your life now, feel better, and be more active with yourself and your family.

This is usually due to damage to the pelvic floor caused by the birth itself.  I have discussed how this happens elsewhere on my website.  This damage is reparable, the looseness can be fixed, and the vagina will function better sexually, and be more comfortable the rest of the time if there was any sense of pressure or bulge at the opening.

When these pelvic floor defects or herniations are repaired, along with tightening the appropriate muscles, this is called a pelvic floor reconstruction.  This is the medical term for cystocele and rectocele repair, or anterior and posterior repair.  “Vaginal rejuvenation” is a marketing term, used to sell procedures to women.  I am not a great fan of “selling” anything to women but I do believe we have the right and the responsibility to understand our bodies and how they work and what makes them function optimally.

If you are suffering from vaginal laxity or looseness, the first thing to do is Kegel exercises. Very often tightening and strengthening the pelvic floor muscles will increase sexual satisfaction for you and your partner. (See prior blog about vaginal tightening and pelvic floor exercises).  If you cannot figure it out alone, try either biofeedback or a session with a specialized pelvic floor physical therapist to instruct you.  If this is not the answer, it is time to consult a qualified pelvic floor surgeon: a urogynecologist who can properly evaluate and treat this surgically.

The surgery is done vaginally, can be done without mesh for most natural results, and is minimally uncomfortable.  It is either an outpatient procedure or possibly 1 night in the hospital and patients typically return to most activities in 1 – 2 weeks. It can be done in conjunction with a minimally invasive sling for incontinence if that is also a problem.

Since this is a medical condition, this is covered by most insurance.  Not to be confused with labioplasty, which is plastic surgery to make the vulvar lips smaller.  Labioplasty is a cosmetic procedure and is not usually covered by insurance, nor is it necessary for sexual function or satisfaction.