Gynecology

There are many drugs that can be delivered through the skin and achieve the same or better benefit to the body. The birth control patch is one of these products. The patch, which contains the active ingredients in a birth control pill (estrogen and progestin), delivers continuous levels of hormones to your system through the skin. It works exactly like a birth control pill to prevent pregnancy: it thickens mucus in the genital tract, prevents the formation of eggs, and prevents ovulation. For some women who find taking the birth control pill daily difficult, the patch can offer more effective pregnancy prevention and menstrual control. The patch can be 97-99% effective in preventing pregnancy.

You have 4 choices: the lower abdomen, buttocks, upper outer arms, or back of the shoulder. The patch should never be applied to the cheek or the breasts. To ensure the effectiveness of ORTHO EVRA®, do not place the patch on areas of your skin where makeup, lotions, creams, powders, or other products are or will be applied. In addition, do not place ORTHO EVRA® on skin that is red, irritated, or cut.

Women change the location of the patch weekly to avoid skin irritation and enable you to remove the adhesive from the old site. When removing your used patch, simply lift one corner and quickly peel it back. If a small ring of adhesive is left on your skin, remove it by rubbing a small amount of baby oil on the area.

The patch adheres well to the skin, allowing you to perform your daily activities such as bathing, showering, swimming, and exercising without interruption. If the sticky surface of the patch becomes wet, discard it and apply a new patch. Once you have prepared the skin and applied the patch, you will not be able to remove it and place it in a new location. The adhesive is unlikely to adhere adequately. You will have to use another patch.

Patches cannot be altered or cut. Modifying the patch will decrease the effectiveness in preventing pregnancy and controlling your periods.

Apply your first patch on the first day of your period. The patch will be effective in 2 weeks. Apply a patch every 7 days for 3 weeks. Remove the patch for 1 week while you have your period and then refill your prescription and reapply the patch for the next cycle.

You will need to change the patch every 7 days to maintain effective period control and pregnancy prevention. Although using the patch means that you will not have to take a daily birth control pill, you must still remember to change the patch weekly. Try these ideas to remind you:

• Set an alarm on your cell phone for a weekly reminder
• Make it part of your routine to change your patch before you start your day Monday morning
• Add a weekly reminder to the calendar on your work and / or person e-mail
• Keep a weekly “to do” list, and add a patch reminder to your agenda
• Put a yellow sticky note on the bathroom mirror: “TUESDAY!” Only you will understand the meaning
• Keep a calendar on your refrigerator and circle all “Patch Change Days” for the year

In clinical trials, less than 2% of birth control patches had to be replaced because of complete detachment, and less than 3% had to be replaced because of a partial detachment. Proper preparation of the skin will ensure that your patch will stick for a week thru exercise, swimming, and bathing. Still, you should ask your provider for an extra prescription that allows you to obtain just 1 patch at the pharmacy in case you need to replace one.

Go to www.orthoevra.com to find more information on the patch.

Estrogen-containing pills can increase the risk of clotting in women with high blood pressure, diabetes, migraine, clotting disorders, and smokers. The women that fall under these risk factors are suggested to take birth control pills without estrogen. Estrogen can also decrease the production of milk in breastfeeding women. Women who want to continue breastfeeding should avoid birth control pills with estrogen.

A progesterone-only birth control pill is effective at 97-99%.

As with all birth control pills, daily use of the product is required to help prevent pregnancy.

The most common complaint from women that use progesterone-only birth control pills is irregular periods. The irregular periods aren’t heavy — just unpredictable bleeding. Over months of use, most women begin to have light periods and do begin to have a pattern in their periods; some women do not get a period after taking the pill for many months. This is not harmful. Periods will return once the pill is stopped.

This is the injectable form of birth control that is 99.7% effective in preventing pregnancy. It prevents pregnancy by stopping ovulation in some women and also by thickening the mucus in the genital tract, obstructing the forward movement of sperm, and reducing the ability of the uterine lining to be receptive to pregnancy.

The first dose of Depo must be injected the first 5 days of the menstrual cycle. Subsequent doses will be given every 12 weeks. Doses of Depo can be given earlier than 12 weeks, but no later than 13 weeks. If you miss your window to get your injection, you will not be given the shot unless you are on your period, you abstain from intercourse or you take a pregnancy test in office that comes back negative.

The recommended site of injection is the buttocks. The site of injection may be sore, but do not massage the area. This could cause the medication to disperse too quickly.

Common side effects are: irregular bleeding, breast tenderness, bloating, weight gain, acne, headache, worsening depressive symptoms.

After the 4th injection, most women do not menstruate anymore. This is not permanent but after discontinuing Depo, regular menstruation may not resume for 3–12 months.

Depo prevents pregnancy 2 weeks after the first injection. Use back up protection until then. Depo doesn’t prevent against sexually transmitted diseases.

Depo can decrease your bone density. We strongly suggest that you take a daily multivitamin and 1200 mg of calcium.

If you are over 40 years old, Depo may lead to irreversible bone loss. Ask us about other birth control options if you fall under this risk factor.

Clomid (Clomiphene Citrate) is a widely used ovulation induction drug and is frequently a first-line fertility treatment for women who have irregular ovulation or who do not ovulate at all.

Lack of ovulation (anovulation) is one of the most common causes for infertility. Once successful ovulation is achieved, fertility is often restored. Clomid is successful in inducing ovulation in about 80% of women. Ultimately, about half of these women will get pregnant.

Clomid is a tablet taken orally. It works by increasing levels of follicle stimulation hormone (FSH).

Clomid is usually started at 50 mg on day 3 or 5 of the menstrual cycle for 5 days. If this dose does not produce eggs, then the dose can be increased to 100 mg and then 150 mg.

Clomid can produce more than 1 egg per cycle (superovulation). Despite this, the success rate per cycle is 10-20%. The twinning rate is 8-10%. The triplet rate is about 1%.

In rare cases, Clomid can make too many eggs (hyperstimulation). There are times that your fertility program has to be suspended and a birth control pill used for 3 months to calm the ovaries down. Some women have been hospitalized and have had surgery to drain the ovaries when they make too many eggs.

If ovulation occurs on a dose of Clomid, there is usually no benefit in increasing the dose in a subsequent cycle. In fact, increasing the dose of Clomid could increase the side effects with no increase in successful pregnancy.

Clomid should not be used without close monitoring by your doctor or for more than 6 months. If a patient has not been able to achieve pregnancy in this time, the efficacy of Clomid may have already been maximized. Use of Clomid beyond 6 months is not associated with increased rates of pregnancy but does delay more aggressive treatment offered by a fertility specialist. This is especially important for mature women with declining ovarian function.

Clomid can produce side effects. Clomid's adverse reactions range from ovarian enlargement (too many eggs), hot flushes, abdominal discomfort and cramping, breast discomfort, nausea, vomiting, visual symptoms (blurring), headache, abnormal uterine bleeding, and multiple births. Clomid's side effects are usually transient and not severe. If you are experiencing severe or persistent abdominal pain, you should consult your doctor immediately.

We now know that over 47% of infertile couples will have a male component. Therefore, semen analysis should always be performed prior to initiating Clomid.

During your fertility treatment, please keep a detailed calendar. This calendar should include your period, days you took Clomid, ovulated, had sex, etc.

Many studies show that pregnancy is likely to result sooner when a reproductive endocrinologist is consulted. Your doctor can recommend a specialist if you would like a consultation.

Getting a call from your gynecologist saying that your Pap smear came back abnormal is terrifying, but not all abnormal Pap smear results mean that you have cervical cancer. There are a number of things that can cause your Pap smear to be abnormal.

A Pap smear can only screen for potential problems, not diagnose them, your gynecologist may want to take a closer look at your cervix to determine the cause of your abnormal Pap smear results. Your doctor will perform an examination called a colposcopy if your Pap smear results show cervical dysplasia, cervical cancer, evidence of HPV or show first-time or repeat atypical squamous cells of undetermined significance (ASCUS).

This in-office procedure takes about 10 to 15 minutes. It is typically painless or may cause mild cramping. You are in the same position as with your Pap smear and acetic acid (table vinegar) is placed on your cervix. Your physician will use a colposcope (a large, electric microscope) to view your cervix. A bright light on the end of the colposcope lets your gynecologist clearly see the cervix. During the colposcopy, the gynecologist focuses on the areas of the cervix where light does not pass through. Abnormal cervical changes are seen as white areas (the whiter the area, the worse the cervical dysplasia.

If your doctor can view the entire abnormal area through the colposcope, a tissue sample or biopsy is taken from the area or areas and sent to the lab for further evaluation. You will be asked to return back to the office in 2 weeks to discuss your results and set up your treatment plan or when you should revisit the office. Patients with abnormal Pap smears will either be advised to have repeat Pap smears every 6 months until you have 3 normal Pap smears in a row, have an out-patient procedure done at the hospital called a LEEP / CONE or if severe enough you may be advised that a hysterectomy is the best option for you.

If your provider has told you that you need to have a LEEP or CONE procedure, it’s because a Pap smear and colposcopy indicated the presence of abnormal cervical cells or cervical dysplasia.

LEEP is an acronym for the procedure’s full name: loop electrosurgical excision procedure. LEEP uses a thin wire loop electrode that is attached to an electrode that is attached to an electrosurgical generator. The generator transmits a painless electrical current that quickly cuts away the affected cervical tissue. This is one of several procedures your doctor has available to help diagnose and treat abnormal cervical cells. 

CONE is a surgical procedure where a cone-shaped tissue sample from the cervix is removed for examination. It is also known as a cervical conization. It is used to diagnose cervical cancer or to remove cancerous / precancerous tissue. Your physician will determine which procedure is best for you during surgery when he gets a clear view of the area.

Complications are usually mild but can include:

• Mild pain or discomfort
• Bleeding
• Vaginal discharge with a slight odor

You should call the office if you experience bleeding that is heavier than a normal period or if pain is severe.

For 2 weeks after the procedure you should NOT:

• Have sexual intercourse
• Lift heavy objects
• Use tampons
• Douche
• Take tub baths — showers only to prevent infections

Remember that cervical dysplasia does not mean that you have cervical cancer. However, having the abnormal area treated is important to prevent the abnormal cervical cells from developing into cervical cancer.

After your procedure, make sure to follow your doctor’s instructions precisely. Your doctor will have you return to the office in 2 weeks to make sure that the area is healing appropriately. You will then be advised to have repeat Pap smears every 6 months until you get 3 normal Pap smears in a row. It is very important to keep these follow up appointments so that we can ensure that all of the abnormal cervical tissues have been removed, as well as to make sure that any new development of abnormal cells is caught early and treated appropriately.

Urinary incontinence is the involuntary loss of urine. Some women may lose a few drops of urine while running, coughing, sneezing, etc. Others may feel a strong, sudden urge to urinate just before losing a large amount of urine. Many women experience both symptoms. It can be slightly bothersome or totally debilitating. The risk of public embarrassment keeps them from enjoying many activities with their family and friends. Urine loss can also occur during sexual activity and cause tremendous emotional distress.

Women experience this problem twice as often as men. Pregnancy and childbirth, menopause and the structure of the female urinary tract account for this difference. But both women and men can become incontinent from neurologic injury, birth defects, multiple sclerosis, and physical problems associated with aging.

Older women experience urinary incontinence more often than younger women. But incontinence is not inevitable with age. It is a medical problem. Your doctor can help find you a solution. No single treatment works for everyone, but many women can find improvement without surgery.

Stress Incontinence

If coughing, laughing, sneezing, or other movements that put pressure on the bladder cause you to leak urine, you may have stress incontinence. Physical changes resulting from pregnancy, childbirth, and menopause often cause stress incontinence. This type of incontinence is common in women and, in many cases, can be treated.

Childbirth and other events can injure the scaffolding that helps support the bladder in women. Pelvic floor muscles, the vagina, and ligaments support your bladder. If these structures weaken, your bladder can move downward, pushing slightly out of the bottom of the pelvis toward the vagina. This prevents muscles that ordinarily force the urethra shut from squeezing as tightly as they should. As a result, urine can leak into the urethra during moments of physical stress. Stress incontinence also occurs if the squeezing muscles weaken.

Stress incontinence can worsen during the week before your menstrual period. At that time, lowered estrogen levels might lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause.

Urge Incontinence

If you lose urine for no apparent reason after suddenly feeling the need or urge to urinate, you may have urge incontinence. A common cause of urge incontinence is inappropriate bladder contractions. Abnormal nerve signals might be the cause of these bladder spasms.

Urge incontinence can mean that your bladder empties during sleep, after drinking a small amount of water, or when you touch water or hear it running (as when washing dishes or hearing someone else taking a shower). Certain fluids and medications such as diuretics or emotional states such as anxiety can worsen this condition. Some medical conditions, such as hyperthyroidism and uncontrolled diabetes, can also lead to or worsen urge incontinence.

Involuntary actions of bladder muscles can occur because of damage to the nerves of the bladder, to the nervous system (spinal cord and brain), or to the muscles themselves. Multiple sclerosis, Parkinson's disease, Alzheimer's disease, stroke, and injury — including injury that occurs during surgery — all can harm bladder nerves or muscles.

Behavioral remedies: Bladder retraining and Kegel exercises.

By looking at your bladder diary, the doctor may see a pattern and suggest making it a point to use the bathroom at regularly timed intervals, a habit called timed voiding. As you gain control, you can extend the time between scheduled trips to the bathroom. Behavioral treatment also includes Kegel exercises to strengthen the muscles that help hold in urine.