When was your last visit to the doctor? Have you been screened recently for cervical cancer with the use of a pap smear. Have you spoken to a doctor regarding your concerns of irregular periods, vaginal infections or sexually transmitted infections? Do you know that breast cancer affects 1 in 8 women and there are screening tests available? Do you know your risks of ovarian cancer?
In order to maintain good reproductive and sexual health, women should visit a Gynecologist (doctor who specializes in women’s reproductive health) for an exam about once per year. Women usually begin visits to the Gynecologist at the age of 21, when they need their first pap smear. However, if a woman plans to become or is sexually active prior to the age of 21, she should visit her Gynecologist sooner. A pap smear is a test that checks for abnormal cells on the cervix. A speculum is placed into the vagina in order to visualize the cervix and a swab is taken of the cervix. The frequency of pap smears depends on a woman’s age and history.
During an annual exam, the Gynecologist asks about the woman’s sexual history, contraceptive methods, menstrual/period cycle and pelvic pain. The Gynecologist also examines the breasts, external and internal genitalia. In some women with specific concerns, the annual may include a rectal exam. These exams may cause anxiety and some discomfort but they are important to maintaining good health and the doctor will work with you to ensure that you are as comfortable as possible.
At the end of the exam, you may be referred for further testing such as blood work, a mammogram (Breast Cancer screening), a colonoscopy (Colon Cancer screening), and/or a bone density scan (evaluation for Osteoporosis).
HOW TO PREPARE FOR YOUR GYNECOLOGIC VISIT
- Schedule an appointment between menstrual periods, as blood can lead to incorrect pap smear results.
- Do not have vaginal intercourse or insert anything into the vagina for at least 24 hours before the visit. This may also lead to incorrect Pap smear results.
- Bring your menstrual calendar as the doctor will want to know how long your period lasts, and how much time is between the start of each period.
- Alert the doctor to your questions or concerns
BIRTH CONTROL COUNSELING
Are you sexaully active but not ready to have children? Have you just delivered a child but need a break before your next pregnancy? Do you simply want to decrease the blood flow of your period?
Birth control or hormonal contraception may be right for you. There are many forms of birth control available and a discussion of your birth control options does not require a sensitive pelvic exam.
Dr. Jill will want to talk with you about your medical history, whether you or your family members have any history of blood clotting disorders? Have you had any sensitivities to or unwanted side effects from hormones in the past?
Both hormonal and non-hormonal, both short and long-term options are available to you. Birth control comes in pill form that is taken daily, a patch that is placed on your skin and changed each week, a flexible vaginal ring that you can place in the vagina once/month, and an injection that you can get at Dr. Jill’s office every 3 months, often times eliminating your period. Long-term options include a small implantable rod that is placed just beneath the skin in the arm and left for approximately 3 years. 3 or 5 year hormonal intrauterine devices that Dr. Jill would insert into the uterus and even a 10 year non-hormonal intrauterine device! Schedule an appointment to learn which option is best for you.
You may be done having children, or know that you do not want to have a pregnancy in the future. Permanent birth control options may be right for you. You can have a same day surgery (laparoscopy) to get your “tubes tied” in which the fallopian tubes are blocked/“tied off”. The fallopian tubes are where the women’s egg and the male’s sperm meet; if they can’t meet, they can’t hook up.
EVALUATION AND TREATMENT OF ENDOMETRIOSIS
Do you have severe pain and cramping with your periods? Do you experience pain with sexual intercourse? Do you have nausea, vomiting, diarrhea or constipation with your periods? Do you have painful or frequent urination during your periods? Have you experienced some of these symptoms and also have had trouble getting pregnant?
You may be experiencing the symptoms of endometriosis. Endometriosis is when the tissue that makes up the inner lining of the uterus spreads outside of the uterus to lie on other organs in your body. Endometriosis can be found on the lining of your organs (peritoneum), the bladder, bowel, and other places causing scarring. The presence of endometriosis can also lead to decreased fertility. Endometriosis can also be located within the ovary causing a cyst of endometriosis (endometrioma.)
Endometriosis affects 3-10% of reproductive-aged women. The diagnosis is done by performing a laparoscopy with biopsies (a surgery performed in the Operating room where the doctor inserts a camera through the umbilicus and takes a sample of the abnormally placed tissue.) Some women may elect to try treatments first, instead of scheduling a surgery, if their symptoms and exam are suspicious for Endometriosis. These women may need surgery at a later time in order to physically remove the endometriosis “implants”.
Treatment options include:
- Non-steroidal anti-inflammatory medications (NSAIDs)- taken during your period to reduce the pain associated with endometriosis
- Hormonal medications, such as birth control pills, or Gonadotropin releasing hormone agonists (anti-estrogen medications) to reduce the pain and spread of endometriosis. There is some evidence to suggest that birth control pills decrease your risk of endometriosis.
- Elagolix (Orlissa) is a newly FDA approved oral medication used to treat moderate to severe pain from Endometriosis.
- Laparoscopic excision of endometriosis, this minimally invasive surgery both provides a diagnosis and treatment for endometriosis by removing the endometriosis “implants” through excision or burning. Surgery is also used to remove scar tissue from the abdomen and pelvis so the reproductive organs can move and function normally without causing pain. Diagnostic testing to make sure the fallopian tubes are open and not preventing pregnancy can be done during the same surgery.
- Hysterectomy with/without removal of the fallopian tubes and ovaries. This definitive surgery is performed for women who are no longer desiring child-bearing and/or have failed available treatment options.
EVALUATION AND TREATMENT OF PELVIC PAIN AND/OR PAINFUL PERIODS
Do you suffer from heavy periods and/or bleeding between your periods? Are your periods painful? Do you have to miss work or reschedule events due to “your time of the month”? Heavy vaginal bleeding should be evaluated.
If you are over 35 or have risk factors for cancer of the uterus, an evaluation may start with a pelvic exam and an in-office biopsy of the uterus. A small straw like device is inserted through the vagina into the uterus and a small amount of tissue is retrieved with suction. This tissue is sent to the laboratory for evaluation.
A pelvic ultrasound is also part of the evaluation in order to see if there are any masses within or outside of the uterus that would need to be monitored or removed.
Possible causes of abnormal uterine bleeding or heavy vaginal bleeding include:
-Uterine or cervical polyps or fibroids
-Disease of the cervix or uterine lining, non-cancerous or precancerous
-Uterine adenomyosis, where the uterine lining grows into the uterine muscle
-Marked weight gain or Obesity
-Infection of the vagina, uterus, cervix or pelvis
-Trauma to the vagina, cervix
-Medication side effects
Treatment options often include hormonal medication/ birth control or further surgical evaluation with a hysteroscope.
Hysteroscopy can also be performed in-office to further evaluate the inner uterus, to take a focused biopsy or to remove polyps. A small camera is inserted through the vagina and into the uterus. If polyps are present, often times the removal of such polyps will resolve the heavy or irregular bleeding.
Another procedure that can be performed in-office is a uterine ablation. Novasure uterine ablation is a short procedure that removes the lining of the uterus, the part of the uterus responsible for the heavy bleeding. After giving you medication to relax you and manage pain, a small wand is inserted through the vagina, into the uterus. Measurements of the uterus are taken and then a fan like device opens within the uterus. Radiofrequency energy is emitted for less than 2 minutes! The fan is then contracted and the wand is removed. For 77.7% of women, menstrual bleeding is successfully reduced or stopped within one year.
EVALUATION AND TREATMENT OF PELVIC PROLAPSE
Pelvic organ prolapse is the medical term that describes “things falling out of the vagina” The vagina becomes loose with age and/or after childbirth. The ligaments that are necessary to hold up your organs either are no longer attached or not strong enough to hold up your organs and the vaginal walls. As a result the internal pelvic organs begin to fall or produce a “bulge” coming from the vagina. This can cause pressure, pain, make it difficult to urinate or have bowel movements. This “bulge” also causes discomfort with exercise, gardening, or even walking.
Pelvic organ prolapse can take on multiple forms:
- Anterior vaginal prolapse or Cystocele: the bladder and the superior vaginal wall fall downward into the vagina and can also protrude out of the opening of the vagina. This can lead to recurrent urinary tract infections as your bladder may not empty completely, urinary incontinence/leakage of urine, urinary retention or inability to urinate, among other symptoms.
- Posterior vaginal prolapse or Rectocele: the rectum and the inferior vaginal wall fall into the vagina and can protrude out of the opening of the vagina. This makes it difficult to have a bowel movement without placing your fingers into the vagina to push in the bulge, this is called “splinting”.
- Uterine prolapse: the cervix and uterus slide down the vagina, or rarely out of the vagina. This can make sexual intercourse difficult or painful as the vagina is “blocked” by the uterus. This prolapse can also cause pressure and even low back pain.
- Vaginal vault prolapse: prolapse of the top of the vagina after hysterectomy
ThermiVa vaginal rejuvenation: Mild to moderate prolapse can be treated with ThermiVa. ThermiVa is a radiofrequency procedure performed in-office. This vaginal rejuvenation procedure tightens the vaginal tissues with the greatest results after 3 treatments spaced one month apart. During a ThermiVa treatment, a small heated wand is placed into the vagina and the tissues are massaged. External tightening of the vaginal lips (vulva) can be seen immediately.
Pessary insertion: A pessary is a soft removable device that is fitted to your vagina and is placed inside to hold up the vaginal contents. This can improve the symptoms of incontinence and pressure but does not “fix” the prolapse. Often times, women can return to their normal activities with some adjustments with the use of a pessary. The patient must be able to remove it from their vagina for cleaning and replacing or must schedule frequent visits to the gynecologist for pessary care.
Kegel exercises and pelvic floor physical therapy: When Kegel exercises are performed correctly this can lead to strengthening of the pelvic floor muscles. These muscles are important in supporting the vagina. To identify your pelvic floor muscles, stop urination mid stream. The muscles that contracted during this action are your pelvic floor muscles. Work up to contracting/tightening these muscles for 10 seconds and then relaxing the muscles for 10 seconds. Make this action 10 times and repeat 3 times per day. Some women are unable to contract their muscles on their own and may benefit from a referral to a pelvic floor physical therapist.
Surgical treatments: Aside from more extensive mesh treatments, a same day vaginal surgery can be performed to tighten the vagina by removing excess tissue and putting a sling under the urethra to help support the tube that empties the bladder, thereby resolving stress urinary incontinence. If on exam, the uterus is also following, it may be recommended that the uterus be removed as well. Often times, women are able to retain their uterus with a minimally invasive anterior and posterior vaginal repair and a repair of the perineum (the area between the vagina and the anus).
A referral to a urogynecologist or urologist may be necessary, depending on the severity of the issue.
EVALUATION OF ABNORMAL PAP SMEARS WITH COLPOSCOPY AND CERVICAL BIOPSIES
Have you received an abnormal pap smear result? Are you wondering about the next steps in evaluation or treatment?
Pap smears are performed by placing a speculum into the vagina in order to visualize your cervix. A swab is taken of just inside the cervix and evaluated in a laboratory. A human papilloma virus (HPV) test may be also performed on the specimen depending on your age. If either result is abnormal you may be advised to schedule a Colposcopy procedure.
During a colposcopy the speculum is again placed into the vagina. A vinegar solution is applied with a Qtip to the cervix to make abnormal cells more visible. Then tiny biopsies are taken of these abnormal areas, this will feel like a quick pinch. A solution called Monsel’s solution is placed on the cervix to prevent bleeding and the specimen is sent to the pathologist for diagnosis.
In the event that precancerous tissue is identified, you may be advised to have a surgical procedure called a loop electrosurgical excision procedure (LEEP). This procedure can be performed in the office and you can return home within the hour. During this procedure the portion of the cervix that contains the abnormal cells is cut away using a thin wire loop that carries an electrical current. Blood vessels are then sealed to stop bleeding and the Monsel’s solution is placed to prevent further bleeding. Prior to performing the LEEP procedure, the cervix is numbed with a Lidocaine solution. Some patients may feel more comfortable with conscious sedation (oral medications to make you relaxed and narcotic medications to decrease pain) or with IV sedation, both of which are offered and can be arranged.
EVALUATION OF FERTILITY AND TREATMENT OF INFERTILITY
EVALUATION AND TREATMENT OF URINARY INCONTINENCE
Are you afraid to laugh or cough in public because you may leak urine? Do you avoid certain exercises or activities because you may not make it to the bathroom in time? Do you have to plan out bathroom locations and times to void prior to leaving the home for an extended time?
Urinary incontinence, or the involuntary leakage of urine affects up to 40% of women over age 40 and 50% of women over age 50.
There are 3 main types of urinary incontinence:
*Stress Urinary Incontinence: leakage of urine that occurs with increased pressure on your abdomen, occurring during exercise, sneeze, cough, lifting, squatting or even laughing. A typical cause is bladder or urethral prolapse/ “fallen bladder”, urethral hypermobility and/or intrinsic sphincter deficiency. Treatment options include surgical lifting of the urethra (tube that carries the urine from the bladder to the outside) by making a single small incision in the vagina under the urethra and inserting a small piece of mesh to act as a hammock around the urethra. The hammock supports the urethra in times of stress such as with coughing or sneezing.
*Urge Urinary Incontinence: leakage of urine that is characterized by the urgent feeling that you need to urinate and being unable to get to the bathroom in time. Overactive bladder is likely the cause of Urge Urinary Incontinence, this is a problem with bladder storage. Possible treatment options include Kegel exercises, the use of a vaginal TENS unit in the privacy of your home, a referral to a pelvic floor physical therapist, or even medications.
*Mixed Urinary Incontinence: This is the most common type of urine leakage, when you have a combination of both of the above types of incontinence
A consultation with Dr. Jill will help to determine the type and cause of your Incontinence. Surgical and non-surgical options may be available to you. Dr. Jill will discuss treatment options with you and work with you to formulate a plan. ThermiVa and/or PRP regenerative therapy, done in-office, may resolve the symptoms of both types of incontinence. Ask Dr. Jill if this is an option for you.
HYSTERECTOMY (LAPAROSCOPIC, VAGINAL, ABDOMINAL)
What is a hysterectomy?
This is a surgical procedure resulting in the removal of the uterus and the cervix. A hysterectomy does not refer to the removal of the ovaries, where your female hormones are made, however this may often times also be done during the same surgery. When the fallopian tubes and ovaries are removed this is referred to as a Salpingo-oophorectomy. When the ovaries are left in place and you are not yet menopausal, your ovaries are still expected to produce your female hormones as removal of the uterus does not make you menopausal. A surgical menopause occurs when you have a hysterectomy as well as removal of your ovaries.
How is a hysterectomy performed?
This surgery can be performed by a minimally invasive approach using cameras, either laparoscopically or robotically. The uterus and/or tubes and ovaries are removed through the vagina and the vagina is stitched closed. When this surgery is performed with a minimally invasive approach, patients typically go home the same day and do not stay overnight in the hospital.
When only the uterus and cervix need to be removed and the abdomen does not need to be evaluated, a minimally-invasive vaginal surgery may be right for you. The entire surgery is done through the vagina, the uterus is removed and the vagina is closed. There is no evaluation of the abdomen or pelvis with this approach.
The final approach to hysterectomy is the abdominal approach, this is done when the uterus or a pelvic mass is too large to be removed through the vagina, the patient has scar tissue that is difficult to separate, or heavy bleeding is encountered during a minimally invasive surgery. Either a low abdominal incision (C/section incision) or a larger vertical incision is made and surgery is performed in the traditional manner. This requires a hospital stay of several days and a longer recovery period at home.
Why is a hysterectomy performed?
The most common reason a hysterectomy is performed is for uterine fibroids. Other common reasons include abnormal or heavy uterine bleeding, endometriosis, uterine prolapse, and pre-cancerous cells of the cervix. Only 10% of hysterecomies are performed for cancer.
Should I remove my fallopian tubes and/or ovaries?
Dr. Jill will ask you about your age, menopausal status, and possible history of endometriosis before giving a recommendation. Even if you decide to keep your ovaries, you may decide to remove the fallopian tubes at the time of hysterectomy as removal of the tubes will decrease your lifetime risk of ovarian cancer. Ovarian cancer can arise from the fallopian tubes in up to 25% of cases.
MINIMALLY INVASIVE PROCEDURES
Minimally invasive surgical procedures are performed instead of open invasive surgery. During minimally invasive surgery the abdomen is closed or surgery is performed locally, leading to less trauma, less scar tissue, less pain and a faster recovery. Often these procedures are done vaginally or involve the use of laparoscopic instruments. Laparoscopic visualization of the abdomen and pelvis is done using an endoscope (camera) inserted through small incisions in the skin. can often be done vaginally or involve use of laparoscopic instruments.
Minimally invasive surgery should have less operative trauma for the patient and is usually done as an out-patient/same day procedure. The procedure time is shorter, causes less pain, and less scar tissue and adhesion formation. Complications are not common and occur in only 5% of all operations.
TREATMENT OF LICHEN SCLEROSUS
Lichen Sclerosus is a skin condition that can affect many areas of the body, in the women’s health arena, this chronic skin condition affects the vaginal lips (vulva) and around the anus. It is a condition characterized by thinning skin and white patches. Most commonly, symptoms include severe itching (pruritis), painful sex, smooth white patches, easy bruising or tearing, even bleeding from these areas can occur. The exact cause is unknown but it is believed to be an auto-immune condition and hormonal imbalance may contribute to the progression. A biopsy in the office is needed to diagnose this condition. Common treatment options include the chronic use of topical steroids. However, another option without the side effects of steroid use include the injection of Platelet Rich Plasma (PRP). PRP is injected into the affected areas stimulating the growth of new normal tissue, thus eliminating the need for topical steroids. Radiofrequency can also augment the use of PRP, using ThermiVa (vaginal rejuvenation machine) the affected tissues are heated in order to further stimulate the PRP and lead to increased collagen production, the stimulation of your body’s growth factors and stem cells, and new blood vessel generation leading to healthy tissue growth.
TREATMENT OF UTERINE FIBROIDS
Do you experience painful or heavy periods? Do you have low back pain?
Do you feel like your mid section is bloated or growing? Do you urinate frequently?
Uterine fibroids, also known as uterine leiomyomas, myomas and fibromas, are the most common reason a hysterectomy is performed. Uterine fibroids are benign growths/tumors of the uterus that can grow excessively leading to pressure, urinary incontinence, constipation, pain, severe bleeding and severe anemia. A woman can also experience uterine and vaginal prolapse as the support muscles and tissues of the pelvic floor loosen due to this constant weight and pressure from fibroids. It is possible that the cervix and uterus can fall to such a degree that it protrudes through the length of the vagina and is visible outside of the vaginal opening. The cause of uterine fibroids is not clearly known, however it develops from muscle cells within the uterus multiplying rapidly due to the influence of Estrogen. Over 99% of fibroids are benign (non-cancerous) and do not turn into cancer.
Some treatment options include:
Hysterectomy– this surgery is the only definitive option for management of fibroids. Other methods may have high success rates but often times results in the regrowth of the fibroid tumors.
Uterine artery embolization (UAE) or uterine fibroid embolization– referral to the Interventional Radiologist to insert a small catheter through the leg and place blood-stopping particles in the artery that feeds the fibroid tumors. After blood flow to the fibroid is stopped, the fibroid starts to degenerate, thus decreasing in size. UAE is not routinely recommended for women wishing to retain their fertility.
GnRh agonist injections– these are anti-estrogen injections that are recommended in a monthly dosage or an every 3 month dosage. They will lower your estrogen levels and trigger a short term “medical menopause”. These medications are often used to shrink the fibroids, thereby making surgical treatment easier.
Myomectomy– surgical removal of the fibroids, done for women who plan to attempt pregnancy. This method is often associated with increased blood loss and can be associated with increased scar tissue formation post-operatively over hysterectomy.
Hysteroscopic myomectomy– this procedure is done for patients who may only have fibroids on the inside lining of the uterus and/or they want to retain their fertility. This is a minimally invasive approach that is highly successful for a specific patient population. Hysteroscopic myomectomy is a same-day, minimally-invasive surgery in which a small camera is inserted through the vagina and into the uterus to visualize the fibroid that is located on the inner lining of the uterus. The MyoSure tissue removal system is a device that is inserted to quickly remove fibroids, polyps, or other intrauterine tissue using suction without incisions.
Close monitoring– Since most fibroids stop growing or decrease in size as a woman approaches menopause, Dr. Jill may suggest close monitoring without therapeutic treatment. Dr. Jill will monitor your symptoms carefully and perform pelvic exams or ultrasounds to ensure that there are no significant developments and that the fibroids aren’t growing. This approach is most common for women that are not experiencing significant unwanted symptoms due to fibroids.