The Interesting Enigma of Endometriosis

I see women who have painful cycles all of the time.  Most are controlled with over the counter medications or some degree of rest, and after ruling out other causes of pelvic pain (ovarian cysts, for example) I can start my patients on pain medications or hormonal contraceptives that significantly improve their pain.  That’s the norm.  Every once in a while, however, I come across a patient who has REALLY awful pain with cycles.

I recently saw a young woman, in her early 20‘s, who came to see me with complaints of periods that were so painful that she was unable to get out of bed for the first 2 days of her cycle.  She would load up on prescription pain medication, call off of work and literally lie curled up in a fetal position with hot compresses on her belly to try to ride it out.  Some months she could.  Other months she would end up in the emergency room needing stronger pain medications.  She was frustrated and angry at the course of these progressively worsening periods, and by the fact that every ultrasound she had showed normal anatomy.  The pain was disruptive to her work schedule and her relationship.  She had pain with intercourse.  She had pain with bowel movements.  In short, it sounded like endometriosis.

Endometriosis is best described as a condition where the normal lining of the uterus (the kind that comes out of the vagina every month as menstrual blood) ends up lining the pelvis and abdominal cavity.  There are a variety of theories as to how it manages to do this, but the take home lesson is that this tissue is stimulated every month by the hormones of the menstrual cycle.  It “bleeds” into the pelvis, causing inflammation and scar tissue formation.  That is why the treatment to endometriosis almost always involves suppression of these female hormones.  This can happen via any form of hormonal birth control, or an injection medication called Lupron.  This is also the reason that endometriosis can often cause infertility, through scarring of the fallopian tubes.

I always stress to my patients that I can only clinically assume that they have endometriosis.  The definitive diagnosis can only be made surgically.  We ob/gyns do not take every person with painful cycles who we think has endometriosis to the operating room just to confirm our diagnosis.  Rather, we treat as though it is endometriosis, and if things improve, that can confirm our suspicions.  The key to treatment is to minimize the number of cycles that occur.

Every so often, a patient has to be taken to surgery for a suspected endometrioma (ovarian cyst filled with endometriosis tissue) or for pain that doesn’t resolve with medical treatment.  Endometriosis can surgically be removed.  And this is where things can get really strange.  In residency, the mantra that was often repeated to us regarding endometriosis was that the extent of pain does not predict the extent of disease.  I have seen patients with debilitating pain taken to the operating room and when upon entering the abdomen, we were hard pressed to find 2 or 3 spots of endometriosis.  Then again, there are patients who are having no pain whatsoever who end up in surgery for often unrelated reasons and their pelvis is plastered end to end with endometriosis.  It is a medical enigma, no doubt.

For women who have endometriosis, the reproductive years can be challenging.  The only definitive treatment is not just hysterectomy, but removal of both ovaries as well, since the ovaries are the source of the hormones of the menstrual cycle.  This is not a feasible option for most, because ovaries provide a host of important and necessary functions, especially in younger women.  That leaves us with hormonal medical management and surgical management when needed, at least until we understand more about this disease.

Genetic Testing for Breast and Ovarian Cancer

Angelina Jolie did the medical world and women all over quite a service by stepping forward last month and shining a spotlight on BRCA status and testing.  She revealed that she is a carrier of the BRCA gene, and that she had undergone a complete bilateral mastectomy.  For those who are not yet familiar, the BRCA gene stands for “BReast CAncer” and encompasses a hereditary genetic mutation that is passed down through families.

If someone is a carrier of the BRCA gene, it increases their odds of getting breast and ovarian cancer in their lifetime.  Angelina was tested because her mother died of ovarian cancer, and her aunt had (and subsequently died from) breast cancer as well.  There are 2 types of BRCA genes that can be tested: BRCA1 and BRCA2.  Each one changes the odds a bit numerically, but the increased risk of breast and ovarian cancer over a lifetime remains.  Generally speaking, the risk of breast cancer in someone who carries the BRCA gene is 5 times that of the normal population, and the risk of ovarian cancer is 10-30 times higher.

Despite this, the rate of BRCA mutations in the general population is pretty uncommon, and these genes account for about 5-10% of breast cancer cases in women.  If you have a family history of breast and ovarian cancer, it may be worthwhile to see a genetic counselor and determine your risk for carrying this gene.  It can be tested by a simple (but expensive!) blood test, which could potentially be lifesaving.

As a diagnosis, it is a difficult one to know about.  There are young women in my practice who know that they are carriers of BRCA, and it puts tremendous pressure on them to have their families early so that the ovaries can be surgically removed before the age of 40.  Not to mention having both breasts removed is a difficult decision for any woman.  Each person’s clinical, social and emotional circumstances are different, so the decision to move forward with surgical treatment should be tailored to the individual.

Despite the fact that carrying this gene is very uncommon, the media attention surrounding Jolie’s announcement of her BRCA carrier status is a welcome one in increasing awareness of breast and ovarian cancer for everyone.

How To Protect Your Kids Against HPV

As a gynecologist who takes care of a fair number of teenage patients, I sometimes find myself walking a fine line between patient privacy and parental information.  For example, I saw a young woman the other day who had recently become sexually active.  She had convinced her mother to bring her to me because she had painful cycles and wanted to control them with hormonal contraception.  The issue was twofold, of course.  She wanted the birth control pills because she wanted to protect against pregnancy as well.

We talked about the pill and about safe sex practices.  I gave her my speech about always using condoms.  I talked to her about Plan B, in case the condom broke or she forgot her pills or whatever else happens.  I talked to her about trying to talk to her parents about this (“Are you kidding?”  she tells me.  “They would die!”).  I reassured her that they wouldn’t.  I also talked to her about Gardasil, which is the HPV vaccine.  She was definitely interested in getting it, but knew that her mom was not in support of this.

Since Mom carried the insurance and needed to be in the know, I brought her into the room so we could discuss.  Mom was vehemently opposed, to say the least.  She informed me that the vaccine was not out long enough to be safe, and who knew what long term consequences it may have?  She did not want to impair her daughter’s ability to have children one day.  Plus, she told me, that vaccine is for girls who are having sex, and "my daughter isn’t doing any of that stuff".  She looks over at her daughter, who nods in agreement.  I just had to shake my head in disbelief.

Myth #1:  Gardasil is unsafe because it has not been out long enough, and has not been well studied.  (Myth debunked: Gardasil was released in 2006 after extensive study, and has since been shown through millions of doses administered that it is just as safe as any other vaccine out there.)

Myth #2:  Gardasil can make you infertile. (Myth debunked:  Immunity to HPV will never make you infertile.)

Myth #3:  Gardasil is for women who are already having sex. (Myth debunked: Gardasil is ideally for girls who haven’t become sexually active yet!  The whole goal is to give you immunity before you are exposed to it through sexual activity.)

Sadly, there are a lot of parents out there who are hesitant about this vaccine.  April’s issue of Pediatrics has some interesting numbers.  The percentage of parents who said they did not intend to vaccinate their daughters against HPV in the next 12 months went from 40% in 2008 to 41% in 2009 to 44% in 2010, even as parents said physicians were increasing their recommendations to get the shot.  Why wouldn’t parents vaccinate their daughters? 9% said it was not recommended; 17% said it was not needed/not necessary; 16% cited safety concerns/side effects; 11% said it was because their daughter was not sexually active.

HPV is a small virus that is sexually transmitted that causes cervical cancer in women and a variety of unpleasant things like genital warts in men and women.  It also plays a role in anal and oropharyngeal cancers.  85% of people in this country have had some exposure to it.  Given all of that, wouldn’t it be nice to have some immunity to it, especially before your first exposure?

I talked myself blue to try to get my patient’s mother to come around, and she finally did, although her rationale was a little skewed.  Her daughter was going to remain a virgin until marriage (Okay, fine- whatever).  The person she married, she conceded, may not be a virgin.  So it would be okay to protect her daughter against the HPV that her future husband may potentially give her one day.  Good grief.

The FDA has approved Gardasil for both boys and girls.  Pediatrician’s offices carry it, as do family medicine offices and ob/gyn offices.  Ask about it.  If you have the opportunity, vaccinate your kids.  They will thank you for it down the line, and we will be one step closer to decreasing the problems that HPV causes worldwide.

-Dr. Jahedi

Why (and How) You Should Stop Smoking Now

Last month, a very near and dear member of my family was diagnosed with lung cancer.  The diagnosis was devastating to our family, of course, as was the stress of the subsequent lung surgery and recovery.  My family member was a longtime smoker in her youth, who quit over a decade ago.  I had the conversation with her about smoking for so many years of her life, and she said “I never thought that I would be the one to get lung cancer”.

It brought to the front of my mind the importance of trying to convince the smokers in my practice to quit.  I counsel every patient who is a smoker to stop smoking, almost as a matter of routine.  Most of my patients are young women, and there is a disconnect for a lot of young people that this habit directly results in lung cancer later in life.  There is no doubt that it does.  So quit already!

As I tell my patients, I can wax poetic about the reasons that you should stop smoking, but YOU are the only one who can make that decision.  Until you do, there is little that I can do to help you other than quote scary statistics about how smoking:
-causes lung cancer, which is the number one cause of cancer deaths in the US today
-causes heart disease by damaging the arteries in your body
-has a direct correlation to abnormal pap smears, as the nicotine in cigarettes can be found in cervical secretions, impairing your body’s ability to fight HPV
-etc, etc.

If the medical stuff doesn’t bother you, then there are the untoward cosmetic effects:
-bad breath and smelly clothes
-yellow teeth
-wrinkles! (enough said.)

Once you have made the decision to stop smoking, your doctor can help you.  There are a variety of methods smokers use to quit successfully, including:
-nicotine replacement patches, gum or inhalers
-antidepressant medications that help decrease cravings
-acupuncture and alternative therapies

The most important thing to remember if you are trying to stop smoking is that it takes most smokers multiple tries to kick the habit.  Nicotine is highly addictive, and there is a real physical dependence that develops from its use.  Don’t become discouraged.  I have found that smokers who are trying to quit while living with another smoker (usually a spouse) have the hardest time, because cigarettes are so readily available to them.  Keep trying, and try to get your significant other on board too.

Dr Richard Hurt, director of the Nicotine Dependence Center at the Mayo Clinic put it best when he said “This is only product that I know on the face of the Earth which, if it is used as recommended by manufacturer, kills 60 percent of its customers." 

Now that’s reason to quit.

Top 3 Reasons to Get a Flu Shot

Well, it’s official.  The flu has now spread across all 50 states, and by all accounts, this year’s flu season is turning out to be a bad one.  Despite the overwhelming numbers of people that have become sick with this virus, I still can’t convince some folks to get a flu shot!  Reasons vary depending on the individual, and I have heard everything from “It doesn’t work for me” to “I hate needles” and my all time favorite “I get the flu every year that I get the flu shot- it’s pointless!”.  Please allow me to review some reasons that the flu shot would be a good idea for you:

1.  You presumably love your relatives and friends.  While you may decide that you are immune to the flu or don’t believe in vaccines or would rather suffer with it, take a moment to consider those people in your life (and I’m sure that there are some!) who do not have your immune capacity.  This includes all children (especially under the age of 5), pregnant women, and people 65 years and older.  Surely you must know someone in the categories listed above?  If so, your lack of vaccination means that you are quite possibly carrying and spreading those germs to people who cannot recover from them the way you can.  What may be a simple flu to you could land a baby or a pregnant woman in the ICU fighting for their lives.  There are people nationwide who have lost that battle this year.  Don’t let your relatives and friends be part of that statistic.

2.  You don’t have to miss work to get this vaccine.  People tell me that they are busy working and don’t have the time to go to the doctor for a flu shot.  Good news!  You can get this vaccine at practically every street corner in America.  Most drugstores (Walgreens, CVS, Osco, Target, Costco, etc.) have care clinics that house health care personnel that can vaccinate you.  These pharmacies are open late into the evening hours and they all accept medical insurance, so stop by after work and get a flu shot.  If you don’t have health insurance, the vaccine costs about $20.  That’s not a bad deal, considering how much the cold medicine to treat the flu would end up costing you (and not to mention how much work you would have to miss if you’re home with the flu).

3.  This year’s vaccine is a pretty good match for the flu virus.  Every year, scientists develop the flu vaccine based on what strains of influenza they think will be prevalent that flu season.  Some years have a better match than others.  This year’s flu vaccine is spot on!  The flu shot will reduce your chances of getting influenza by 60-80%, and if you do get the flu, it will likely be a less severe case.

So stop taking chances with your own health, not to mention the health of those surrounding you.  Make sure that you are healthy enough to go to work and that your kids are healthy enough to go to school.  Rest assured that the vaccine this year is a good one.  Get your flu shot- you will be glad that you did.

-Dr. Jahedi

Violence Against Women

The country of India is up in arms over the recent gang rape of a young woman on a public bus.  She was assaulted with a metal rod and beaten, left for dead on the side of the road.  She did, in fact, die 2 weeks later of injuries sustained during the attack.  She has brought renewed vigor to a national conversation about the violence against women that is prevalent in Indian society.  Women- and men- across the globe mourn the loss of a promising young life and the violent way in which it was taken.

We in the United States do not have to look so far from home to see that similar violence toward women is present in our own society.  It is, in fact, present in every human society on this planet.  It is unique in that it crosses all age groups, socioeconomic classes and geographies across the globe.  

The statistics, when you examine them, are alarming.[1,2]
- Every 9 seconds in the US a woman is assaulted or beaten.
- Around the world, at least one in every three women has been beaten, coerced into sex or otherwise abused during her lifetime. Most often, the abuser is a member of her own family.
- The costs of intimate partner violence in the US alone exceed $5.8 billion per year: $4.1 billion are for direct medical and health care services, while productivity losses account for nearly $1.8 billion.
- 1 in 5 women will be the victim of a sexual assault while in college
- 1 in 10 teens will be hurt on purpose by someone who they are dating
- Studies suggest that up to 10 million children witness some form of domestic violence annually.
- Men who as children witnessed their parents’ domestic violence were twice as likely to abuse their own wives than sons of nonviolent parents.

What can we do about this? 
1.  As parents, talk to your adolescent and teen children.  Discuss the prevalence of this issue and the fact that abuse in any relationship is not okay.
2.  Know the warning signs.  There is a great website: www.loveisnotabuse.com that reviews common signs.
3.  Talk to your health care provider.  Often times a health care provider’s office is the safest place to discuss concerns.  We will not judge you and will maintain absolute confidentiality.

Violence against women, domestic violence included, is a problem that is multifaceted in its reasons for occurrence, and thus one that is not easily solved.  Non tolerance of violence against women should be the standard of every citizen of our country- and indeed our world. 

-Dr. Jahedi

1. http://www.whitehouse.gov/1is2many
2. http://domesticviolencestatistics.org/domestic-violence-statistics/

My Lessons of the Year

I started my small gynecology practice in January 2012- almost one year ago.  With the holidays and new year approaching, I cannot help but reflect on the lessons that the year has brought me- both personally and professionally.  Opportunity and challenge seem to come knocking together most days, but the risks- and rewards- have been worthwhile.  I hope that these top 5 lessons of my year can be applied to your lives as well.

1.  Take big projects and break them down- then tackle each one day at a time.
My business made it through its first year...successfully!  For me, this is a tremendous accomplishment.  Last year at this time, I was trying to sort through the thousand details that opening up a medical practice requires.  It was overwhelming, it was expensive and it was scary.  It is easier to take a big task and break it down into smaller tasks.  It is also important to stay organized!  Done in small increments, the big task can be accomplished well.

2.  When you don’t know how to do something, find someone who can.
I don’t know much about accounting, or calculating payroll, or building a website, or the fine details of medical billing.  So I found people that I liked and trusted, and relied on their expertise to guide me.  I read a lot- and continue to read a lot- about these topics, so that I can stay on top of my game.  You are not going to know everything about everything- so trust others to help you.

3.  Running my practice is easier than running after my one year old.  
This one really caught me off guard!  People did tell me that being at work is easier than being at home, but it took this year for me to believe them.  There is an ever elusive work-life balance that we are all searching for, and then there is my rambunctious daughter.  Let me just say that I have a tremendous respect for women who are stay at home moms- there is nothing easy about it!  Let us stop the mommy wars and respect women on both sides of the front.

4.  Use your time creatively.  
I joke around that I put the practice together while my daughter was taking her naps.  (Seriously though, I did.)  As it stands now, I still do all of my administrative work from home when she is napping.  I return phone calls with lab test results, pay bills, work on charting.  This is not how most doctors do it, but this is what works for me.  It allows me to spend time with her and still do what I need to do for the practice.  As long as the work gets done well, the methodology behind it can be creative.

5.  Women are amazing- we should learn from each other.
I exclusively take care of women given my medical specialty, and they never fail to amaze me.  I have learned so much from my patients this year.  I am invariably drawn in to their life stories and the overcoming of obstacles that each woman does in her own right.  Women are incredibly strong and resilient people, and have so much to learn from each other.  Our diversity is our strength.

May your holidays be happy and the new year ahead bring us all joy, scholarship, success and most importantly, good health!  

-Dr. Jahedi