Abnormal Bleeding and What It Means

Periods can be weird.

Some women are regular as clockwork and can tell me the exact date and time of day that their periods will arrive.  Others have a range of normal, somewhere between 28 and 30 days, for example, that they mark the calendar by.  Then there are periods that don't follow the rules.  These are periods that set in with a vengeance, causing heavy bleeding never experienced before, or an "extra" period in the month, or bleeding after intercourse, or spotting with wiping.  Women end up in my office for all kinds of unusual bleeding patterns.  For women who are regular- and even those who aren't- a bout of unexpected bleeding usually causes great concern.

The reasons behind what we in gynecology call "Abnormal Uterine Bleeding" are diverse.  Whole chapters are written on how to address these issues and come to a diagnosis.  For all intents and purposes, abnormal bleeding can be broken down into three main categories:
1.  Hormonal:  The first thing we check in abnormal vaginal bleeders is a pregnancy test!  Assuming that that is negative, there can be a myriad of other hormonal causes.  Thyroid disorders cause irregular bleeding.  Hormonal imbalances such as those seen in polycystic ovarian syndrome can lead to irregular bleeding.
2.  Anatomic:  These are actual structural problems found in the pelvis.  Fibroids or polyps of the uterus and/or cervix can contribute to abnormal bleeding.  Ovarian cysts also can be a cause of abnormal bleeding.  The best way of diagnosing structural problems is with a physical exam as well as imaging via ultrasound.  To better visualize the lining of the uterus, a procedure called an SIS (saline infused sonohystogram) may be done in the office setting.  The results from ultrasound generally aid significantly in making the diagnosis.
3.  Cancer: This is the least likely category, but is a consideration based on age and risk factors.  Cervical cancer and uterine cancer can both present with abnormal bleeding.  The diagnosis is made here with a tissue biopsy, where tissue is removed from the uterus (endometrial biopsy) or cervix and sent to be examined under the microscope.  Any kind of vaginal bleeding in a postmenopausal woman warrants immediate evaluation.

There are other reasons that don't fit neatly into the categories mentioned above: sexually transmitted infections (especially Chlamydia!) or genetic bleeding disorders can lead to prolonged or unexplained bleeding.  Then there is the "we don't really know why" category.  Really- it is its own category in the medical literature!  This diagnosis should only be used when everything else has been thoroughly evaluated and come up negative.

The causes of abnormal bleeding can usually be determined with a good history and physical exam, as well as with the aid of laboratory testing and the occasional pelvic ultrasound.  So if your period goes wacky on you- get it checked out.  Actually, first take a pregnancy test and then get it checked out.  It is always good to know if there is something more going on that you should be aware of.

-Dr. Jahedi

The Affordable Care Act: What it Means for Us

For the past month, there has been a tremendous interest in the Supreme Court’s decision regarding the constitutionality of the Affordable Care Act (ACA).  As it turned out, the Supreme court upheld the law as constitutional, and we are now moving forward in shaping healthcare to uphold the law and its mandates.

To be perfectly honest, I am not sure how the ACA will affect the everyday practice of medicine- I do not think anyone can say exactly how this is going to play out.  I am hardly a legal professional, but what I can do is offer my perspective as a physician in solo private practice in trying to understand what the ACA is going to do for my practice and for my patients.  

The Good:  The ACA gets rid of health insurer’s practices of denying patients coverage based on pre-existing conditions.  Thank goodness for that!  It never made sense to me that the people who needed healthcare the most were denied coverage because they were sick.  The law also brings forward provisions that will allow most people to obtain health insurance coverage at (what we hope) will be reasonable rates.  As we are all too aware of in medicine, disaster can strike anyone at any time- indiscriminately.  For all of the griping that everyone is doing about the mandate to purchase insurance, having everyone have access to healthcare is not a bad thing.   

The ACA will increase the number of insured patients in our population, which in turn will necessitate that we have physicians that can take care of these patients.  My concerns about the ACA are almost entirely centered on the lack of medical liability reform built into the law.  Without serious attention paid to federal liability reform laws, we in Illinois will never be able to hang on to the physicians we train here, and will lose them to other states where the cost of practicing medicine is cheaper.  According to ISMIE, half of physicians who train here leave after residency; of those, two-thirds cite Illinois' liability climate as a chief reason for leaving. National projections suggest we will soon have an inadequate number of doctors to meet patient needs.  Those of us who choose to stay (because this is home, for goodness’ sake!) are left paying huge sums of cash to obtain medical liability insurance.  

Take my little practice, for example.  My biggest monthly expense is my liability insurance- more than rent, more than payroll.  And because practicing obstetrics is so expensive (to the tune of over $100,000/year just in malpractice insurance costs!), I have limited my practice to gynecology only in an effort to keep afloat.  So here you have a physician who has trained for years to practice the art and science of delivering babies and who loves doing it.  To make her small business run, she cannot continue in this practice- not because she is incapable or unwilling- but because she cannot come up with the thousands required to purchase the insurance necessary to protect herself from a legal environment that is hostile to physicians.  It is a sad commentary on healthcare in America, and why I often wish that doctors instead of lawyers were the leaders of healthcare law. 

The ACA will undoubtedly bring about some good, but I think that we physicians are watching fearfully to see where it will land us in terms of our ability to practice medicine.  That is the reality of our situation, and that is where we have some real work ahead of us.  

Optimizing Your Chances of Pregnancy

Imagine a typical scenario- a young woman who is sexually active but needs to finish school.  And then has to get a job.  And then has to find Mr. Right.  She has spent years of her life carefully taking contraception to make sure that a pregnancy doesn't happen.  Every month brings a period and a huge sigh of relief.

Then the time comes where work is good and she is settled and ready to start a family.  She stops all contraceptives and awaits what she is certain will be an immediate pregnancy.  But the months come and go and she battles disappointment with every period that arrives.  Inevitably, she ends up in my office, asking  “why am I not getting pregnant?”

While achieving pregnancy seems like a pretty basic concept,  it is easy to become frustrated by the process.  (Alternately, there are a lot of people who get pregnant easily and unexpectedly- this article is not for you!).  There are books written on this topic, and an entire medical subspecialty devoted to the art and science of helping couples get pregnant.  Every woman’s circumstance is different, and I cannot cover the hundreds of different scenarios that exist out there.  So I will review the very basics, including what I counsel my own patients about.

First and foremost, the chances of a pregnancy occurring in a given month is about 20%.  And that is assuming that the couple is young and healthy, the timing is perfect, the woman’s cycles are regular, and the man’s sperm count is normal.  Even if all of those stars are aligned, a pregnancy will occur only 20% of the time.  It is amazing that there are any babies born at all!

Patients ask me what they can do to optimize the process, and here are a few basics:
1.  Time intercourse to the time of month that you are ovulating.  If you don’t know when you are ovulating,  you can try...

2.   ...an ovulation predictor kit.  They sell these at drugstores next to the pregnancy tests.  The kit will involve you peeing on a stick, which will show lines that become progressively darker to indicate ovulation.  For what it is worth, ovulation occurs 2 weeks before menses begins.  Do a retroactive calculation for a few months.  If your cycles are regular, chances are you will ovulate on day 14 of a 28 day cycle, or day 16 of a 30 day cycle, etc.  (Day 1 is the first day of menstrual bleeding).

3.  Have a lot of sex.  This seems basic, but we all lead busy lives and sometime couples miss each other during that fertile time of month.  Aim to have sex every other day starting at day 10 until the day after ovulation occurs.  Every other day (instead of every day) will give his sperm a chance to recoup to optimal capacity, and beginning at day 10 will ensure that sperm are around the egg when it is released.  Better yet, have sex a few times a week all month long and you’ll never miss that window of opportunity!

4.  Don’t forget your prenatal vitamin.  Taking a vitamin with folic acid can help prevent neural tube defects, and starting this pre conception is ideal.

Most couples conceive within 3 months of trying, and 70% will conceive within 6 months.  As ob/gyn’s, we don’t worry about infertility until 1 year has passed (6 months if you’re older than age 35).  Why?  Because approximately 90% of couples will conceive within the first year.  So the odds are in your favor, even if it seems things are taking a while.  It is really easy to become stressed when awaiting a pregnancy, especially when it seems that everyone around you is getting pregnant easily.  Do your best to relax and have fun with the process- chances are excellent that you will end up pregnant!

-Dr. Jahedi

Birth Control that is not The Pill

As a gynecologist, I discuss birth control options with women a dozen times a day.  And I start someone on the pill at least once a week.  As a matter of fact, most patients who come to me are interested in oral contraceptives pills.  This past month, however, brought several women who specifically were looking for non-pill options.  It was in counseling these patients that I realized that a lot of women have only a vague idea of what non-pill options exist out there.  So here is the skinny on birth control that is not The Pill:

NuvaRing:  NuvaRing is a small plastic ring that is placed inside of the vagina monthly.  It works the same way as the pill, but the hormones are released from the ring slowly over the course of the month.  It stays in place for 3 weeks and is removed for the last week, which is when a period occurs.  
When I first describe NuvaRing to patients, they almost always make a face.  For some women there is an "ick" factor involved with putting the ring into their vagina.  But as I remind folks, tampons are inserted into the vagina too, and no one thinks twice about that!  
NuvaRing is great for people who can't remember to take a pill daily.  It stays in place during intercourse and isn't felt by either partner.  Most women who try NuvaRing are pleasantly surprised by how simple and easy it is to use.  Like the pill, it can be manipulated to skip cycles (just bypass the ring free week and go straight to another ring).

Intrauterine device (IUD):  IUDs are my favorite.  Why?  They are essentially foolproof.  Almost all forms of birth control work really well...if used properly.  Condoms, as a matter of fact, are 98% effective at preventing pregnancy if used consistently and correctly.  The average person, however, does not use birth control consistently and correctly.  People forget to take pills, put in rings, show up for injections or use condoms.  They just don't.
That is the beauty of the IUD.  It is a small device that is placed inside of the uterus by a physician in what amounts to a 5 minute office procedure.  One type of IUD is hormonal and lasts for 5 years.  The other is completely non-hormonal (made of copper) and is good for 10 years.  Viola!  You're covered.  No trips to the pharmacy, no refills on the pill pack, no hassle.  And should you decide to get pregnant, the IUD can be pulled out at any time and fertility returns.
IUDs are safe to use in any woman, and are seeing a renewed popularity these days.  They are long lasting reversible forms of contraception, which is what most people are looking for.  Among my ob/gyn colleagues, IUDs rank highest in personal use!

Implanon:  Implanon is the new contraceptive implant that is placed just under the skin of a woman's upper arm.  It is reversible and lasts for up to three years. The procedure to insert it is quick, and a local anesthetic is given to the skin of the arm to minimize discomfort with the insertion.  I don't use Implanon as much as IUDs, because it tends to cause irregular and unpredictable bleeding.

DepoProvera:  aka "the shot".  This injection is given every 3 months.  It works well, but has the hassle factor of having to come in to the clinic every 3 months, as well as a prolonged return to fertility once the injections are stopped.  A few years ago, there was concern raised that it causes bone loss which may or may not be reversible.  And it causes weight gain in a majority of patients.  Enough said.

Condoms:  The good old condom may be the easiest form of non hormonal contraception out there.  It is relatively inexpensive, does not require a doctor's visit or a prescription, and has a high efficacy rate when used correctly.  It also offers what no other method can: protection against sexually transmitted infections!  Alas, the condom is often misused (or not used), which leads into a common joke among doctors.
Q: What do you call people who use condoms?
A: Parents.

There are a handful of other options that I have not reviewed: patches, diaphragms, cervical caps, sponges, spermicides and the rhythm method (to name a few).  And then there are the surgical options: tubal ligations and vasectomy.  The bottom line is that birth control has to be matched to the individual and the lifestyle, and each person's situation and needs are different.  Talk to your doctor about what will work best for you.  And know that there are lots of great options out there that are not The Pill.

-Dr. Jahedi

HPV 101: Why you have a Pap smear and what it means

I have had the HPV conversation with a lot of women in my office this month- as pap smear after pap smear has come back abnormal and we move to the necessary steps of follow up.  My patients are mostly young women, and my discussion of HPV (human papillomavirus) is usually the first time that they are really learning about this little virus.  I am always surprised at how little women know about why we do Paps and how abnormal results can affect them.  So here is a primer for Pap smears and HPV- with a little history thrown in!

The cervix is the opening to the uterus, and is found at the very top of the vagina.  Back in the day, cervical cancer was the leading cause of death in women, and no one knew why, or how to test for it.  Enter Dr. Georgios Papanicolau, who in 1923 was doing research on female guinea pigs and studying vaginal fluid to try to better understand the menstrual cycle.  As chance would have it, one of his guinea pigs had uterine cancer and he realized that he could plainly see the abnormal cells under the microscope.  It was an "a-ha!" moment for Dr. Papanicolau and a breakthrough in what ultimately became known as the Pap smear.  Cells are obtained from a woman's cervix with a brush and studied under the microscope.  Abnormal cells signal precancerous changes that can then be treated, thus preventing cervical cancer!

So what happened?  Women starting seeing their doctors for annual pap smears, and cervical cancer rates dropped drastically- it was a public health success of tremendous proportions.  But the cause of these cellular abnormalities was still a mystery.  Then in 1976, German virologist Harald zur Hausen proposed that HPV was the cause of cervical cancer.  As is often the case with important scientific discoveries, no one believed him, and he went on to prove his theory in 1983 with the discovery of HPV DNA in cervical cancer tumors.  For this important work, he received the Nobel Prize in 2008.

Now we know: HPV is the cause of abnormal pap smears.

When you have a pap that comes back abnormal, it is because of HPV.  So how does someone get HPV anyway?  It is sexually transmitted.  As a matter of fact, HPV is the number one sexually transmitted infection out there.  The prevalence is high- it is estimated that between 75-80% of Americans have been exposed to HPV at some point in their lifetime.  That means 8 out of 10 people walking around have (or have had) HPV!

Patients ask me all of the time what they can do to prevent getting it, and the answer gets tricky.  HPV is small enough that even condoms don’t protect you entirely.  The key would be not to have intercourse with anyone who has already been exposed- but how can you tell if someone has been exposed?  While men certainly carry this virus, most never know that they have it, because it does not cause any symptoms at all.  And it is not something that they are ever tested for,  so when someone tells you that they have "been tested for everything", it usually does not include HPV.  In most men (except for the HPV strains that cause genital warts), it does nothing.  In women, it can cause cervical cancer.  It is an inherently unfair setup!

I tell my patients not to stress about an abnormal pap smear, even if it means that they have been exposed to HPV.  So have 8 out of 10 people out there!  It is so common that I hate to give it the stigma of an std.  It is something that people live with, and that their immune systems fight successfully every day.  Keep on top of your pap smears and follow ups, and HPV won't interfere too much with your life.

For our younger generation of daughters, consider the HPV vaccine.  Once HPV was definitively linked to cervical cancer, the scientific world raced to develop a vaccine, and Gardasil was introduced in 2006. In 2009, it was approved by the FDA for young boys as well, since they are carriers of the virus and transmit it to women.  It has been safely given to thousands of young women and men, with the understanding that it is most effective BEFORE the onset of sexual activity, and hence before exposure to HPV.  This vaccine is the newest tool in our evolving fight against abnormal pap smears and cervical disease in women.

Dr. Papanicolau would have been proud.

Love Your Heart...and Know Your Numbers

February came and went, and there were hearts everywhere...pink ones, red ones and my personal favorite- heart shaped boxes filled with chocolate!  I encourage every woman who walks into my office to take a moment to love her own heart.  Yes, I'm talking about the flesh and blood heart that is beating away in your chest.  This heart has faithfully served you since you were a wee embryo, and continues to beat tirelessly day in and day out, asking little in return.

The human heart beats at an average rate of 70 beats every minute.  Think of it...that's 4,200 beats in one hour...and over 100,000 beats a day! In one year, your heart beats 36,792,000 times.  When you actually think about it, those numbers are tremendous.  This fantastic organ keeps life's blood flowing through your veins, and deserves a moment of recognition.  What can you do to keep your heart healthy?

• Exercise!  The benefits of exercise on heart health have been solidly proven.  I could write a book about the various types of exercise and how to get started, but that is a different story for a different day.  I usually counsel my patients to walk.  Its cheap, it works and it has the lowest dropout rate of any exercise regimen.  If you have a gym membership, then walk the treadmill 30 minutes a day at least 3 days/week.  If not, then walk at the mall.  Walk at home.  Walk around the neighborhood.  Take the dog for a walk.  In short, walking works.  There is a great website: startwalkingnow.org that can help you get started.
• Eat right.  Sure, we have heard this one over and over.  And god only knows that I am as guilty as anyone else of ordering takeout for dinner at the end of a long day (isn't every day a long day?).  Our culture of eating out is making us fat, and in turn, destroying our hearts.  I try to practice what I preach, and I really do believe that with some minimal effort, healthy meals can be made at home.  It is a mindset.  To help you get started, the American Heart Association has a website www.heart.org, with a Nutrition Center link that will help guide you.
• Stop smoking.  This is a no brainer- but awfully hard to do.  Tobacco causes real physical dependance by actually creating nicotine receptors on cells in the body.  The average smoker tries to quit several times before actually succeeding.  To stop smoking, you have to make a mental decision to do so.  And once you do, your doctor can provide you with tools to help beat that dependance on tobacco.  Just ask us for guidance- we are here to provide it!
• Have your cholesterol checked.  And get to know your numbers!  Cholesterol screening is recommended once every 5 years for everyone over the age of 20.  Have you had your cholesterol checked?  You'll remember having it done, because it is a fasting blood test, which means that you couldn't have anything to eat or drink overnight before your blood was drawn.  There are a lot of numbers in cholesterol screening, but here I have boiled it down to the very basics.  
• LDL is bad cholesterol. You want to have levels under 100.  
• HDL is good cholesterol.  Aim for levels above 60.
• Your total cholesterol should come out less than 200.
• Triglycerides, which are another measure of heart health, should measure less than 150.

I have multiple patients a day who walk into my office worried about their risk for breast cancer.  I have yet to have anyone ask me about their heart- despite the fact that heart disease is the number one killer of women.  More women die of heart disease per year than all types of cancer, including breast cancer.  So make an effort to change your lifestyle a bit, know your cholesterol screening numbers and take good care of your heart!  In turn, it will take good care of you.

-Dr. Jahedi

New Year's Resolutions: The Annual Exam and Why You Should Get One

Attention to health is life's greatest hindrance.
~Plato


Ah, the New Year.  This is the time of year when everyone looks at life anew, measuring and marking accomplishments of the year past and new goals for the year to come.  It is no surprise that they sell more exercise equipment and gym memberships at this time of year than any other!  We all want to start the new year on the right foot, and that means new year's resolutions across the board.

As a physician whose specialty revolves around taking care of only women, I am continually amazed at how much women accomplish on a daily basis.  Women are the backbones of their families, and they keep everyone on track, from making sure that kids get to appointments/school/practice on time to doing the family's shopping and getting dinner on the table to keeping the house in some semblance of order.  And the majority work outside of the home to boot!  Since becoming a mom myself, I am beginning to realize how women do all of this....they don't sleep much.  But they know that if they don't take care of things- things may very well not get done.

This is why I am not surprised when women tend to ignore their own health needs.  After all, there are only so many hours in a day, and most women will address the needs of their family members before their own.  Every person has to reach their own balance in life, and there are some things that women are going to sacrifice for their families.  That is just the reality of it.

The annual exam to your doctor should not be one of those things.  Why?  Because the only way that you are going to be around to keep your family running is if you take a moment to address your own health.  This doesn't have to be a long and drawn out affair- we are talking simple prevention!  When Benjamin Franklin said that an ounce of prevention is worth a pound of cure- he really was on to something.

The annual exam comes in different shapes and forms and can be done with a variety of doctors: family medicine doctors, internists and one near and dear to my heart- your gynecologist!  What does this involve, you ask?  Every speciality does things a little differently, but the principles are all the same.  Most exams involve a head to toe physical- the kind where they listen to your heart and press on your belly- in addition to some conversation about your lifestyle.

• What are your health habits?  Do you have good nutrition in your busy life?  Do you get out and get moving every once in a while?
• When was your last lipid screen?  This simple blood test can detect high cholesterol levels that could otherwise negatively impact your future health in a big way (we're talking early heart disease and stroke!).  Catch this early and you can make changes that can literally save your life.  It's a big deal.
• Are you up to date on immunizations?  Many people do not realize that simple, preventable diseases- like whooping cough- are making a comeback in the United States today.  This is because folks don't up to date on their immunizations.  Immunization is singlehandedly one of the best prevention techniques out there.  Other vaccines, such as the HPV vaccine, can actually help prevent some cervical cancers.
• Speaking of cervical cancer, when was your last Pap smear?  Most women get one annually, although this can be spaced out to every three years if you have had negative HPV testing.  HPV is a pesky little virus that causes big problems like cervical cancer.  The bad news?  Over 75% of the population has been exposed to some form of HPV.  The good news?  A pap smear can detect precancerous changes in your cervix- so get one!  Pap smears save lives.
• If you are over the age of 40, mammograms become a part of your prevention arsenal.  No one said they were pleasant, but newer technologies have made them less uncomfortable than they were previously, and mammograms can detect early breast cancers.  I will repeat:  mammograms detect breast cancer!  Why would you not want to detect breast cancer if you can help it?
• If you are over the age of 50, then a colonoscopy becomes a must.  I have had patients come up with really creative excuses not to get a colonoscopy.  Don't get creative- just get your colonoscopy done already.  The reasons are simple: colonoscopies detect colon cancer, and colon cancer kills people.  Enough said.  The bad news?  You have to clean out your colon beforehand and have a camera up your butt during the procedure. The good news?  They put you under for it and you won't remember a thing.  The best news?  You only have to have it done once every ten years- and it could very well save your life.      
• What is your family history?  Do you have a strong history of a certain illness that runs through your relations?  There is a genetic component to some diseases such as breast&ovarian cancers, colon cancers, early heart disease/stroke, etc.  The doctor at your annual exam will take the time to review this with you as well, and direct you accordingly.

I always tell my patients: there are a lot of things in life that you have no control over- like getting into a car accident for example.  As a physician, there are a lot of things that I don't have control over- I won't be able to prevent you from getting leukemia, or kidney failure, or brain cancer.  In medicine, we have the ability to prevent only a handful of conditions- that's it.  And those things are listed above.  Since these are the things that you do have some control over, exercise that control and take a minute to address your health this new year.

As women, we want to be there for our families- that is a top priority for so many of us.  And I can certainly appreciate how busy life gets- god only knows my own life is chaotic most days.  But think of the big picture.  How are you going to get little Johnny to soccer practice if you are recovering from surgery for an abnormal Pap smear?  It will definitely be harder to get dinner on the table if you are battling a breast cancer that a simple mammogram could have picked up.  In the grand scheme of things, the complex life that you lead (not to mention all of the lives that revolve around you) will run even more smoothly if you are a happy, healthy captain at the helm.

So go ahead and put yourself on the books for your annual exam- and then begin the task of convincing your significant other to go as well (we all know that is the harder thing to do!).  As the caretaker of your family, you owe it to yourself to be taken care of as well.
Best wishes for a happy holiday and a healthy new year ahead!
-Dr. Jahedi