Providing Exceptional Care On Your Terms

There are many different ways to manage irregular, heavy and/or frequent periods. The initial evaluation often includes lab work and an ultrasound of the uterus and ovaries to try and determine the cause of the bleeding irregularity. Frequent problems we encounter are fibroids, polyps, thyroid dysfunction or hormone imbalance. Sometimes we are unable to determine the cause of the bleeding. Treatments depend on the findings during the evaluation but can include correcting a thyroid issue or removing a uterine polyp. Fibroids can be treated with medication, minor surgery or major surgery. Hormonal imbalance can be treated with hormones or surgery. The medications most frequently offered include birth control pills, progesterone IUDs, or Lysteda (nonhormonal). Surgical options offered
could be a uterine ablation (like Minerva Tm) or myomectomy (removal of fibroid). Hysterectomy is also an option. This can involve conservation or removal of ovaries – removing both ovaries results in surgical menopause, so we often leave at least one. Although a major surgery, there are several types of hysterectomy: open/abdominal, vaginal, laparoscopic, or robotic. Each one involves a different recovery time, from as short as 10 days up to 6 weeks. The decision of what type of treatment depends not only on the clinical situation, but also on the patient’s needs and preferences.

There are so many types of contraception available to women today, it’s hard to know what will serve you best. We often use hormones to prevent ovulation, but there are non-hormonal methods as well.

Long Acting Reversible Contraception:

• Hormonal IUD- Mirena, Kyleena, and Liletta – these IUDs are >99% effective and last for up to 7 years. They are placed in the office, and have to be removed by your doctor as well. Return to fertility is immediate once the IUD is removed. Since IUDs do not change ovarian function, they have limited hormonal side effects.
• Nonhormonal IUD – Paragard – >99% effective and lasts up to 10 years. There are no hormones, so no hormonal side effects, but periods can be a bit heavier and/or more crampy with this contraceptive.
• Nexplanon – this small plastic rod is inserted just under the skin of your inner arm by your doctor. It is >99% effective and lasts up to 3 years. This device contains only progesterone and prevents ovulation. It does not regulate periods, though, so the most common side effect is irregular bleeding, which can last the first 3-6 months of use.

Short Acting Contraceptives:

• Combined hormonal contraception – vaginal ring, pills, patch – containing both estrogen and progesterone, these methods stop ovulation and regulate menstrual cycles. They are >90% effective, but depend on proper use. These all contain similar hormones but vary in how the hormones are introduced into your body. The vaginal ring is placed in the vagina and releases the hormones slowly over 3 weeks. There is also a newer ring that will last for a full year, eliminating the need to pick up a prescription every 1-3 months. The patch is applied to skin like a band-aid and needs to be changed each week. The most familiar form, birth control pills, are taken daily, preferably during the same hour of the day.
• Minipills – these pills contain only progesterone and are often taken by new moms who are breastfeeding.
• Depo-Provera – this injectable contraceptive is given every 12 weeks in your doctor’s office. It only contains progesterone and does not regulate periods. Irregular bleeding is the most common side effect, but 75% of women will stop having periods after the first 6 months. It is very effective, but has been associated with increased risk of depression and weight gain.
• Barrier methods include condoms and diaphragms. These have the benefit of being hormone free, but their effectiveness depends completely on proper and timely use.

For some women, the path to pregnancy and a baby can be confusing and frustrating. They see their friends get pregnant in 2 or 3 months, read countless birth announcements on Facebook, or attend baby showers for friends and family, all while their heart aches for a baby of their own. It is important to know what is normal in the realm of human fertility. In a couple with no medical problems or infertility issues, it can take 12 months to conceive. In fact, for couples in their 20’s and early 30’s, 90% will conceive in the first 12 months of trying. Of the remaining 10%, only a small percentage will need fertility treatments to get pregnant. As we age, our chances of successful pregnancy decrease, but not abruptly. If you are under age 35 and have been trying to get pregnant for 12 months or if you are 35 years or older and have been trying for 6 months without a pregnancy, consider seeing your doctor for a basic evaluation. If you are in your early 30’s and have not found your life partner yet or are simply not ready to have a child, ask your doctor about oocyte cryopreservation (or egg freezing) options to maximize your chances of a healthy baby when the time is right.

For patients who are finished with childbearing, permanent sterilization eliminates the need for further contraception and the fear of an unwanted or unexpected pregnancy. Women can have a tubal ligation or “have their tubes tied”. This procedure is done in an outpatient surgery center and takes 3-7 days to recover. Men can have a vasectomy, which is done in a urologist’s office, involves a small incision and requires 2 days of rest to recover. Ask your doctor for more details on any of these methods to help make the right choice for you and your family.

These exams are meant to be preventive visits. Your doctor will review your medical and surgical history, update your current medication lists and ask you a number of questions about gynecologic symptoms and needs. These questions vary depending on age and stage of life. In younger patients, I discuss menstrual cycles, screen for depression and anxiety, and determine whether there is a need for contraception. As patients reach their adult years, the focus changes to menstrual irregularities, appropriate contraception and presence of sexual dysfunction, as well as appropriate screening with breast exams and Pap smears. We perform a written screen for hereditary cancer syndromes each year. In menopausal patients, questions about hot flashes, foggy thinking and sleep issues arise. Information about hormone therapy or non-medicated treatments is made available. If a patient is dealing with pelvic prolapse, urinary leakage or pain with sex, there are effective therapies, both medical and surgical. These questions and evaluations are meant to identify problems. We will often make a follow up appointment to discuss treatment options, so that enough time is available to explain the problem, offer solutions, and find the treatment that is best for each individual patient.

Sexual dysfunction is not a topic most women bring up with their doctor, but I often ask about it at annual exams. Sex is an important part of healthy relationships. If there is pain or fear present, intercourse will not be enjoyable, and we will begin to avoid it. Sometimes pain is due to a history of vaginal infection and needs medical treatment to improve the health of the tissues. Other times there is a history of physical or psychological trauma that has to be dealt with at the psychological level with a counselor or sexual therapist. On rare occasions, there is a physical barrier within the vagina preventing normal intercourse. In our clinic, we listen to the symptoms and do a careful physical exam. Then we create a treatment plan. Because a woman’s sex drive is based on many different factors, treatment often involves several modalities: medication, counseling, pelvic floor exercises. The main thing I emphasize is that painful sex doesn’t have to stay that way. This is not a taboo topic, but should be a part of our discussions about women’s health.

The typical symptoms of menopause occur as women transition from premenopausal to postmenopausal. This transition can take from 6 months to 2 years. Symptoms include irregular periods, hot flashes, night sweats, insomnia, foggy thinking, increased irritability or depressed mood, vaginal dryness, and decreased sex drive, among others. The choice of whether to take hormone replacement therapy (HRT) is a personal one and based on many different factors. There are people who feel very strongly on both sides, and the internet is chock full of personal opinions and false information. In my counseling, I inform patients of the results of the Women’s Health Initiative Study of 2001 and the information that has been gleaned since that time. We review the risks and benefits of HRT in detail, as well as non-hormonal alternatives. We then look at the patient’s family history, medical risk factors, and personal preferences to decide what is right for her.