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with Jane Harrison-Hohner, RN, RNP and Laura Corio, MD

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Monday, July 23, 2012

Do It Yourself Vaginitis Care: Testing

By Jane Harrison-Hohner, RN, RNP

Questions from our readers bring forward some of the most interesting topics. After last month’s blog on home pregnancy testing, I received a query about home vaginal infection testing. This spurred an investigation about all facets of do-it-yourself (DIY) vaginitis care. Here, as a two-part series, is what I learned about home testing kits. Next month, we’ll cover over-the-counter vaginitis treatments.

Vaginal Infections 101

Vaginitis is a general term that covers fungal (“yeast”) and bacterial infections within the vagina. Vaginitis can be an overgrowth of organisms normally found in the vagina or surrounding genital-rectal skin (e.g. yeast or bacterial vaginosis/BV). Some types of vaginitis can only be acquired by sexual contact, also known as a sexually transmitted infection or disease (“STD”). Examples of STDs which infect the vagina are trichomoniasis (“trich”), Chlamydia, and Gonorrhea. Unfortunately, if you are a woman with a new vaginal discharge, itching, or a malodor, it is not easy to know if one has an STD or simply an overgrowth of one of the “normal” vaginal organisms.

Testing for Vaginitis at Home

The most readily available home test kit for vaginitis is the Vagisil Screening Kit®. The cost at my local chain pharmacy was $17.50 ($15.00 for store brand). While availability and cost are good, the diagnostic capacity of this home test is very limited. This kit checks for vaginal pH. It does not indicate causes of symptoms (e.g., itching, burning, bad smell or unusual discharge), nor can it identify a specific type of infection. At best, it can indicate a more alkaline pH — 5.0 or greater, which suggests that either bacterial vaginosis (BV) or trichomoniasis (“trich”) might be present. When a pH of 3.5 is found, symptoms could possibly be from a healthy vagina or a yeast infection. Furthermore, the manufacturer suggests that the test may not be accurate if the woman is on her period, has breakthrough bleeding, is postmenopausal, or has recently had intercourse. Thus, in most instances, a woman should still see a GYN or clinic to get the most correct diagnosis.

This is not to say that very accurate results cannot be obtained with DIY home testing. Self-collected tests on urine or vaginal swabs have been used in research studies for over ten years. Such tests identify DNA from the infectious organisms using several kinds of nucleic acid amplification (NAAT) screenings. All of these NAAT tests are very accurate at identifying sexually transmitted diseases (e.g., Gonorrhea, Chlamydia, trich). In fact, two studies have shown that vaginal self-collected tests have almost the same accuracy as MD-collected swabs from the cervix during a speculum exam.

Through the internet, one can order the same types of testing kits for Gonorrhea and Chlamydia used in doctor’s offices. The reagents used for reading the results are included as well. These are very specific and reliable, but have to be purchased in boxes of 25 tests for upwards of $400.00—not including shipping. These are intended for medical offices.

Some internet sites advertise single test kits. One of the pitfalls of trying to order vaginitis or STD testing kit online is that some of the online, for-profit companies that sell these kits have little or no assurance of quality control. In 2010, an STD researcher ordered six kits from different, online, for-profit labs. She returned the tests filled with chlamydia organisms from her lab. Two of the companies never replied with results, two companies replied that the “patient” did not have chlamydia, and only two returned accurate results!

Your best bet is to avoid for-profit sites and obtain test kits through research-based programs. Women living in Alaska; Maryland; West Virginia; Philadelphia; Washington, DC; and select counties in Illinois can order free, in-home testing kits for gonorrhea, chlamydia, and trich over the phone or online. If a woman lives in selected areas of California she can also get a free test kit. Both of these research-based programs will send out kits, process them in a standard lab, and the woman can receive her results through the privacy of her home computer. If she tests positive, medications are provided through an associated pharmacy.

There is clearly a future for properly conducted in-home testing of gonorrhea and chlamydia. The medical literature has almost 80 published research studies on home testing for chlamydia. There are studies that show home testing for STDs gives excellent results in either initial testing or “test of cure” (re-testing after antibiotics to be sure the infection has gone). In one study, almost 1200 women (average age of 23 years) were either sent home testing kits or were screened in family planning clinics. Those testing at home had a positive chlamydia rate of 10%, compared to 3-5% rates in the clinic. It has been demonstrated that 98% of women can properly collect, then mail, their specimens from home. Among women doing yearly followup STD testing, the majority of women opted for home testing kits (75%) rather than testing in a clinic (6.1%) or with their own personal doctor (8.2%). Note that all of these studies were conducted by medical researchers and state health departments rather than for profit internet “labs”.

The future for in-home testing may even expand beyond the usual vaginal STDs. Health researchers are examining the possibility of testing for the STD which has been linked to severely abnormal PAP smears and cervical cancer—“high risk” HPV (human papilloma virus). A recent publication compared home test kits for sampling vaginal fluids for HPV to standard PAP smears done in a clinic. In a group of 3600 women, aged 50-65, significantly more cervical dysplasia (greater than CIN 2) was eventually found among the home tested.

Finally, for those who cannot get their sexual partner to go to the doctor, in-home testing for STDs is available to men. Both links above offer the same services to men.

Reliable testing can be available through the internet; the best programs seem to be run through public health projects. If you do decide to use one of the programs available, remember that getting adequate treatment and notifying your partner(s) are still very important. Should you be seeking screening because of known STD risks (e.g., unprotected sex, multiple current partners, or past history of an STD), remember that regular screenings and less risky sex will protect your future health.

Posted by: Jane Harrison-Hohner, RN, RNP at 7:43 am

Monday, June 18, 2012

K is for Kidney/Bladder

By Laura Corio, MD

Woman in pain

Many women experience a bladder infection, also known as a urinary tract infection or UTI, at some point in their lives. A UTI can occur alone or along with an infection of the kidney (pyelonephritis). UTIs are caused by bacteria (commonly e coli) that ascend from the vagina and rectum into the urethra and then up into the bladder. Risk factors include sexual intercourse, spermicide use, and a history of UTIs. Woman with an infection often experience pain on urination, increased frequency of urination, greater urgency (the feeling of having to continually go to the bathroom), supra pubic pain, and/or blood in the urine. Urine analysis and a sterile urine culture need to be examined to make the diagnosis, and treatment typically involves antibiotics. Cranberry pills, yogurt, blueberries, probiotics all decrease the incidence for recurrent UTIs.

Recurrent UTI’s are defined as more than two infections in six months or more than three infections in one year. Urologic evaluation of women with recurrent cystitis is not warranted, but if structural or functional abnormalities of the genitourinary tract are suspected, then a work up is reasonable. Continuous treatment with antibiotics, post-coital treatment with antibiotics, or intermittent self-treatment are all effective ways to deal with recurrent bladder infections.

A kidney infection presents with the symptoms of a UTI along with fever, chills, nausea and vomiting, and upper back pain. Treatment consists of antibiotics and bladder analgesics, with follow-up cultures to make sure that the infection has been treated and cured.

Hematuria, or blood in the urine, is very common. In young adults, it can be transient and not worrisome but after 40 years of age, it can be a sign of kidney or bladder cancer. When blood first appears, a urine culture should be sent off to rule out a UTI. A workup by a urologist is the next step if the hematuria persists and a bladder infection has been ruled out. The urologist is looking for a stone or a cancer either in the bladder or in the collecting system to the kidney, or the kidney itself.

Kidney stones or nephrolithiasis are a common problem. Patients may present with renal colic (pain) and hematuria. Calcium stones are the most common. Risk factors include a family history of stones, previous history of stones, and patients with histories of previous gastric bypass procedures, bariatric surgery, or short bowel surgery. High blood pressure increases the risk twofold for renal colic. Diabetes, obesity, gout, and marathon running with low intake of fluids are also risk factors. Presentation of a stone can be subtle or very pronounced. Acute, one-sided flank pain, hematuria, and an X-ray showing a stone can be seen in 90% of patients. It’s important to diagnose a stone before it causes persistent kidney obstruction, which can lead to permanent kidney damage. Treatment can be conservative: management with pain meds and hydration until the stone passes.  If this fails, then the stone needs to be removed by lithotripsy (SWL). Once the acute episode is over, the patient needs to be evaluated; prevention of further stones is required and therapy must be instituted.

Kidney cancer has been on the rise in the U.S. Risk factors include smoking, obesity, high blood pressure, diabetes, chronic hepatitis C infection, and childhood chemotherapy. The good news is that we are picking up these tumors earlier and therefore five-year survival rate has doubled over the last fifty years.

Bladder cancer is the most common cancer of the urinary tract. Hematuria is the most common symptom, and if a woman is over 40 years of age, she needs to have an evaluation by a urologist to rule out bladder cancer. Men are more at risk, and smoking and chemical carcinogens increase the risk for bladder cancer. However, symptoms mimicking a UTI or difficulty with emptying your bladder could also be signs of bladder cancer. The problem with this is that it makes it difficult to diagnose bladder cancer and, therefore, the cancer may be fairly advanced when it is finally picked up. A cystoscopy can diagnose and manage this disease. Treatment always involves removing the tumor, and based on the stage of the tumor, chemotherapy, BCG, and other treatments may be needed.

I hope this has helped you understand a little bit about the urinary system

Stay tuned for L is for liver: hepatitis C infection.

Photo: Polka Dot

Posted by: Laura Corio, MD at 6:02 am

Monday, June 11, 2012

Is My Home Pregnancy Test Telling the Truth?

By Jane Harrison-Hohner, RN, RNP

Woman with Home Pregnancy Test

There are a huge number of home pregnancy tests (HPTs) available now, but that wasn’t always the case: HPTs were not readily available until the late 1970’s. In 1976 the FDA granted approval for the first home pregnancy testing kit, the “e.p.t.” Since that time HPTs have become one of the symbols of women taking control of their fertility. From the public health perspective, studies have shown that use of HPTs has shortened the time it takes for women to seek care for either a pregnancy or a pregnancy termination.

How do HPTs work?

After ovulation it can take several days for fertilization to occur. The rapidly dividing mass of cells has to go through the Fallopian tube and find a comfortable spot in the lining of your uterus. Once implanted the “pregnancy hormone” hCG (human chorionic gonadotropin) is produced and enters the blood stream. The average time from ovulation to implantation is about 10 days (range 6-12 days). Initially hCG is present in small amounts, but in a thriving pregnancy hCG levels should double about every 48 hours.

HPTs work by testing for the presence of hCG. Thus, if a woman has ovulated later, has had a longer time to implantation, or is using a test that cannot measure very small amounts of hCG, she might end up with a negative HPT result, even though she’s in the very early stages of pregnancy.

When should I take the HPT to get the most accurate result?

Current HPTs are advertised as being sensitive on the first day of a missed period—or perhaps a few days before. The most recent review of accuracy of HPTs, published in August of 2011, tested these claims. One brand, First Response, detected 97% of pregnancies on the first day of a missed period. The EPT manual (54%) and digital (67%) and the Clear Blue manual (64%) and digital (54%) tests all detected fewer actual pregnancies. These results may reflect that the First Response could detect as little as 5.5 mIU/ml of hCG in the urine while the other two brands could detect 22 mIU/ml. Generally speaking, a reliable pregnancy test in a doctor’s office should be able to detect a level of 22 units of hCG or higher.

Remember, it takes an implantation to produce hCG to trigger a test. In a study where the day of implantation was documented with a sensitive blood test, it was determined that 10% of viable pregnancies were not yet implanted by the first day of the missed period!

Having read all this you can now understand why a GYN may recommend using a HPT twice, if the first instance is at the time of a missed period. About 97% of viable pregnancies will have implanted by seven days after the first day of missed menses. Taking a second reading can also enhance accuracy where your HPT is not one of the super-sensitive brands.

Are there things that can interfere with accurate results?

There are two general areas where false answers can be generated: medical conditions and user-linked problems.

Medical conditions. Here at WebMD we get frequent questions asking if birth control pills, progesterone, recreational drugs, antibiotics, or blood in the urine from a bladder infection can influence HPT results. The short answer is no. Only drugs that contain hCG can give a positive result. Such medications (e.g., Novarel or Pregnyl) are usually given by injection. Other fertility medications (e.g., Clomid, Pergonal) do not influence hCG levels. If you are taking injectable hCG your GYN should have given you guidelines about when you can test with a HPT. It can take 7-14 days, depending upon the dose given, for the injected hCG to disappear from your body.

There are a few, uncommon, medical conditions which might yield a false positive result. These can include: high levels of LH, and some immunoglobulin antibodies.

The most common medical condition to produce false positive results is a pregnancy that will be lost to very early miscarriage. It is believed that up to 25% of pregnancies are lost in very early miscarriages. Before the advent of super-sensitive hCG tests (and women testing even before a missed period), the loss of pregnancy which did not have an embryo or gestational sac could look like a slightly late period. There might be just enough hCG to trigger a very sensitive HPT, but levels would fall shortly after. This is why we say that it is difficult to judge if a slightly late period was a miscarriage or a late period — one would have had to have a positive hCG test around the time of the bleed to know for sure.

User-linked problems. A test can be very reliable but if instructions are not clear, or if its results are not easy to interpret, one can get a wrong result. In 2009, when 16 HPTs were reviewed for readability, the investigators found that the reading levels ranged from 7th to 10th grade on user instructions, and 11th to college level on the question and answer section. The recommended level for medical instructions is 6th grade reading level. Thus, it may not be surprising that another survey found only 32% of women totally complied with the written instructions on the HPT.

In another experiment, volunteers testing urine in a lab had more accurate results than when actual patients performed tests on their own urine samples. To get around some of these sources of inaccurate results (including evaporation lines and confusing interpretations) manufacturers of HPTs are shifting from manual to digital tests with a built-in monitor reading the results, then giving a simple yes or no.

There is an abundance of written material available on the topic “What to Expect When You Are Expecting.” If you would like more detailed information on what to expect when you are testing for expecting, you might want to check both these sites:

http://www.webmd.com/baby/home-pregnancy-tests

http://www.fertilityplus.org/faq/hpt.html

Photo: Stockbyte

Posted by: Jane Harrison-Hohner, RN, RNP at 6:17 am

Monday, May 21, 2012

Oh No, Where Did It Go? When Things Get “Lost” In the Vagina

By Jane Harrison-Hohner, RN, RNP

Surprised Woman

While the vagina is actually a structure with side and back walls, women can get panic stricken when an item seems to get lost or is not retrievable. We get requests on our Community Board for help in getting things back out of the vagina. Similarly, as a clinician I would sometimes find “lost” objects during a speculum exaam.

Lost Condoms

According to some studies, 28-33% of condom users have reported breakage, slippage, or both. According to one study of 834 condom-protected sex acts, 7% involved slippage with sex and 8% had slippage during withdrawal. Either breakage or slippage could result in all or part of a condom being left inside the vagina.

Should this happen to you, a first concern might be to obtain the morning after pill (also known as emergency contraceptive pills [ECP]) if one wishes to avoid an unplanned pregnancy. Depending upon the specific type of ECP, you can use the medication up to 72 hours after the condom accident. Some types of ECPs are most effective if taken right away. For a brief overview of where to get an ECP and how to take it, you can check out my blog on this topic.

To get the remains of a condom out of the vagina you can try one of several methods. The quickest is to have your partner insert two clean fingers (index and middle finger work best) into the vagina and use a gentle sweeping motion from the back walls of the vagina toward the front. They might feel your cervix (feels firm like the end of one’s nose) at the end of the vaginal canal. If they do feel the cervix they should gently sweep their fingers around the cervix to be sure the condom is not pushed up against the back of the vaginal wall. If you do not ask for your partner’s help, you can do this same technique half sitting with your back up against a firm surface (e.g., headboard of bed).  If you have short fingers, or a longer vaginal canal, you can put one foot up on the toilet or tub, insert the two clean fingers, and bear down like you are trying to have a bowel movement. This will bring the cervix and back wall of the vagina down so you can reach farther up inside. Certainly you could choose to see your GYN or local family planning clinic and have them remove the condom.

Lost Tampons

As one MD stated in an article about unusual causes of vaginal discharge, “seek and you shall find” applies to retained tampons and other foreign objects. In my experience the most common explanation for a retained tampon was a forgotten tampon that was then pushed even further back by inserting a second tampon. I have also removed small tampons that were inserted at the end of menstruation for less messy sex. After intercourse the tampon, and more importantly the string for removal, were pushed to the back wall of the vagina.

To remove a retained tampon one can try any of the three methods described above. If a tampon is accidentally left in place for several weeks it can change vaginal pH. This will encourage overgrowth of the anaerobic bacteria responsible for bacterial vaginosis (“BV”), a well-known cause of bad-smelling vaginal discharge. Once the tampon is detected and removed, if the smell like dead tuna fish does not resolve, antibiotics can be prescribed to eliminate BV organisms.

A question that frequently arises is, “What about the risk for Toxic Shock Syndrome with a lost tampon?” Beginning in the 1980’s Toxic Shock Syndrome (TSS) was reported with increasing frequency in menstruating women using tampons. Its symptoms included a fever of greater than 102 degrees, vomiting/diarrhea, low blood pressure, and a sunburn-like rash on the palms of the hand which later peeled like a sunburn. TSS, both menstrual and that associated with pneumonia and skin infections, is caused by a super-antigen-producing strain of one of our normal skin bacteria (Staph aureus). Like many skin bacteria, Staph aureus can be found in the vaginas of between 10-30% of healthy women. But far fewer women will test positive for the super-antigen producing subtype. This might explain why only 70-100 cases of TSS (both menstrual and nonmenstrual) are reported in the USA per year. Thus, the relatively low numbers of women having the TSS-producing subtype of staph bacteria may be the reason why every retained tampon is not an immediate time bomb for TSS.

Foreign Objects

Unlike condoms and tampons, which are designed for vaginal use, other objects can be inserted in the vaginal canal. Objects reported in the medical literature to have been found in vaginas include: aerosol deodorant cap, the plastic top to a can of hair spray, and a hard plastic stopper. I have personally found a plastic ring with spikes, designed to fit around the base of a penis, in a woman’s vagina. She stated that she did not know how it got in there. So readers, do not fear to see a GYN if a sex toy part needs to be fished out; a GYN will have already seen or heard it all.

Removal of foreign objects, especially if large, should be left to a GYN. If needed, removal can involve day surgery or anesthesia. If a foreign object is left in place it is likely to create a malodorous vaginal discharge. It can also place pressure on delicate tissues, creating an ulceration or fistula (open channel between the vagina and bladder or rectum). This kind of tissue damage tends to be the result of long misplaced objects.

In conclusion, many women (especially condom and tampon users) can expect to have difficulty removing an object from the vagina at some point in their lives. Try to stay relaxed, use the techniques discussed above, and above all know that there is no other place for the object to go.

Photo: Polka Dot

Posted by: Jane Harrison-Hohner, RN, RNP at 6:27 am

Monday, April 23, 2012

“J” is for Joints

By Laura Corio, MD

Arthritis

Osteoarthritis(OA) is a degenerative joint disease that affects many adults. It is a frequent cause of joint pain and disability in the aging, commonly presents in patients over 40, and is multifactorial. Its causes are many, including aging, gender, genetics, occupation, previous injuries, muscle weakness, obesity, sports activities, and lack of osteoporosis. Common joints involved are knees, hands, hips, spine, feet and shoulders. Pain and stiffness are common complaints.

One of the strongest risk factors is aging, with 97% of patients over the age of 65 affected. Women seem to be more at risk for OA than men. Obesity seems to affect the knees and the hands, but less on the hips. Lack of muscle strength, a previous injury, and physical activities related to sports or occupation increase the risk for OA. Genetics definitely are involved, especially in hands and knees. There has been some (conflicting) evidence of a relationship between osteoarthritis and hormone replacement therapy, but if you are on HRT and doing well, there is no reason to stop it based on the development of osteoarthritis.

X-rays and MRI imaging will help diagnose what is happening in the joints. If a diagnosis is made, a Rheumatologist may be the physician you need to see.

The thought process when it comes to OA is to control pain and swelling of the joints, improve the quality of a patient’s life, educate the patient about how to minimize the disability, and prevent the disease from worsening. Resting the affected joint to reduce pain may be good but only for a short period of time, since the muscles around the joint can weaken. If a patient is overweight, losing some pounds will help lower extremity joint mobility and pain. Physical therapy, exercise, and isometric strengthening and even water aerobics can all make a huge improvement in the arthritic joints. Heat and cold  can both raise the threshold for pain. If the patient is really having a difficult timing coping and depression is part of the picture, psychosocial intervention can also make a huge difference in how a patient deals with their disability.

The goal with managing patients with osteoarthritis is to help control the pain and improve the patient’s quality of life. Analgesics such as Tylenol are tried first. If there is little improvement, non-steroidal medications such as Advil are attempted. Sometimes, injecting steroids into the joint can be satisfactory. Persistent symptoms may need to be treated with colchicine, a medication used for gout that is also helpful for other joint pain. If all medications have been tired without relief, it may be time for surgical intervention.

My last word about osteoarthritis is about vitamins. It has been shown that vitamin C in a dosage of 200 mg daily can reduce the risk of progression of OA by three-fold in patients with OA. Beta-carotene, another antioxidant, also helps reduce the risk as well. 9000IU daily is what the experts recommend. Vitamin D in a dosage of 1000 IU of D3 will also reduce the risk for the progression of OA. Lastly, three grams of omega 3 fatty acids daily is the recommended  dosage according to osteoarthritis experts. Limit omega 6 fatty acids because they will make your joints worse.

Clearly this a disease that can affect all adults. Keep moving, stay active, exercise, and do not let this get the better part of you. There are treatments available both alternative and conventional and educating oneself about all that is available is essential for coping with osteoarthritis. I hope I have given you some solid information about OA.

Stay tuned for “K” is for “Kidneys and Bladder”

Photo: Creatas

Posted by: Laura Corio, MD at 12:15 pm

Tuesday, April 10, 2012

Should You Have an Endometrial Ablation?

By Jane Harrison-Hohner, RN, RNP

Currently our WebMD discussion on the side effects of endometrial ablation (EA) has nine pages of posts. It took me almost an hour of heavy-hearted reading to read every entry. Some 16 women stated that they had no further problems after their procedure. More than twice as many women reported continuing, or worsening, problems with pain in the pelvis, lower back, hip, or thigh. Some had the pain much of the time; others only monthly. Admittedly, our discussion forum is not a scientific study, but it made me wonder if one could predict who was more likely to have a good outcome—or who might be wise to consider another treatment option. Here are some of the possible reasons for a “bad outcome” after an EA.

Differences in types of EA procedures. While almost all EAs are done for a similar reason (abnormal/heavy uterine bleeding) there are a variety of methods used to destroy the lining of the uterus. These methods can be divided into two general groups:

1. First generation methods use a fiber optic light scope (hysteroscope) to actually look inside the uterus before and during the procedure. These have the advantage of “seeing” large polyps or other structural features which may be part of the bleeding problem. The disadvantages include need for surgical suite time and the risk of fluid overload when fluid is used to distend the uterus so all the walls can be seen. First generation procedures include:

Loop with an electric current

Rollerball with electric current

Yag laser

2.  Second generation methods can be “blind,” without direct visualization of the lining. This means that this type of EA can be done in the GYN’s office. The GYN may not need to utilize fiber optic scope skills. Second generation procedures include:

ThermaChoice—hot water (190° F) in a balloon inside the uterus

HydroThermAblator—circulating hot water (190°) directly inside the uterus

Her Option—freezing or cryo destruction of the lining

Microsulis—microwaveheated destruction

NovaSure—mesh net triangle which conducts a bipolar radiofrequency

There are MANY studies which have compared at least two of these methods to see if one method is superior or works better with a certain type of patient. For example, 126 women were randomly assigned to NovaSure or ThermaChoice procedures. Five years after procedure, no further menstruation (“amenorrhea”) was reported by 48% in the mesh net group and 32% in the balloon group. Unfortunately, most of the comparison studies have had small numbers of women.

According to the largest review, there were no overall differences in patient satisfaction or bleeding outcome between all the first- and second-generation EA procedures. The advantage of the newer techniques (second-generation methods) were decreased risks for perforation through the wall of the uterus, less fluid overload, fewer tears of the cervix, and cervical scars which close off the cervical canal. However, women were more likely to have nausea, vomiting, and cramping.

Individual patient characteristics. So if the type of EA procedure seems to be generally equal, can we identify specific women who might not have as good an outcome based upon her medical history or personal anatomy? You may have read that large fibroids sticking out into the uterine cavity can impede the correct placement of NovaSure, or that a very large uterine cavity (e.g., greater than 5 inches) can be harder to treat.

Physicians from the Mayo Clinic reviewed the outcomes of 816 women who had an EA. Factors that seemed to predict successful stopping of all bleeding (“amenorrhea”) included: age 45 or older (menopause would be kicking in within five years or so), a thin uterine lining of less than 4 mm, normal size of uterine cavity (less than 9 cm), and use of NovaSure rather than a heated balloon. Patient characteristics linked to treatment failure were: age younger than 45 years, five or more pregnancies (leads to larger uterine size), prior tubal ligation, and a history of bad menstrual cramps. Of note, 5% of the women complained of pelvic pain after their EA procedure. Among that 5%, 40% had retained fluid within the uterus—referred to by the authors as “postablation syndrome.”

EA and adenomyosis. As many of you know, one can have endometriosis which invades into the muscular walls of the uterus. This is called adenomyosis. It is very difficult to diagnose; most often it is identified after removal of the uterus. Adenomyosis is not well visualized on ultrasound; an MRI may be needed. Like endometriosis it can worsen menstrual cramps, create uterine pain, and even prompt bleeding problems. I began to wonder if there was a link between continued pain after EA and possible undetected adenomyosis.

I found a study of 190 women with known adenomyosis who had a rollerball EA. After an average of five years follow up, almost 87% reported reduced or no menstrual cramps. This leaves 13% who had continued monthly pain. In a smaller study of women receiving microwave ablation, 59 had known adenomyosis. After an average of five years of follow up, younger age and presence of adenomyosis were found to be linked to unsatisfactory treatment outcomes.

The pain of endometriosis and adenomyosis can be referred from the uterus to the lower back, (e.g., like “back labor” during childbirth). Pain from the uterus may also be referred down the thigh. There can be many other causes of low back pain, including disc problems, muscle strain, and nerve entrapment. Thus it may be difficult to establish if back or pelvic pain after an EA was related to the EA or a concurrent medical condition.

In summary, abnormal uterine bleeding can be treated with medications and/or a synthetic progesterone containing IUD (“Mirena”). Surgical techniques such as hysteroscopy or endometrial ablation can be utilized to retain the uterus as a support for other pelvic structures. Even with these options a percentage of women will go on to have a hysterectomy because of continued symptoms.

If you are a woman contemplating an endometrial ablation, you might want to give some thought to possible factors which might decrease your satisfaction with an EA. It is certainly worth discussing with your GYN. I think Leah, posting in 2009, said it best: “To all the women reading this—yes, good things will come with your choice (EA or other) but not perfection. Choose wisely, then live happy.”

Posted by: Jane Harrison-Hohner, RN, RNP at 10:50 am

Monday, April 2, 2012

“I” is for Infertility

By Laura Corio, MD

Infertility

Before we speak about infertility, it is important to define the word. Many of my patients believe that if they do not conceive on their first try, they will never get pregnant. This is so untrue. Infertility is defined as a lack of conception after 12 months of trying without birth control and with frequent intercourse in a woman under the age of 35, and after 6 months in a woman over age 35. Eighty to 90 percent of couples will conceive within 12 months of trying to get pregnant.

Unfortunately, fertility peaks at 24 years of age and decreases as we age. It is difficult for a woman to conceive after 40, so I would waste little time working up a patient for infertility if she was over 40. I would give her only 3 months to try, and then start a workup.

Infertility can be due to either of the partners (or both), so both need to be evaluated. We propose an infertility work up by 12 months of not conceiving or earlier depending on the patient’s history, physical exam, and age.

The man is examined first and is sent for a sperm analysis. If it comes back normal, we turn to the female partner. If the analysis comes back abnormal, it should be repeated. If it is still abnormal, then I refer the man to a male infertility specialist. There, he is given a thorough workup, including a medical history, physical exam, and bloodwork. After that, treatment options can be discussed.

The female partner now needs to be worked up as well. She needs a history and physical, a menstrual history, lab testing, and an assessment of the Fallopian tubes and uterus. Is she ovulating? This means that every month she is releasing an egg from her ovary to be fertilized by a sperm. If she is not ovulating, clearly there will be no conception. Taking your Basal body temperature (BBT) daily, first thing in the morning, and charting it throughout an entire menstrual cycle helps show that a woman is ovulating. Ovulation kits are available at drug stores over the counter but are sometimes hard to interpret, so I prefer the BBT. Polycystic ovarian disease (PCOS) is a very common reason why a woman may not be ovulating. Also, a patient’s BMI will affect fertility.

Determination of open Fallopian tubes and a normal uterine cavity are important in an infertility work up. A hysterosalpingogram (HSG) is a test that will show these characteristics. Dye is put through the cervix into the uterus and X-rays are taken to see the dye in the uterus and then if it passes through the tubes.

If a woman is over 35, I encourage her to undergo second- or third-day bloods. This is an examination of the ovaries and the quality of the eggs. If the FSH is over 12, this could be a poor predictor of ovarian reserve. As we age, it seems that fertility goes down because of our egg quality.

If a woman presents with severe menstrual cramps, back pain, pain on intercourse, abnormal bleeding, and infertility she may have endometriosis, in which case I would recommend a diagnostic laparoscopy to diagnose her disease.

Once the cause of the infertility has been established, therapy can start. I always talk to my patients about lifestyle modifications. If they are a smoker, I tell them this is the time to stop. I allow my patients one cup of caffeine a day, whether coffee or tea or soda or chocolate. I talk with my patients about how much they exercise and I only allow the patient and her partner one glass of alcohol a week while trying to conceive. Also, please no lubricants or jellies while having intercourse. They can kill sperm. The only lubricant I recommend is preseed. It can be obtained on the Internet.

If there is no ovulation, medication such as Clomid may be necessary to help  a woman ovulate. If a woman is heavy (BMI greater than 25), she may need to lose some weight to help her ovulate and respond to the Clomid. If a woman is too thin (BMI under 19), she may need injections of medications to help her conceive. If her tubes are abnormal, she may need tubal surgery or possibly IVF.  If her uterine cavity shows submucous fibroids, polyps, or scarring, she needs to have a surgical procedure called a hysterscopic  resection of the abnormality, D&C. This will allow the embryo to implant in her uterus. And if there is a mucus problem at the level of the cervix, the patient may need to undergo IUI (intrauterine insemination).

I know that many infertility physicians push in vitro fertilization (IVF). This is because they feel they get their best results with this procedure. It is expensive and intense, and couples really feel they have been put through the ringer. But when I deliver those babies, I can only tell you the satisfaction the couples have when they hold their baby in their arms. There is nothing like it in the world.

When I first started in practice, I use to advise patients to try to have their first baby by age 35. Now I am asking them when they plan to start trying to conceive. Infertility will increase with age. The fact that you look young and are in good health can be misleading. If I can give one piece of important advice after everything I have said about infertility, PLEASE do not wait too long to try to get pregnant. My patients come back to me after they have had their first child and say they wished they’d started earlier. Now they want a second child and it is not happening. Why? Because she is now 43 or 44.

Last words to be said: a woman can now freeze her eggs up to the age of 39. It gives women some control over their fertility and it allows them some time. So, if it seems like children are important in your life but the man of your future has not shown up yet, this very straightforward procedure is something to consider.

I hope I have helped you understand a little more about infertility and eased some fears, if it’s been taking you a little while to conceive. If you feel it has been too long, though, then it is time to move on to an infertility workup.

Stay tune to my next blog “J” is for “Joints.”

Photo: iStockphoto

Posted by: Laura Corio, MD at 2:51 pm

Monday, March 5, 2012

H is for Hormone Replacement Therapy

By Laura Corio, MD

HRT

Are you confused about hormone replacement therapy (HRT)? Because many women are. They are worried that HRT could cause cancer. They wonder if it is safe. They suffer from menopausal symptoms and continue to avoid all hormones because they’re unsure of the risks. If you have breast cancer, I would not encourage you take hormones because it could increase your risk for recurrence, but many women can take HRT safely.

Seventy-five percent of women will experience hot flashes and night sweats. Estrogen is the treatment of choice for these symptoms. It can be given orally, transdermally, and vaginally. A woman’s quality of life can improve substantially on estrogen, with decreasing hot flashes and night sweats, helping her sleep and raising her mood. It is a safe and effective option for menopausal women.

Whenever I talk HRT with my patients, I advise them to take the hormones in the peri-menopausal or the early menopausal years. If a patient starts the hormones in the perimenopausal years, she will keep her bones strong if they are normal now and she can also help protect her heart if she is free of heart disease. We are talking preventive medicine, not treatment.

When patients come in for HRT, I talk to them about timing and dosage and try to give the lowest dosage for the shortest period of time. Typically a patient takes HRT for five years, but it’s necessary to tailor this to every patient. Some patients will stop hormones after a year and others will stay on them for a long period of time.

Vaginal estrogen is something I try to encourage every woman to take after menopause to help offset vaginal atrophy. Vaginal atrophy–or thinning of the layers of the vagina and bladder–occurs in every woman post-menopause and can be safely helped with vaginal estrogen. Dryness, itching, and the feeling like there is a vaginal or bladder infection can be helped tremendously with vaginal estrogen. Intercourse is likely to be very uncomfortable without it.

Estrogen, when given for HRT, must also include progesterone. This protects the woman’s uterus from uterine cancer. Only women who have had a hysterectomy can take unopposed estrogen alone.

I love bio-identical hormones, which are chemically the same as what a woman’s body produces naturally during her reproductive years. Synthetic hormones cause weight gain, bloating, and are very strong. Progestins are synthetic progesterone and should be avoided, as they can increase the risk of breast cancer if given as part of HRT. I like estradiol, progesterone, and testosterone in their natural forms, as they are similar to what the body naturally produces. I compound creams, pills, and gels to make up HRT, tailoring the formation to each patient. Some patients will do well on one combination, while another patient will need something different. Needs can also change during the years a woman is taking HRT.

I hope I have cleared the air. There is definitely a role for HRT in the perimenopausal and early menopausal years for the relief of hot flashes, night sweats, insomnia, mood swings, decreased libido, and vaginal dryness. These are some of the menopausal symptoms and estrogen treatment is the best. Talk to your gynecologist and make sure you fully understand HRT.

Stay tuned for I is for infertility.

Photo: iStockphoto

Posted by: Laura Corio, MD at 1:34 pm

Monday, February 27, 2012

Exposure to Birth Control When Pregnant: Will My Baby Be OK?

By Jane Harrison-Hohner, RN, RNP

Woman Holding Pills

Just a few weeks ago one million packs of birth control pills were recalled by Pfizer, a well-known drug company, and more recently seven lots of Norgestimate and Ethinyl Estradiol Tablets were recalled by Glenmark Generics Inc. In both cases, the apparent error had been in the packaging of the pills such that some placebo/sugar pills had been packaged in the area where active pills are supposed to be taken. While most women would note that there was a random mix of colors in the initial 21 days, it might be possible that someone might not question the color mix and could thus become pregnant. What would be the effect on her baby?

Despite the effectiveness of modern birth control methods, some women do become pregnant while using contraception. What are the effects of the “morning after” emergency contraceptive pills, DepoProvera, Implanon, or IUDs on an early pregnancy? The purpose of this blog is to share with you what evidence we have about prenatal exposure to various types of contraceptives.

Birth Control Pills (BCPs)

According to a study done in Denmark, about 1% of pregnant women have used BCPs during the initial part of their pregnancies. In the U.S., BCPs are still the most widely used form of reversible birth control. Thus one would expect to see some obvious, consistent patterns of infant effects. One of the largest studies, published in 1995, looked at some 65,500 women who had infants exposed to BCPs. The primary area of focus was external genital defects, as it was felt that early exposure to synthetic sex hormones (e.g., BCPs) could impact genital development. No increased risk for genital defects was found. Moreover the FDA supports the position that synthetic progesterones found in BCPs did not cause other types of non-genital birth defects.

In 2010, about 10,000 infants with 32 types of birth defects were contrasted with infants without birth defects. Of the 32 types of birth defects only two had statistical links to early pregnancy BCP use (underdeveloped left heart chamber or hole in the abdominal wall). The researchers concluded that those findings may have been by chance, not direct causation. They stated “… our findings are consistent with the majority of previous studies that found women who use OCs [oral contraceptives] during early pregnancy have no increased risk for most types of congenital malformations.”

There has also been a concern about the risk of having a Down Syndrome (Trisomy 21) baby due to prenatal BCP exposure. The weakest study found an increased risk in women under age 34—but no increased risk in women age 34 or older, when Down Syndrome babies are more common anyway. Moreover, in a study done by the U.S. Centers for Disease Control, BCP use by itself was not a significant risk factor for Trisomy 21.

Finally, in Korea 120 women who had taken BCPs at the time of conception were matched to 240 women who had not been using BCPs in early pregnancy. After all women had delivered it was determined that there were no differences in the infants’ weight or age at delivery. In the BCP-exposed group the rate of general birth defects was 3.2% compared with 3.6% in the non-exposed group.

Emergency Contraceptive Pill (ECP)

A much larger dose of hormones is used for the “morning after pill” or ECP. What happens to infants conceived when using a higher dose of hormones? In the Korean study mentioned above, there were 15 women who used high dose synthetic progesterone ECP regimens (e.g., similar to Plan B® in the U.S.). There were no adverse fetal outcomes observed. A Plan B® type of ECP has been available, over the counter, in China since 1999. Among the several hundred ECP pregnancies, a small group of 31 pregnant women were followed through delivery. There were no significant differences in incidence of miscarriage, malformations, or neonatal problems among the ECP exposed babies.

The newest ECP available in the US.. (Ella®) contains a different type of hormone. The manufacturer filed data with the FDA about pregnancies. The majority of women terminated their pregnancies; however, there were two apparently healthy live births. In another Ella® study one infant had optic nerve hypoplasia which was not judged to be related to the medication. Since Ella® was approved in the U.S. about 18 months ago there has not been an increase in reported problems for exposed infants. Usually with a newer medication there is closer scrutiny for problems.

DepoProvera

One of the highest doses of synthetic progesterone that an infant could receive from a birth control method would be from the DepoProvera shot. A large group of children (1207 of them) exposed to Depo in utero were examined for problems with growth or attainment of puberty. The use of Depo during pregnancy did not adversely impact long term growth or sexual development of children.

Implanon

Inserted under the skin, much lower doses of synthetic progesterone are released from the Implanon implant. While there have been no reports of problems with infants conceived with Implanon correctly in place, the number of pregnancies is very low. Among the prior types of implants (Norplant and Norplant II) there were no increases in ectopic pregnancies, birth defects, or infant health problems.

IUDs

With respect to the older type of IUDs, a group in Italy described the outcomes of 10 IUD pregnancies. Five were terminated by abortion, two were miscarried during the first trimester, and three were delivered at term. No abnormalities were found except a major lip lesion in a newborn. Eleven women using copper IUDs had pregnancy tissue examined and it was noted that no malformations or copper deposits were present. For the Mirena, a synthetic progesterone containing IUD, no pattern of birth defects was apparent in the 35 “Mirena babies” reported to the FDA.

As you have read, pregnancies exposed to most types of hormonal birth control seem to yield healthy babies. Thus, women exposed to hormones after conception might be reassured that the chance of a healthy pregnancy, and infant, is good. Nonetheless it is important to see your GYN or family planning clinic promptly if you have a positive pregnancy test, to receive personalized counseling.

Not surprisingly, bad outcomes tend to be reported more than good. Continuing with an unplanned pregnancy is a very personal decision, but I hope that having reliable information is helpful if you find yourself pregnant despite optimal use of birth control.

Photo: Brand X Pictures

Posted by: Jane Harrison-Hohner, RN, RNP at 10:26 am

Tuesday, February 14, 2012

What’s Making My Nipple Itch? Part II

By Jane Harrison-Hohner, RN, RNP

Now that we have reviewed the most, and least common, causes of itchy nipple(s), let’s see if one of these other skin conditions may be the culprit.

Contact Dermatitis

Most people are familiar with the type of contact dermatitis that may arise from poison oak/ivy, nickel earring posts, rubber/latex, or laundry products containing fragrance. These and other substances may trigger an itching of the skin, tenderness, and a variety of lesions (e.g., small blisters, red rashes) which can open to form crusting. Sometimes the skin reaction occurs after first contact, but in some cases repeated exposures over time are needed to induce the allergic reaction. When other causes have been ruled out a steroid cream/ointment, or tacrolimus, may be prescribed.

Seborrheic Dermatitis

Another common cause of itchy, inflamed skin is Seborrheic Dermatitis (SD). It particularly targets upper chest, back, scalp, and face where there is more sebum production. That is, SD is found where the skin is most oily. In addition to itching, there can be skin scales—flakey white or yellow in color. Between 11-12% of adults will have SD. The peak adult incidence is between the ages of 30 and 50.

The diagnosis of SD is based on the location of the lesions. Because it is a chronic condition, the person may give a history of having a similar outbreak in the same area.  SD tends to improve in the summertime. SD on the nipple can be treated with lotions containing selenium, ketoconazole, or corticosteroids. In a rigorous review of treatments for SD, ketoconazole was found to be the most effective, followed by another kind of antifungal, ciclopirox.

Candida

Most vaginal yeast infections are attributable to this type of fungus. Yet this is a less common cause of itchy nipple—except during breast feeding. In a study of 100 healthy breast feeding women between 2 and 9 weeks post partum, flaky or shiny skin accompanied by breast pain was the most likely to accurately predict a “yeast infection” of the nipple.

Diagnosis of candida of the nipple can be done with a skin scraping or a fungal culture. In a breastfeeding woman, itchy nipples may be treated presumptively (especially if the infant appears to have thrush in its mouth). During lactation nystatin-containing ointments or creams are used on the maternal nipples; the infant would receive an oral preparation of the nystatin.

Joggers’ Nipples

Irritation of sensitive nipple tissues can arise from rubbing of rough clothing or underclothes. Perhaps the most dramatic example of this is “joggers’ nipples”. In a report on dermatology injuries after running marathon races, between 3-16% of runners complained of nipple itching and irritation. Both men and women can be affected.

Neurodermatitis

Neurodermatitis is known by a variety of names including “itch scratch phenomena”. It starts with an irritation which could be eczema, atopic dermatitis, a fungal infection, or even rubbing by clothing. Chronic itching and scratching create a cycle of continued itching as nerve endings are stimulated. The result can be a roughened, thickened area of skin. While the extremities are common sites, it can also be found on the nipple—usually one side only. Neurodermatitis is more common among women, and is more prevalent between the ages of 30-50.

Diagnosis is made by ruling out other sources of itching. A skin biopsy might be done to confirm neurodermatitis if there has not been a response to other skin treatments. Since neurodermatitis can be exacerbated during times of stress and anxiety a person may be asked about their current stressors.

Given the variety of causes there are an assortment of treatments. Steroid ointments, or even steroids injected into the area to decrease inflammation might be prescribed. A 5% topical doxipen cream has had good results relieving itching. Tacrolimus ointment reversed the thickened, leathery skin caused by scratching. Successful alternative therapies have included TENS unit stimulators, and Chinese red hot needle therapy with cupping!

Self-help strategies encompass ways to stop the scratching to allow the skin to heal. The dermatologist may recommend occlusive dressings or bandages that both cover the skin from scratching and encourage medications to penetrate more deeply through thickened skin surfaces. One trigger for itching is dry skin, so avoiding long hot baths, minimizing soap use, and lubricating the skin while still damp may be helpful.

Before you feel crazed enough to “tear off” that itching nipple, my advice to you would be to see a healthcare provider to get an accurate diagnosis. Bear in mind that the culprit may be more than one condition, and that there are likely things you can do to decrease future problems. If you are interested in more information about either breast, or skin, problems, visit the WebMD Gynecology and Skin and Beauty communities or post your questions in the comments below.

Posted by: Jane Harrison-Hohner, RN, RNP at 12:35 pm

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