Learn more about Minimally Invasive and Robotic Surgery

I’d like to invite you to my website www.MinimallyInvasiveGYN.com

I’m a strong believer in laparoscopic and robotic surgery for a single, simple reason. It’s better for the patient. Minimally invasive surgery, a catch-all term which includes laparoscopy, hysteroscopy, and robot-assisted surgery, has proven benefits.

The benefits of minimally invasive surgery, compared to conventional “open” surgery include:

• less post-operative pain
• reduced need for pain medication
• faster return of normal appetite and bowel function
• smaller incisions
• less scarring
• faster recovery and return to work

Robotic surgery in particular has advantages which allow the surgeon to perform more complex procedures via a laparoscopic approach than might otherwise be possible. The robotic system gives the surgeon the benefits of:

• greater magnification with the laparoscopic camera
• 3 dimensional (3D) vision
• greater range of motion for laparoscopic instruments
• increased comfort, which may reduce a surgeon’s fatigue during long procedures
• reduction of biologic hand tremor

The robot doesn’t bear much resemblance to what we’ve come to expect from science fiction. It doesn’t have artificial intelligence and it cannot operate independently. In fact, the robot is just another instrument. It is controlled by the surgeon who sits at a console next to the patient.

The Da Vinci Robotic Surgical System

The robot has arms whose attachments are miniature versions of conventional surgical instruments (i.e. scissors, clamps, needle and suture-holders). These tiny instruments mimic the surgeon’s movements at the console (but on a much smaller scale). This allows the surgeon to perform surgical procedures with extraordinary precision.

Laparoscopy revolutionized surgery by making many major surgeries into outpatient procedures. Robotic surgery is revolutionizing laparoscopy by broadening the range of surgeries which can be performed with a minimally-invasive approach.

Take charge of your health by learning more about minimally invasive and robotic surgery. An educated patient is an empowered patient!

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February 25, 2012 at 12:51 am 4 comments

2011 in review

The WordPress.com stats helper monkeys prepared a 2011 annual report for this blog.

Here’s an excerpt:

The concert hall at the Syndey Opera House holds 2,700 people. This blog was viewed about 19,000 times in 2011. If it were a concert at Sydney Opera House, it would take about 7 sold-out performances for that many people to see it.

Click here to see the complete report.

January 4, 2012 at 5:50 pm Leave a comment

So, you think you have heavy periods?

Whenever I ask a patient “do you have heavy periods?”  I feel like I deserve the kinds of answers I receive.  I’m just as likely to hear “Yes.  I have to change a panty liner every few hours.” As to hear, “No.  I only go through one box of super-overnight maxi-pads per day now.  It used to be two boxes.”  Which is to say that every woman perceives whether or not her periods are heavy through the filter of her own personal experience.  

So, what exactly is a heavy period?  Well, the standard definition is a period that lasts longer than 7 days or in which a woman loses more than 80 millileters of blood.   The first definition is easy.  You just count the days on a calendar.  The second is much more difficult to determine.  (Unless you go wringing your sanitary products into graduated cylinder flasks.  In which case, maybe you need a psychiatrist, not a gynecologist.) 

So, how is the average woman to know what constitutes a truly heavy period?  If you’re saturating your pad or tampon every hour, it’s a good bet your period is heavier than average.  Similarly, if you tend to bleed through your tampon, onto your pad, and soak your pants, you probably need to see a doctor (and a good dry cleaner).  

There are lots of reasons why women get heavy periods.  The medical term for them is menorrhagia. Heavy menses aren’t just an inconvenience.  They’re a real medical problem which can result in anemia (a reduced blood count) and fatigue.  They can also be a sign of other serious medical conditions. 

Adolescents and teens may have heavy, irregular periods as they begin to establish their menstrual cycle.  These natural fluctuations in the menstrual cycle are often temporary, and usually resolve when monthly menses begin over the next few months to years.  Adolescents and teens with very heavy menses, or whose cycles do not become lighter on their own, may need to be evaluated for bleeding disorders, such as von Willebrand disease.

Women in their reproductive years may have heavy menses or irregular cycles because of hormonal conditions, such as polycystic ovarian syndrome (PCOS), which can cause irregular menses and heavy menstrual bleeding on the rare occasions when menses take place.  Another hormonal condition which can case heavy menses is an underactive thyroid gland (hypothyroidism).  Both of these conditions can cause excess weight gain.  Being overweight (even in the absence of other medical conditions) can worsen heavy menstruation.  This is because adipose (fat) tissue produces excess estrogen, thickening the lining of the uterus.  When the lining is shed at the end of the menstrual cycle, heavier bleeding occurs.

Hormonal conditions may be suspected on the basis of a physical exam, history, blood tests, ultrasound (sonogram) or a combination thereof.  A combination of medication and dietary and/or lifestyle changes may be helpful in regulating the menstrual cycle and reducing bleeding.

Certain medications can lead to heavy menses.  Blood thinners (Coumadin, Lovenox) and Non-steroidal anti-inflammatory medications (Motrin, Advil, Ibuprofen and Aspirin) can increase menstrual bleeding.  Missed doses of oral contraceptives can also lead to heavy menses or irregular cycles.

Some women have heavy menses due to abnormalities of the uterus and its lining.  An endometrial polyp is a growth of tissue in the lining of the uterus.  Because polyps have a rich blood supply, they can cause heavy bleeding either during or between menses.  Uterine fibroids can also cause heavy menses.  Fibroids are benign muscle tumors which can impinge on the lining of the uterus, causing heavy menstrual bleeding.  They can also cause other symptoms (such as pain, pelvic pressure, frequent urination, miscarriage) which likewise bring them to a doctor’s attention.  Both endometrial polyps and uterine fibroids are readily diagnosed by an ultrasound (sonogram).  Bleeding due to polyps and fibroids can often be managed with the use of minimally invasive surgical techniques (such as hysteroscopy and laparoscopy).

The most serious cause of heavy menstrual bleeding, especially in women who resume menstrual-like bleeding after the cessation of normal periods (menopause), is endometrial cancer.  This type of cancer is rare in women under the age of 35 and is much more common after menopuause.  Endometrial cancer may be suspected on the basis of an ultrasound (sonogram).  It can be diagnosed by a biopsy or by a surgical procedure called a dilatation and curettage (D and C).  Endometrial cancer is often responsive to treatment when caught early.  

In summary, heavy menses are very common.  They may represent a normal variation in a healthy woman’s cycle, or they may be due to a medical condition which requires treatment.  Attention from a skilled healthcare provider can help determine whether additional care is needed.

A Good Resource:

ACOG Guide to Abnormal Uterine Bleeding

One Last Cartoon:

October 7, 2011 at 3:34 am 33 comments

Before Baby

Often, patients who come see me ask whether I deliver babies.  Indeed I do!  And it’s always nice to build a relationship with patients before they get pregnant so that they are more comfortable with me during the 9 months we’ll spend caring for mom and baby.

In addition to what usually happens during an annual gynecologic visit, good pre-pregnancy care deserves special consideration.  The peroid of thime before you get pregnant is the best time to improve control of any chronic medical conditions you may have (high blood pressure, asthma).  A doctor should talk to you about any medications you may be taking which pose a potential risk to a developing fetus.

One medication is routinely recommended for all pregnant women.  Folic acid (folate) supplementation should begin prior to conception.  Ideally, it should begin at least 2-3 months prior to trying to conceive.  Most women require 400 micrograms (mcg) of folic acid to prevent a specific birth defect (Spina Bifida, which can cause a child to be unable to walk).

Some women require more folic acid (800-4000 micrograms) depending on their risk factors for delivering a baby with spina bifida.  These risk factors can include certain medications (especially anti-seizure drugs), certain medical conditions, and a prior history of a child or other family member with spina bifida. 

Prenatal vitamins usually contain 400-800 micrograms of folic acid in combination with other vitamins and minerals.  You can bring your prenatal vitamin (in the bottle) to your doctor’s visit to review whether it contains everything you’ll need during pregnanty.  Alternatively, ask your healthcare provider to recommend a prenatal vitamin or other supplements for you.

Good pre-pregnancy care also includes certain blood tests.  A test may be required to determine whether a prospective mother is immune to Rubella (also called “German measles”) and Varicella (a.k.a. “Chicken pox”).  That’s because both of these disease can cause birth defects if the virus that causes them is contracted during pregnancy.  Immunizations are available for both Rubella and Varicella and should be administered to non-immune women several months prior to attempting to get pregnant.  Neither vaccine is administered during pregnancy.

Testing for infections, including HIV (Human immunodeficiency virus), gonorrhea, chlamydia, and tuberculosis may be a good idea for women who are at risk for these conditions.  A conversation with your doctor can help him or her determine whether you are at risk and require screening.

It’s always a good idea to maintain a healthy weight.  This is espceially important before and during pregnancy.  Managing your weight before you get pregnant may help reduce your risk of diabetes and blood pressure problems during pregnancy.  Avoiding excess weight gain during pregnancy can make for an easier delivery and a faster return to your pre-pregnancy body.   A healthy diet and regular exercise will help you manage your weight.  Advice  from a doctor, nutritionist, or weight-loss counselor may help if you’re having trouble.

Lastly (and perhaos most importantly) avoiding alcohol, cigarettes, illicit drugs and other toxic substances is of tremendous importance when you are pregnant.  All of these substances can seriously impair maternal health.  They may also contribute to to an increased risk of miscarriage, preterm birth, low birth weight, and (in the case of alcohol) low I.Q. and birth defects.  The best time to stop using these substances is before conception.  Again, assistance from a doctor or substance-abuse program may help.

It’s a good idea to schedule a visit with your gynecologist to discuss the best way to prepare for a healthy pregnancy.

For some great resources on pre-pregnancy health and pregnancy planning, check out these links from the American College of Obstetrics and Gynecology.

June 29, 2011 at 7:48 pm Leave a comment

Buyer Beware – Suspect Supplements and Hurtful Herbals

As an obstetrician/gynecologist, one of the things I do is take care of pregnant women.  And, while this blog is dedicated to gynecology, I thought I’d share with you a cautionary tale about my recent care of a woman in her first trimester of pregnancy.

She was asked to try a remedy for morning sickness.  The remedy  is described on its own website as  “a safe, non-addictive, FDA registered natural remedy containing 100% homeopathic ingredients formulated to relieve nausea (morning sickness) during pregnancy.” 

I was asked to look at the product to determine if it was safe for my patient.  At the bottom of a website with abundant testimonials and positive reviews, I found a list of ingredients.  5 of the 7 ingredients were safe and nontoxic.  These were:

Two ingredients posed serious potential health risks (regardless of pregnancy status).  These were:  

  • Nux Vom (Nux Vomica– derived from the Strychnine tree).  That’s right, I said strychnine.  As in the stuff they use in rat poison and gopher bait.  While very small doses of strychnine cause an increase in bowel motility, which can releive nausea, larger doses can cause neurological toxicity, seizures, and death.
  • Nat Phos (Sodium Phosphate — another salt) Oral phosphates were widely used in bowel preparations for colonoscopy. They have been withdrawn in the United States because evidence suggests that sodium phosphate causes serious kidney damage, a condition called phosphate nephropathy

I told my patient that I had serious concerns about the safety of the ingredients listed on the website.  I told her that, although the remedy is very unlikely to cause injury in the small amounts in which it is administered (it is sprinkled on foods throughout the day), I could not recommend that she take it when safe alternatives exist. 

And, just to clarify, I am not recommending for or against the use of this (or any other product) on this blog.  I am sharing this anecdote to remind you to share with your healthcare provider ANY vitamins, nutritional supplements, herbal or traditional medicines you desire to take. 

That’s because only a medical professional, who is familiar with your medical history and has an inventory of the other medications you may be taking, is qualified to help you determine whether a particular product is safe for you.  He or she can determine whether the product interferes with other medicines you may be taking .  Your healthcare provider may also have valuable instructions on how to take the product safely (i.e. on an empty stomach, not with grapefruit or acidic juices, etc.)

Vitamins and nutritional supplements are not governed by the same strict set of rules which regulate drugs and medications.  While an herbal remedy, supplement or nutritional product may be registered with the FDA, this should not lead you to believe that a particular product is safe for you (or anybody else).

And, as for morning sickness, my advice to the patient was that peppermint tea, ginger ale, and ginger candies were likely just as effective and by no doubt safer than many of the specialty products marketed to relieve the gastrointestinal suffering of pregnant women. I also recommended small, frequent meals of bland, starchy foods. 

As for over-the-counter treatments, I often recommend vitamin B6, which is safe and non-toxic.  I often recommend this in combination with doxylamine  (found in Unisom), an antihistamine which can alleviate nausea (especially when combined with vitamin B6), although it does cause drowsiness.  

If that’s not enough, I said, call me for a prescription.

February 4, 2011 at 7:26 pm 1 comment

2010 in review

The stats helper monkeys at WordPress.com mulled over how this blog did in 2010, and here’s a high level summary of its overall blog health:

Healthy blog!

The Blog-Health-o-Meter™ reads Fresher than ever.

Crunchy numbers

Featured image

A Boeing 747-400 passenger jet can hold 416 passengers. This blog was viewed about 4,500 times in 2010. That’s about 11 full 747s.

In 2010, there were 20 new posts, not bad for the first year! There were 31 pictures uploaded, taking up a total of 25mb. That’s about 3 pictures per month.

The busiest day of the year was May 7th with 147 views. The most popular post that day was I’m The Gynecologist!.

Where did they come from?

The top referring sites in 2010 were facebook.com, med.nyu.edu, en.wordpress.com, healthgrades.com, and google.com.

Some visitors came searching, mostly for mirena coil, speculum sizes, gynecologist blog, dr nicoll, and paragard iud.

Attractions in 2010

These are the posts and pages that got the most views in 2010.

1

I’m The Gynecologist! May 2010
1 comment

2

About Me May 2010

3

The IUD 4 U! (An intro to the Intrauterine Device) June 2010
7 comments

4

Understanding Ovarian Cysts May 2010
2 comments

5

Abstinence: The world’s oldest form of contraception May 2010
1 comment

January 3, 2011 at 12:22 am 2 comments

What happens in Vegas stays in Vegas (Sometimes)

I recently went to Las Vegas for a medical conference.  Everywhere I went, I saw signs with the slogan “What happens in Vegas stays in Vegas!”.  This led me to joke to one of my gynecologist friends– “Sure.  Except if it’s herpes.” 

I guess I thought that was funny at the time.  But it occurred to me that it’s dangerous to propagate the idea that acting out (sexually or otherwise) is without consequences.  

It’s not that there’s anything wrong with Vegas.  And I’m not one to knock bachelor/bachelorette parties and a night of cocktails.  But if being forewarned is being forearmed, then using a condom is some food for thought you won’t find at the $19.99 dinner buffet.  And I’d like to give you, gentle reader, the skinny on a few souvenirs you don’t want to bring home with you.

Some sexually transmitted diseases can be cured with antibiotics.  These include gonorrhea, chlamydia, syphillis and trichomonas.  All of these can be diagnosed with simple tests available in your doctor’s office. Treatment of sexual contacts is important, and should occur for both partners at the same time.  All can be prevented with the use of latex condoms.

Gonorrhea and chlamydia are often lumped together when discussing sexually transmitted diseased (STD’s).  They are distinct diseases caused by different microbes, but are often found together in co-infections.  Both can be asymptomatic.  When symptoms occur, they often show up 2 to 3 weeks after infection.  Common complaints include

  • A yellow vaginal discharge
  • Painful or frequent urination
  • Burning or itching in the vaginal area
  • Redness, swelling, or soreness of the vulva
  • Pain in the pelvis or abdomen during sex
  • Abnormal vaginal bleeding
  • Rectal bleeding, discharge, or pain 

Gonorrhea and chlamydia are diagnosed by laboratory analysis of samples taken from the cervix using a cotten swab.  Timely treatment of gonorrhea and chlamydia can prevent infertility, which can be a complication of advanced infection.  Treatment is usually oral medication or a combination of oral medication and a shot (like a flu shot) given in the arm.  Advanced infections may need to be treated in a hospital with intravenous medication.

  

 

Syphilis first appears as a painless genital sore called a chancre (pronounced like “shank-er”). It lasts 10 days to 6 weeks after contact with an infected partner. Swollen lymph nodes in the groin m ay also occur.  A rash on the palms and soles (of hands and feet) occurs durng a second stage of infection 1 week to 3 months later.  Flat warts or a flu-like illness may occur at this time.  Syphillis can be diagnosed with a combination of physical exam and blood tests.  Early treatment is important to prevent long-term problems including birth defects in children of infected mothers.  Treatment usually consists of antibiotics given as a shot (in the arm or buttocks) and may need to be given more than once. 

Trichomonas vaginitis is a microscopic parasite that is spread through sex. Many people have no symptoms of trichomonas. When symptoms do occur, they include discharge from the vagina and vaginal itching and redness.  Trichomonas can be diagnosed on a vaginal exam (sometimes in combination with testing samples of vaginal fluid). Treatment usually consists of oral antibiotics or an antibiotic gel which is placed in the vagina. 

Some sexually transmitted diseases can’t be cured.  Usually, these are due to viruses. 

Human Immunodeficiency Virus (HIV), Human Papilloma Virus (HPV), Herpes Simplex Virus (HSV), and Hepatitis B and C can all be sexually transmitted.  All can be treated with medication, but none can be cured.

Human Immunodeficiency Virus (HIV) is the virus that causes AIDS (Acquired Immunodeficiency Syndrome). Transmission can occur during intercourse.  It is possible for transmission can occur through orogenital (oral) sex too.  Anal sex is particularly risky.    Transmission rates can be significantly decreased with the use of a latex condom.  It can be diagnosed with a blood test and is treated with antiviral medications.  Untreated, it can cause compromise of the immune system, illness, and death.

Human papillomavirus (HPV) is one of the most common STDs in the United States.   There often are no signs of genital HPV. However, a few types of HPV cause warts. These can appear on the vulva, vagina, cervix, and anus. In male partners, they may occur on the penis, scrotum, or anus.

Sometimes warts go away on their own. If they do not, there are several treatments for warts available at your doctor’s office. Treating yourself with over-the-counter wart medications (compound W etc.) is NOT recommended.

Even after the warts have cleared up, the virus may be present. The virus can remain in the body for weeks or years without any symptoms.

Certain types  of the HPV virus are associated with an increased risk of cervical cancer.  HPV also may be linked to cancer of the anus, vulva, vagina, penis, head, and neck. 

Some types of HPV infection and pre-cancerous changes in the cervix are detected with a Pap Smear or Pap Test.  So while your Pap Smear doesn’t test for sexually transmitted diseases per se, it can diagnose HPV-related conditions. 

If abnormalities associated with HPV are found on your Pap Smear, your doctor will discuss diagnosis and treatment options with you.  You may also want to discuss the HPV vaccine, which prevents several types of HPV infections, and can be given to most girls and women aged 9-26 regardless of whether they have had an HPV infection in the past.

Herpes Simplex Virus (HSV) causes herpes.  It also causes “cold sores” on the face and mouth.  Although people sometimes refer to the HSV 1 virus as “oral herpes” and the HSV 2 virus as “genital herpes”, both viruses can cause lesions in both areas, so this distinction  isn’t particularly useful.  The best description is to say that genital herpes is any herpes ocurring on the genitals, regardless of virus subtype (1 or 2).

The most common symptom of genital herpes is a sore on or around the genitals. These sores are often multiple, usually red or blister-like, and may be itchy or exquisitely painful.  The sores can last from a few days to a few weeks.  Herpes can be diagnosed by a combination of physical exam, viral culture of open sores, and blood tests.

The symptoms go away by themselves, but the virus remains in your body. The sores may come back at any time, usually in the same place they first occurred. Treatment can help heal the sores and reduce the number of future outbreaks, but it cannot kill the virus. 

A person who has herpes can transmit the virus even in the absence of symptoms.  If you or your partner have oral or genital herpes, avoid sex from the time of first symptoms until a few days after the scabs have gone away.

The Hepatitis B and C viruses can also be transmitted by sexual intercourse. Hepatitis may occur with limited or no symptoms, but often leads to jaundice, anorexia (poor appetite) and malaise.  Hepatitis is acute when it lasts less than six months and chronic when it persists longer.  Chronic hepatitis may be asymptomatic, but can cause cirrhosis (scarring of the liver), liver failure, liver cancer, and death.  Hepatitis B and C can be diagnosed by blood tests.  Treatment is directed at reducing symptoms and slowing the progression of the disease. 

The Hepatitis B vaccine reduces the risk of contracting hepatits and is widely available.  It is recommended to all children and to high-risk adults (those with multiple sexual partners, who use intravenous drugs, or who are in occupations which may involve exposure to blood or other bodily fluids).  There is no hepatitis C vaccine. 

Hepatitis A, by the way, is not sexually transmitted.  It is food-borne and does not result in chronic infection. It causes an acute gastrointestinal illness and is often contracted by eating undercooked shellfish.  So, You can still get it in Vegas.  You’re welcome.

So, remember, there are some souvenirs nobody wants to bring home from vacation (or any other encounter).  If you have a new sexual partner or have any other reason to think you may be at risk for sexually transmitted infection, visit your heathcare provider for simple tests. 

And since I started this post with a poorly conceived joke, I’ll end with one.  Practice safe sex: Use your head (and use protection when giving it)!

November 18, 2010 at 9:03 pm 4 comments

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Linda M. Nicoll, MD

Welcome to my blog! Here you will find information about minimally invasive gynecologic surgery as well as some more general information about common gynecologic disorders such as endometriosis, ovarian cysts, fibroids, infertility, and pelvic pain.

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