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

Vaginal Discharge: The Good, The Bad, and The Ugly

One of my patients’ most common gynecologic complaints is about vaginal discharge.   It’s not something most women want to talk about.  I mean, if you watch enough commercials for “feminine hygeine products” you start to think that vaginal discharge will make you a social outcast who wears loose, flowy clothing  in varying shades of mauve and gray. 

But what causes vaginal discharge?  When is it normal? What can you treat at home?   And when do you need to see a gynecologist?  Those are some of the questions I’d like to address in this post.

First of all, vaginal discharge is one of the symptoms of a medical condition gynecologists call “vaginitis.”  Literally, it means inflammation of the vagina.  (And you thought taking Latin in high school would never come in handy.)

They key to vaginitis is the vaginal flora.  Vaginal flora aren’t roses and peonies blooming in your nether-regions.  They are microscopic organisms, like bacteria and yeast, who normally live in the vagina and are beneficial.  They need a certain level of moisture, acidity, and estrogen in order to function properly.  When the balance of normal vaginal flora is upset, vaginitis can result.

Normal vaginal discharge is often clear, white or yellow.  It can be thin and watery, creamy or similar to mucus in character.  Normal vaginal discharge may lack an odor or may smell musky (as opposed to abnormal discharge, which often smells foul and unpleasant).   When the vagina is in a healthy balance, it shouldn’t smell bad, burn/itch or hurt. 

The normal balance of vaginal flora may be upset by activities such as douching and tampon use.  Both can worsen the symptoms of vaginitis and should be avoided while symptoms persist.

One of the most common causes of vaginitis is a yeast infection.  These are caused by a fungus called candida which is normally found in small amounts in the vagina.  When candida overgrows, the symptoms of a yeast infection may occur.  These include itching and burning of both the vagina (inside) and the vulva (the outside skin near the vagina).  Symptoms may be worse after urination or intercourse. Some (but not all) women notice thick white discharge which may be odorless.    

Risk factors for developing a yeast infection include pregnancy, diabetes mellitus, recent antibiotic use, human immunodeficiency virus and oral contraceptive use.  Treatment is available by prescription or over-the-counter.  It usually involves antifungal medication (cream or suppository)  inserted in the vagina for 1 to 7 days.  Oral treament with a pill may also be offered, but is available by prescription only.  Longer courses of treatment may be necessary  Sexual partners do not require treatment. 

Bacterial vaginosis (BV) is caused by an overgrowth of certain vaginal bacteria, particularly gardnerella.  The main symptom of BV is increased discharge can be copious (a large quantity)and may be white, gray or even greenish in color.  A strong, fishy vaginal odor is often present.  The odor may increase after a mesntrual period or after sexual intercourse.   Itching may also occur.

Treatment is by prescription antibiotics.  Metronidazole (Flagyl) gel or oral capsules are prescribed for 5 days.  Oral metronidazole can not be taken in combination with alcohol or severe nausea/vomiting may occur.  Clindamycin suppositories or cream can be used for 3 to 7 days.   Longer courses of treatment are sometimes necessary. Sexual partners do not require treatment.

Vaginal discharge may also be a symptom of trichomoniasis.  This is a condition caused by the microscopic parasite Trichomonas vaginalis. It is a sexually transmitted disease (STD). Signs of trichomoniasis may include a yellow-gray or green vaginal discharge.  The discharge may have a fishy odor, which may lead one to confuse it with bacterial vaginosis. Burning, irritation, redness and swelling of the genitals may occur.  Pain may occur during urination. 

Trichomoniasis is usually treated with metronidazole (flagyl) by mouth.  Women who have trichomoniasis are at an increased risk of infection with other STDs, so they should be screened accordingly.  Sexual partners must be treated to avoid re-infection.  Sexual intercourse shoudl be avoided until both partners have received treatment.

Vaginal discharge may also be a sign of atrophic vaginitis.  This condition can occur when the level of estrogen in the body drops, as usually happens during breastfeeding or menopause.  Symptoms include dryness, itching and burning of the vagina.  Discharge may be present and pain may occur during sexual intercourse.  Treatment is usually aimed at restoring estrogen to the vagina through topical medications.  Water-based lubricant can also be helpful, especially during intercourse.

In summary, vaginitis and discharge are common conditions which may require special diagnostic tests and/or treatment by a gynecologist.  If you are experiencing bothersome symptoms, especially if over-the-counter treatments have failed, it is time to talk to your doctor.

October 19, 2010 at 7:39 pm 31 comments

The Office

Having a good experience at the doctor’s office isn’t just about choosing a good physician. For better or for worse, a doctor’s office itself, as well as his or her staff can contribute significantly to the care you receive. As such, they are often seen as a reflection on the doctor himself.

Most doctors take pride in keeping an office that’s clean and efficient. It’s a good sign when your doctor is conscientious about the environment in which you receive care. While Persian rugs and Ming vases make for an impressive waiting room, it’s more important that an examing room be well lit, clean, and stocked with essential tools.

Blood drawing is usually available in the office. Some doctors have access to bedside ultrasound or obstetric monitoring. You may ask whether these are accessible or are performed off-site. If services are off-site, check if they take your insurance in order to avoid a surprise bill.

The most important tool in the physician’s arsenal is his or her staff. Receptionists are responsible for keeping the office moving. They are the gatekeepers to your care, handling the often difficult task of finding convenient appointment times, arranging off-site testing, rescheduling missed visits, and contacting the doctors in-between patients in cases of emergency. They help keep the doctors running on time by avoiding disturbances to the doctors’ schedule (thereby minimizing your wait time – a big plus!).

Receptionists should be polite, helpful, well-organized, and efficient. In return, they should be treated with respect and patience. If you find that access to your doctor is limited by poor service at the reception desk, you should share these concerns with your doctor. He or she has a definite interest in making sure your needs are met and may have ways of facilitating optimal service.

Medical assistants, phlebotomists and other office staff are also key to providing good care. They should be polite, attentive, and accurate in performing their assigned tasks. It’s often frustrating when you find that somebody has difficulty drawing your blood or takes your blood pressure with a cuff you feel was too tight. It’s important to discuss concerns about their service with your doctor, as he or she relies on the quality of their work in interpreting your results.

That being said, going to the doctor is never going to be fun. When you’re a patient, you may be nervous about your health, pressed for time to return to work, or caring for little ones in a waiting room that’s designed for adults. Let the staff know when you’re struggling with something so that they can do everything possible to make you more comfortable.

If you give (hopefully positive!) feedback about the office to your doctor, you’ll be doing both of you a favor.

September 23, 2010 at 10:47 pm 1 comment

How do I find a good gynecologist?

I always ask new patients, “How did you find me?”  The answers I get are fascinating.  Some patients see me because their friend is my patient and they were told I am a good doctor.  Others are referred to me by their primary care providers or other specialists.  Some patients picked my name out of a register of providers in their insurance network.  Still others found me on the internet.

It all seems so random.  There are so many doctors out there and so many ways to pick from among them.  But (besides getting a recommendation from a doctor, friend, or family member you trust) what’s the best way to pick a doctor?  And once you’ve selected one, how can you check-up on the person who does your check-ups? 

The importance of finding a good gynecologist can't be understated!

There are certain things I look for when choosing a doctor.  For one thing, I’d like somebody who takes my health insurance.  If you don’t have coverage for out-of-network providers, it can be a burden to pay “out-of-pocket” for health services.  (It may be worth paying extra to see a doctor with special training or qualifications, but that depends on your healthcare needs and your ability to cover the cost.)

The website for your health insurance company probably lists covered providers in a database that can be searched by specialty and location.  Always call the doctor’s office to find out whether a provider is in your network (or will accept your out-of-network benefits).  Online lists may be out of date and include providers who are no longer in network and may not include providers who have joined more recently.

If you don’t have health insurance, you can call a doctor’s office to inquire about his or her fees before the visit.  Also ask about additional fees for lab work or pathology (which can be important if you are having testing for sexually transmitted diseases, are having a Pap smear, or need a biopsy).  Otherwise you may be surprised by the amount you are charged at check-out or by mail a few weeks later.

Once you have selected a few possible providers, you’ll want to find out a little more information about them.  Many providers have a website for their practice or have a bio posted on a hospital website.  This information may help you learn where the doctor went to college and medical school.  You can also find out where he or she completed residency (and in which specialty), and where any fellowship or advanced training took place. 

The government is also checking up on your doctor.  This is done through a process through which physicians must apply for and maintain a license to practice medicine in a given state.  Physicians submit information to the state medical board who evaluate the adequacy of a physician’s training.  They also seek to know whether a physician has been convicted of a crime, and whether he or she is fit (physically, mentally) to practice. 

Most physicians will make their state license readily available, often displaying it in their office.  The medical board of most states also offer a site online where you can look up a physician by name.  The American Medical Association has a site where you can find a link to your state medical board. Physicians can (and often do) hold licenses in multiple states.

Whatever you do, make sure your doctor makes you comfortable at the time of your visit.  A positive relationship with your doctor is key to making good health decisions!

September 7, 2010 at 11:51 pm 31 comments

Whose advice are you taking anyway?

Hello all!  Sorry I’ve been out of touch for a while.  After a brief vacation, I think I suffered a sense of discouragement under the impression that my blog was being frequented exclusively by my facebook friends (thanks guys!  keep reading!) and not reaching anybody new.

So imagine my surprise and joy when a patient came to my office with the following request “I want an IUD like you describe on your blog.”  No way!  Somebody who had never met me read my blog, liked what she read, and acted upon it to improve her healthcare.  Wow. 

So that got me thinking about how people find health information on the internet and who they go to when they seek healthcare.  So many of my patients come in to the office with questions they think about after a perusal of others’ internet blogs and Mommy/Baby related bulletin boards.  They often quote something they saw on ‘The View’ or mention an advertisement on T.V.

I want you to be careful what you read.  Obviously, an advertisement is aimed to sell you something.  But I’m not just talking about the pharmaceutical company ads that suggest you allow a fluorescent green butterfly to lull you to sleep.

If you read somebody’s post or watch a T.V. segment and think “Hey, now there’s something I should do!” you should first consider the following:  Who is this person giving advice? 

Is it a doctor? Not everybody who calls themself a doctor is a physician.  Then again, as Dr. Evil (from the Austin Powers movies) so succinctly puts it “I didn’t spend 4 years in Evil Medical School to be called Mister Evil.” 

Dr. Evil

Any person who received a doctorate in any field of study can call themself a doctor.  For example: Dr. Ruth completed a PhD in psychology and a masters in sociology.  She can give you great advice, but she can’t write you a prescription and won’t do your pap smear.  Remember “Ross” on friends?  He was Dr. Geller, a PhD in paleontology.  You wouldn’t let him give you medical advice of any kind, would you?  Unless you were a dinosaur. (And don’t get me started on Dr. Phil, who also has a psychology degree and who also is not performing my pap smear.)

In contrast, Dr. Mehmet Oz, Dr. Drew Pinsky and even Dr. 902010’s own Dr. Robert Rey have medical doctorate (M.D.) degrees.  They are physicians, like me.  Wait, did I just say Dr. 90210 is like me?  Well, nevermind.  But eew.

A physician can also be a D.O. (doctor of osteopathy, a degree which is essentially identical to an M.D.).    A physician may call him or herself by a first, last, or nickname.  But they’ll all tell you about their hard-earned degree and extensive medical training.  That information is usually also available by reading their bio (see mine) on a website, on Google, or by looking at their degree-covered wall.  My Mom made sure all of mine had matching frames.  Seriously.

Most practicing physicians have completed a residency in some field of medicine (Internal Medicine, Neurosurgery, Dermatology, Obstetrics/Gynecology, etc) which can take three to seven-plus years of training in addition to the four years spent in medical school.  That’s a whole lot of years devoted to the study and practice of medicine before anybody is going to let you hang up your shingle.  And even then, you definitely want to check out your doctor before you check in for a visit (more on that in my next post, but kudos to me for the pun).

Is it a nurse?  Nurses also give great medical advice.  A nurse may have L.P.N. (licensed practical nurse) or R.N. (registered nurse) after her name.  A nurse practitioner has had additional training and may add N.P.  Back in the old days, each nursing school had a different shape of those white nursing caps you still see in old movies.  A nurse was literally wearing her bona fides on her head.  Nowadays, a person who calls him or herself “Nurse” will usually be proud to tell you of her hard-earned degrees and outstanding qualifications. 

Julianna Margulies (as Nurse Carol Hathaway on E.R.)

On the other hand, a lot of information on websites, blogs and bulletin boards comes from people just like you.  Patients who may or may not have any formal medical knowledge can use the internet to share information and help other people who may find themselves in similar circumstances.  This is incredibly empowering.  Learning about other people’s experiences can lead patients to ask better questions, seek alternative treatments, and otherwise ensure that the care they receive is the best available. 

But beware of negative posts describing the unfortunate experience somebody had with a disease, doctor, hospital or medication.  The internet is often a place where posts describing gripes far outnumber those recounting tales of successful care.  People who are pain-free, pregnant, or otherwise relieved of their health woes are less likely to spend hours on the computer blogging/posting about it.  They are often busy working, raising children, and enjoying their family and friends.   

A person who is dissatisfied with her care may have ample reason to be unhappy.  People out there really get crappy care/luck sometimes, and some of the things I read absoultely break my heart.  But if there’s supposed to be a take-home message from somebody’s post, you’ll want to find a reliable source against which to check it.

So if you see something on the internet that sounds like somebody giving you advice, it’s best to talk it over with somebody who is is medically knowledgeable and trustworthy.  And I’m going to hope your doctor or nurse is one of those people.

August 3, 2010 at 8:30 pm Leave a comment

The IUD 4 U! (An intro to the Intrauterine Device)

I think it’s time to introduce you, faithful reader, to the best contraceptive you’ve probably never used.  Yet.    

 An intrauterine device (IUD) is a small, flexible, “T”-shaped piece of plastic which is inserted into a woman’s uterus. Its job there is to prevent pregnancy. IUD’s are a very popular method of birth control throughout the world, but only 2% of women in the United States choose this method from among the many contraceptive choices we enjoy.    

There are two types of IUD approved by the FDA (the US Food and Drug Administration).    

The Mirena IUD is distinguished by its hormonal activity. The plastic in the device releases a small amount of levonorgestrel, which is a type of progesterone similar to those found in birth control pills. The amount of progesterone in the IUD is much much MUCH less than in a birth control pill. It only acts locally, on the uterus and cervix, as opposed to circulating around the body to be absorbed systemically.     

Mirena IUD

  

    

The progesterone in Mirena causes a number of changes in the uterus and cervix. First of all, it makes the cervical mucus thick and inhospitable to sperm. They can knock all they want, but they can’t get in. Sorry guys, you don’t have to go home but you can’t stay here.    

But your Mirena doesn’t stop there. It also affects the fallopian tubes. So, whereas the cells lining the fallopian tubes normally ferry the egg down toward the uterine cavity, these cells slow down under the influence of progesterone. The egg is delayed at the departure gate and never makes the flight to rendezvous with her awaiting sperm (assuming he somehow got past security). Honeymoon cancelled. No pregnancy.    

The lining of the uterus is also affected by progesterone. It thins out and becomes inhospitable to a pregnancy. So even if a fertilized egg were to arrive in the honeymoon suite, it would find a cruddy motel room it wouldn’t want to stay in anyway. This thinning of the uterine lining also has the added benefit of giving you shorter, lighter periods. Yay!    

The other kind of IUD is called Paragard. It does not contain ANY hormones. It has a copper coil around the shaft of the “T”. This coil slowly releases copper ions into the uterine cavity. This makes the womb inhospitable to both sperm and egg. It’s a toxic environment where fertilization is unlikely to occur and pregnancy can’t establish itself. Like your mother-in-law’s house.    

Paragard IUD

  

Both types of IUD have thin strings which pass through the cervix and allow the IUD to be easily checked (to see if it’s in place) or removed. A Mirena IUD lasts up to 5 years before it needs to be replaced. A Paragard lasts up to 10 years. Both can be removed anytime after placement if a woman changes her mind or if side effects (such as light bleeding between periods) are troublesome.     

On a serious note, I’d like to remind you that none of this represents an abortion.  If a fertilized egg never implants, it hasn’t established a pregnancy.  It passes with the next menstrual cycle.  You get a period.  Period.    

 So, why wouldn’t everyone want one of these?  Well, for starters, you can’t just pick one up at your local pharmacy. An IUD needs to be inserted in the uterus by a healthcare professional. This can be done during a woman’s peroid to minimize discomfort. It’s often easy to insert in a woman who has been pregnant in the past. It’s a little more tricky if a woman has never been pregnant, but obstacles can be overcome with a little medicine and proper counseling.    

The other reason an IUD requires careful consideration is that it’s not a great form of contraception in women who are not in a monogamous, trusting relationship. An IUD does not protect against sexually transmitted infections (but it doesn’t CAUSE them either). However, if you get a sexually transmitted infection, like gonorrhea or chlamydia, with an IUD in place, it can turn into a very serious medical condition called pelvic inflammatory disease. This may require hospitalization and DEFINITELY requires removal of your IUD.    

I think it’s also a good idea to address myths about the IUD.  The IUD does not cause ectopic (tubal) pregnancy.  A woman with an IUD in place is LESS likely to have an ectopic preganancy than either woman who is not using contraception or one using condoms.  However, in the unlikely event that a pregnancy occurs in woman who has an IUD in place, she needs prompt medical evaluation.      

A properly placed IUD is also very unlikely to ”slip out of place.”   Whereas an IUD can be lost (i.e. slip out of the uterus and into the vagina, from which it will inevitably fall out), it would be pretty obvious that your IUD isn’t protecting you anymore when it shows up in your panties or toilet.  If the IUD is put in place properly, it CAN NOT migrate up the uterus/tubes and into the abdominal/pelvic cavity.  But that’s why it’s important to have the IUD placed by a trained professional.    

In summary, an IUD is a great way to prevent pregnancy. They may be an especially good idea in women who have been pregnant in the past and are at minimal risk of contracting a sexually transmitted infection. They are placed by a healthcare provider and can stay in place for 5 to 10 years if desired.    

For more information, try this link to the American College of Obstetrics and Gynecology’s patient education materials on the intrauterine device.  Planned Parenthood also has a very informative site.    

And if you still have questions, you know who to ask!

June 25, 2010 at 11:05 pm 25 comments

Progesterone In Your Pill: If the shoe fits, wear it!

So, what makes one combination oral contraceptive pill (OCP) different from another?  What’s the difference between brand-name and generic versions, if any? 

The answer generally boils down to one word: progesterone.  How do we know this?  Because the chemical composition of the estrogen component of almost every OCP marketed in the U.S. is exactly the same.  It’s ethinyl estradiol.  The only thing that changes from pill-to-pill is the dose (thus the idea of “low dose” pills, “triphasic” pills etc), as described in my previous post

So, although all “low dose” OCP’s may contain 20 micrograms of estrogen, there are dozens of different kinds because each manufacturer uses one of eight different kinds of progesterone in each type of pill. 

Progesterone

The type of progesterone is indicated by the second word in the pill’s generic name.  For example, Loestrin is ethinyl estradiol and NORETHINDRONE.  Other pills have other progesterone components (i.e. Ortho-Tri-Cyclen and Ortho-Tri-Cyclen-Lo contain NORGESTIMATE, Yasmin andYaz contain DROSPERINONE).  You get the idea.

So, why do we need so much variety?  Can’t everyone just use the same pill in different doses?  Like Advil or Tylenol, just use a higher dose if you need more of it?

Well, it’ s not that simple.  The dose isn’t the important thing (it’s usually low, about 1-2 mg).  It’s the differences in the chemical characteristics of the progesterone that make each pill unique and separate it from its similar contraceptive cousins.   

Some progesterones have a higher level of progestational activity.”  This means the degree to which it binds with progesterone receptors in the body.  In addition to preventing pregnancy, stronger progestational agents can lessen menstrual bleeding, reduce acne, lessen excessive hair growth, etc. 

Some progesterones have an effect on blood levels of potassium or cholesterol.   Some can increase a person’s risk of blood clots.   These risks and benefits are an important topic to discuss with your gynecologist (or other prescriber). 

As if things weren’t confusing enough, generic OCP’s have active ingredients (estrogen and progesterones) which are chemically identical to the brand-name version.  They are, however, made by different manufacturers. They may contain different additives or be formulated in a slightly different way.

That’s why some people find that, while the brand name version worked well for them, different symptoms occur when they switch to the generic version(or vice-versa).   This means you may need to pay more (or less) for the version you prefer.  The cost difference can be significant ($50 or more!), so consider the choice carefully. 

It’s often difficult to predict which oral contraceptive (and which progesterone) will work best with a particular person’s chemistry.  While your gynecologist (or other provider) can often guide you toward picking an oral contraceptive which is the most likely to satisfy your partiuclar needs, sometimes, it’s necessary to try out a few different types before you hit on a pill that you like.  

But when you do…  Wow.  It’s like Cinderella fitting perfectly into that glass slipper and living happily ever after.   And not getting pregnant on that pumpkin-carriage ride home.

Happily Ever After

June 21, 2010 at 11:16 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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