Posts tagged ‘gynecologist’

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

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

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

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

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

Why are there so many different types of oral contraceptives? – The Estrogen Equation

Well, if you’ve read my previous post (which I’m sure you did!) you already know that the two main components of combined OCP’s are estrogen and progesterone.  What makes each type of pill distinct is the way in which these two components are dosed and formulated.  In this post, let’s discuss only the estrogen component.  We can talk about the progesterone later.

Combination OCP’s can be described as low-dose, medium-dose or (rarely) high-dose.  This refers to the dose of estrogen in the tablet.  A low-dose pill usually contains 20 micrograms of estrogen.  Medium dose pills contain between 30 and 35 micrograms.  Higher doses can go up to 50 micrograms.   

Why does it matter?  Well, a low-dose pill is great for somebody who needs the pill for pregnancy prevention, but doesn’t require the higher doses needed to suppress other conditions (like endometriosis or excessive menstrual bleeding).  A low dose of estrogen also minimizes the risk of complications from oral contraceptives (such as an increased risk of blood clots and other potentially life-threatening medical conditions). 

So, why wouldn’t everyone choose to take a low-dose pill?  Some women taking low-dose pills may not have bleeding during the week of placebos (inactive pills) because the low dose of estrogen keeps the lining of the uterus (womb) very thin.  Therefore, little tissue is shed (as menstrual flow) when the body withdraws from the estrogen.  Amenorrhea (absence of a period) can be normal and healthy in this situation and is not a cause for concern in the absence of other symptoms. 

In some women, bleeding between periods (metrorrhagia) may occur when the dose of estrogen is too low to stabilize the lining of the uterus between cycles.  If this occurs, it doesn’t mean the pill isn’t protecting you against pregnancy.  It just means you may need to switch to a different pill in order to reduce inconvenient or unpredictable bleeding

Spotting or mid-cycle bleeding can also be more likely to occur on a low-dose pill if doses are missed or are taken late.  Therefore a low-dose pill may be a poor option for women who can’t manage to take their pill on time every day.  Obviously, back-up contraception (a condom, perhaps?) should be used when necessary.

Oral contraceptives with 30 to 35 micrograms of estrogen may be a better choice for women who need to suppress their menstrual cycles because of endometriosis, pelvic pain, excessive menstrual bleeding (menorrhagia), or who have had irregular bleeding on lower dose oral contraceptives. 

If they dose of estrogen is the same in every pill, the type of pill can be called “monophasic.”  Some oral contraceptives have a dose of estrogen which varies from the first to the third week (triphasic).  These pills are meant to mimic the natural variation in hormones that occurs during a normal menstrual cycle.  Whether a monophasic or a triphasic pill is right for you will depend on a number of factors which you may wish to discuss with your gynecologist.

June 9, 2010 at 10:12 pm 1 comment

Oral Contraceptives: The little pill that could (and did!)

Continuing our journey through the world of contraception, I think The Pill deserves special mention.  It has been used in the US since 1960 as a way of preventing pregnancy.  It continues to be one of the most popular methods of birth control.

Running the risk of waxing overly poetic, I’ll tell you that The Pill has a long and storied history which has helped shape the roles of women in society.  It has freed a generation of women from fear of unwanted pregnancy and has helped countless others battle the miseries associated with their monthly gift.  But what is this miracle tablet?  What’s in it?  And  how is it used?  

‘The Pill’ is a common term for what the medical community calls a ‘combined oral contraceptive’ or ‘oral contraceptive pill’ (OCP).  This consists of a combination of estrogen and progesterone which is taken in order to prevent pregnancy. 

It does this in several ways.  The most important of these is that OCP’s prevent ovulation, the release of an egg from a woman’s ovary.  No egg, no baby.  Easy. 

It also causes a thickening of cervical mucus.  While this may sound kinda icky, it actually serves the important purpose of reducing the likelihood sperm will be able to pass through the cervix and up through the uterus and tubes on its way to fertilize an awaiting egg (which isn’t going to be there anyway… see above).  No egg-sperm rendezvous, no baby.

It also causes a thinning of the lining of the uterus, reducing the likelihood that, even if a runaway egg and super-ambitious sperm were to elope successfuly, a resulting embryo would not be able to implant.  No implantation, no pregnancy.  (This, by the way, is NOT an abortion.  An embryo needs to implant in order to establish a pregnancy.  Otherwise, you get a normal period.) 

In order for an OCP to effectively prevent pregnancy, it needs to be taken every day for 21-24 days a month.  In a best-case scenario, it should be taken at the same time every day.  This is what’s called “perfect use.”  Humans are not perfect.  Given an opportunity to screw up, we will most likely take it at some point in our lives.  This is called “typical” use.  Therefore, when we talk about the likelihood somebody will get pregant while taking OCP’s we talk about “perfect” and “typical” use patterns. 

The pregnancy rate among “typical” users of OCP’s varies depending on the population being studied and ranges from 2-8% per year. On the other hand, the rate of pregnancy among “perfect” users of OCP’s is about 0.3% per year.  I don’t know about you, but I think that’s pretty good motivation to stive for “perfection.” 

Some combined oral contraceptives aren’t pills at all, but are administered as a vaginal ring (Nuvaring) or a patch (Ortho-Evra).  These can be good options for some patients who can’t reliably take a pill every day.  (However, the Ortho-Evra patch has been scrutinized for the possibility that it delivers more estrogen than most other combined contraceptives, including the ring, and that it may lead to an increased risk of blood clots in some patients.  See below.)

A caveat:  You want to talk to your gynecologist before starting an OCP.  The pill doesn’t protect you against sexually transmitted diseases (STD’s).  If you are at risk for STD’s, you should be using a condom and getting tested at regular intervals.

The Pill also has some risks.  That’s because combined oral contraceptives (those containing estrogen) can increase a woman’s risk of blood clots, heart attack and stroke.  This risk is minimal if you are young (under 35– ouch!), otherwise healthy, and do not smoke.  You should ask your gynecologist (or other healthcare provider) about your risk factors to help determine whether The Pill is a safe option for you.

If you have certain medical problems (like heart disease, a prior blood clot, or a history of certain types of cancer), are a smoker over 35, or are taking certain other types of mediation, you should not take estrogen-containing combined oral contraceptives. Ever. There are other, potentially safer options out there for women who can’t take OCP’s.  More on that in a future post.

I’m also planning a post to explain WHY OH WHY there need to be SO MANY different pills out there!  Really, I promise there’s a good reason.  See you soon!

June 4, 2010 at 3:55 pm 7 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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