Gynecology
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Birth Control (Oral Contraceptives, IUDs, Nuvaring)
Bleeding Cancer Screening Colposcopy Endometrial Ablation Essure Incisionless Tubal Ligation Gardasil |
Healthy Living (Diet and Exercise)
Infertility LEEP Menopause Urinary Tract Infections Vaginal Dryness Vaginal Infections Primary Care Referral |
Birth Control
We choose from a wide variety of birth control pills (oral contraceptives) depending upon a patient's medical needs and with the goal of maximizing efficiency, minimizing side effects and keeping costs as low as possible. Please keep us posted if you are paying for your pills or your deductible is very high as we may be able to change products or help with coupons for you.
Please allow 3 months for your body to adjust to the pill. Side effects such as spotting, breast tenderness, mild nausea and acne often resolve over time. Serious complications are rare and include heart attack, blood clot and stroke. If you have chest pain, shortness of breath, leg pain/swelling or unusual headaches/visual changes, call us immediately.
Now available are seasonal type pills allowing you to have cycles only once every 3 months. This is safe and very helpful for many women. Ask us how to do this with your pill if you prefer or we can write for a product designed for this purpose. One example of this pill is Seasonique.
To delay your cycle you can insert an extra row of active pills prior to your placebo if all of your pills are identical (monophasic pill). This will help with upcoming weddings and vacations. Don't be alarmed if you spot a little during the extra pill week.
We also can recommend NuvaRing, a 2 inch ring inserted into the vagina for 3 weeks and removed for one. This contains estrogen and progesterone similar to the pill and is very low in dose, easy to use and wonderful for minimizing side effects. See www.NUVARING.com for added information. NuvaRing can be used continuously as long as it is changed every four weeks.
Another excellent option for contraception is the Intrauterine Device (or IUD). IUDs are easily placed in the office and provide easy, safe prevention. In general these devises are best placed for women in monogamous situations as exposure the sexually transmitted disease can lead to more severe infection and fertility complications in the future. We insert two different types of IUDs in the office, Mirena and Paragard.
Mirena- Contains a low dose of progesterone delivered to the uterus. This hormone allows for 80% reduction in menstrual flow and cramping. Side effects are minimal and include acne, and irregular spotting (especially in the months directly following insertion). This device is good for up to 5 years. Please visit mirena-us.com for more information.
Paragard- This is a copper IUD which is non hormonal. It is effective for 10 years, but associated with slightly heavier, crampier cycles for some women.
Our office will check your insurance for coverage for either the Mirena or Paragard IUD, so you can make an informed decision on which you would prefer. Any portion of the device or insertion not covered by your insurance will need to be paid before the procedure is done. Any women who have not had children vaginally will be given a prescription for a medication that will dilate their cervix slightly, to make the insertion easier. You should take regular strength Motrin or Tylenol 1 hour before the appointment, as there is a small amount of discomfort with placement. Most women compare the discomfort to menstrual cramps. The IUD can be removed at any time, if pregnancy is desired, or if you have negative side effects.
Please allow 3 months for your body to adjust to the pill. Side effects such as spotting, breast tenderness, mild nausea and acne often resolve over time. Serious complications are rare and include heart attack, blood clot and stroke. If you have chest pain, shortness of breath, leg pain/swelling or unusual headaches/visual changes, call us immediately.
Now available are seasonal type pills allowing you to have cycles only once every 3 months. This is safe and very helpful for many women. Ask us how to do this with your pill if you prefer or we can write for a product designed for this purpose. One example of this pill is Seasonique.
To delay your cycle you can insert an extra row of active pills prior to your placebo if all of your pills are identical (monophasic pill). This will help with upcoming weddings and vacations. Don't be alarmed if you spot a little during the extra pill week.
We also can recommend NuvaRing, a 2 inch ring inserted into the vagina for 3 weeks and removed for one. This contains estrogen and progesterone similar to the pill and is very low in dose, easy to use and wonderful for minimizing side effects. See www.NUVARING.com for added information. NuvaRing can be used continuously as long as it is changed every four weeks.
Another excellent option for contraception is the Intrauterine Device (or IUD). IUDs are easily placed in the office and provide easy, safe prevention. In general these devises are best placed for women in monogamous situations as exposure the sexually transmitted disease can lead to more severe infection and fertility complications in the future. We insert two different types of IUDs in the office, Mirena and Paragard.
Mirena- Contains a low dose of progesterone delivered to the uterus. This hormone allows for 80% reduction in menstrual flow and cramping. Side effects are minimal and include acne, and irregular spotting (especially in the months directly following insertion). This device is good for up to 5 years. Please visit mirena-us.com for more information.
Paragard- This is a copper IUD which is non hormonal. It is effective for 10 years, but associated with slightly heavier, crampier cycles for some women.
Our office will check your insurance for coverage for either the Mirena or Paragard IUD, so you can make an informed decision on which you would prefer. Any portion of the device or insertion not covered by your insurance will need to be paid before the procedure is done. Any women who have not had children vaginally will be given a prescription for a medication that will dilate their cervix slightly, to make the insertion easier. You should take regular strength Motrin or Tylenol 1 hour before the appointment, as there is a small amount of discomfort with placement. Most women compare the discomfort to menstrual cramps. The IUD can be removed at any time, if pregnancy is desired, or if you have negative side effects.
Bleeding
Abnormal bleeding is one of the most common problems we handle in our practice. The approach in general is based upon the patient's age and the pattern of bleeding which will usually hint to its cause.
For adolescent and young women irregular cycles are very common in the first few years after menarche, the first period. If cycles are still irregular after two years further evaluation is warranted. Lab work including thyroid function, prolactin (milk hormone), testosterone (male hormone), adrenal hormones and female hormones are assessed. We also look for other bleeding or clotting abnormality. Commonly, polycystic ovary syndrome is diagnosed. We may occasionally perform a pelvic ultrasound and physical exam to evaluate irregular bleeding but a full pelvic and pap can often be delayed until a girl is sexually active.
Most teenagers appreciate the regularity of a low dose birth control pill and can be safely started. On current low dose pills, weight gain, mood swings and are minimal as are more serious side effects such as blood clot, heart attack and stroke. We ask that patients do not smoke while on the pill (or ever).
For women with very heavy cycles again basic labs are drawn including a hemoglobin to look for anemia, thyroid check and female hormone levels including menopause levels. An ultrasound is usually done in our office to evaluate for polyps and fibroids. This is best done on day 4-7 of the menstrual cycle to allow the endometrium to be assessed at its thinnest. Please call us on day 1 of your cycle to schedule this appointment. A sonohysterogram is similar to an ultrasound but allows us to further evaluate the lining by placing a small amount of sterile fluid into the cavity. It causes a small amount of cramping which can be minimized by using Motrin 6oo mg 1 hour prior to the appointment. It is also best done early in the cycle. If we find a fibroid or polyp, an outpatient surgical procedure called a Hysterscopy and D&C (dilation and curretage) will be considered to discover the source of bleeding. If the ultrasound is normal, often hormonal correction can be obtained through low dose birth control pills and other hormonal remedies, including IUD insertion. We also routinely offer endometrial ablation to help minimize menstrual flow in women who have completed childbearing.
For adolescent and young women irregular cycles are very common in the first few years after menarche, the first period. If cycles are still irregular after two years further evaluation is warranted. Lab work including thyroid function, prolactin (milk hormone), testosterone (male hormone), adrenal hormones and female hormones are assessed. We also look for other bleeding or clotting abnormality. Commonly, polycystic ovary syndrome is diagnosed. We may occasionally perform a pelvic ultrasound and physical exam to evaluate irregular bleeding but a full pelvic and pap can often be delayed until a girl is sexually active.
Most teenagers appreciate the regularity of a low dose birth control pill and can be safely started. On current low dose pills, weight gain, mood swings and are minimal as are more serious side effects such as blood clot, heart attack and stroke. We ask that patients do not smoke while on the pill (or ever).
For women with very heavy cycles again basic labs are drawn including a hemoglobin to look for anemia, thyroid check and female hormone levels including menopause levels. An ultrasound is usually done in our office to evaluate for polyps and fibroids. This is best done on day 4-7 of the menstrual cycle to allow the endometrium to be assessed at its thinnest. Please call us on day 1 of your cycle to schedule this appointment. A sonohysterogram is similar to an ultrasound but allows us to further evaluate the lining by placing a small amount of sterile fluid into the cavity. It causes a small amount of cramping which can be minimized by using Motrin 6oo mg 1 hour prior to the appointment. It is also best done early in the cycle. If we find a fibroid or polyp, an outpatient surgical procedure called a Hysterscopy and D&C (dilation and curretage) will be considered to discover the source of bleeding. If the ultrasound is normal, often hormonal correction can be obtained through low dose birth control pills and other hormonal remedies, including IUD insertion. We also routinely offer endometrial ablation to help minimize menstrual flow in women who have completed childbearing.
Cancer Screening
Despite recent controversy in the media, we continue to follow the American College of Obstetrics and Gynecology guidelines in mammogram recommendations. This includes monthly self breast exam (ask us how if you are uncertain), yearly clinical breast exams and mammograms.
We recommend a baseline mammogram at 35 and then yearly mammograms beginning at age 40. We know and are most comfortable with the radiologists at Beaumont Hospital and the equipment used involves Digital Mammogram which is particularly helpful in younger women. We are also using 3D imaging/Tomograms for dense breasts, first baseline mammograms, and strong family history. You will need to call your insurance company to verify coverage, as not every plan covers this testing.
Please know that about 15% of patients will need added views. DO NOT PANIC. This is a precaution in most cases. You will usually be informed prior to leaving the department if a biopsy will be indicated. Again, DO NOT PANIC. We will contact you immediately when we receive a report. This may take up to 7 days. If you have any atypical findings, we will refer you to the Breast Cancer Surgeons at Beaumont who are wonderful. They have a large amount of experience, excellent surgical skills and compassionate bedside manner. Drs. Dekne, Bongers, and Walker are available at 248-551-2200. They can usually see patients within 1-2 weeks. Please call us if there is any difficulty in arranging your appointment. Dr. Ruth Lerman, who specializes in second opinions for high risk women, and difficult finding on breast exam is also available at 248-551-3300.
Overall American women have a 1 in 10 chance of developing breast cancer and a 1 in 55 chance of developing ovarian cancer during their lifetime. Many patients have a very strong cancer history in the family. Particularly concerning would be first degree relatives such as a mother, daughter or sister with breast cancer especially prior to menopause or ovarian cancer at any age. This may indicate a gene mutation in the family. Ashkenazi Jewish patients of European Jewish descent are particularly at risk. Genetic testing provides information on the likelihood of developing these diseases in the future. Knowing your cancer risk may help you to make better informed decisions about screening and prevention options. Genetic testing for breast and ovarian cancer is a way to determine if you or a family member carries a gene mutation that increases the risk of these diseases. This testing is available in our office and may be covered by your insurance. The decision to test is extremely personal and genetic specialists are also available to sort through complicated family history and help provide extensive information about options if testing is positive or negative. (contact genetics) Please ask us about your risk and keep us updated about your family history. For more information on genetic testing, visit www.myriad.com.
Colon cancer screening is encouraged for most patients with a baseline colonoscopy recommended by age 50 and rectal exams and tests for blood in the stool annually on exam. The good news is that screening has become easier with improved prep regimens and excellent anesthesia options for comfortable testing. Cologuard is a new innovative test with a 92% cancer detection rate that will be used to screen patients unable or unwilling to do colonoscopy. This test will only be used for the low risk populations.
Ovarian cancer screening unfortunately has not proven very successful despite many clinical trials aimed at early detection. Ovarian cancer does tend to present as late stage disease but recent approaches with aggressive surgery and chemotherapy have been able to improve lifespan and quality of life. Symptoms are vague and include bloating, gastrointestinal distress, pelvic cramping or fullness, fatigue and weight loss. Testing includes a pelvic exam, ultrasound and occasionally blood work such as CA125. This last blood test has caused a bit of controversy over the last decade. This test is not recommended for routine screening because of false positives and negatives. Unlike the PSA made exclusively in the male prostate, CA125 is made by the entire peritoneal lining and can be elevated falsely in many non cancer situations. I will never deny a patient access to this test but discourage its use as a routine as it may prompt unnecessary surgery and tremendous anxiety if elevated. However, if you have symptoms you are concerned about, please share them with me and mention you are worried about ovarian cancer so that we can discuss your concerns fully.
We recommend a baseline mammogram at 35 and then yearly mammograms beginning at age 40. We know and are most comfortable with the radiologists at Beaumont Hospital and the equipment used involves Digital Mammogram which is particularly helpful in younger women. We are also using 3D imaging/Tomograms for dense breasts, first baseline mammograms, and strong family history. You will need to call your insurance company to verify coverage, as not every plan covers this testing.
Please know that about 15% of patients will need added views. DO NOT PANIC. This is a precaution in most cases. You will usually be informed prior to leaving the department if a biopsy will be indicated. Again, DO NOT PANIC. We will contact you immediately when we receive a report. This may take up to 7 days. If you have any atypical findings, we will refer you to the Breast Cancer Surgeons at Beaumont who are wonderful. They have a large amount of experience, excellent surgical skills and compassionate bedside manner. Drs. Dekne, Bongers, and Walker are available at 248-551-2200. They can usually see patients within 1-2 weeks. Please call us if there is any difficulty in arranging your appointment. Dr. Ruth Lerman, who specializes in second opinions for high risk women, and difficult finding on breast exam is also available at 248-551-3300.
Overall American women have a 1 in 10 chance of developing breast cancer and a 1 in 55 chance of developing ovarian cancer during their lifetime. Many patients have a very strong cancer history in the family. Particularly concerning would be first degree relatives such as a mother, daughter or sister with breast cancer especially prior to menopause or ovarian cancer at any age. This may indicate a gene mutation in the family. Ashkenazi Jewish patients of European Jewish descent are particularly at risk. Genetic testing provides information on the likelihood of developing these diseases in the future. Knowing your cancer risk may help you to make better informed decisions about screening and prevention options. Genetic testing for breast and ovarian cancer is a way to determine if you or a family member carries a gene mutation that increases the risk of these diseases. This testing is available in our office and may be covered by your insurance. The decision to test is extremely personal and genetic specialists are also available to sort through complicated family history and help provide extensive information about options if testing is positive or negative. (contact genetics) Please ask us about your risk and keep us updated about your family history. For more information on genetic testing, visit www.myriad.com.
Colon cancer screening is encouraged for most patients with a baseline colonoscopy recommended by age 50 and rectal exams and tests for blood in the stool annually on exam. The good news is that screening has become easier with improved prep regimens and excellent anesthesia options for comfortable testing. Cologuard is a new innovative test with a 92% cancer detection rate that will be used to screen patients unable or unwilling to do colonoscopy. This test will only be used for the low risk populations.
Ovarian cancer screening unfortunately has not proven very successful despite many clinical trials aimed at early detection. Ovarian cancer does tend to present as late stage disease but recent approaches with aggressive surgery and chemotherapy have been able to improve lifespan and quality of life. Symptoms are vague and include bloating, gastrointestinal distress, pelvic cramping or fullness, fatigue and weight loss. Testing includes a pelvic exam, ultrasound and occasionally blood work such as CA125. This last blood test has caused a bit of controversy over the last decade. This test is not recommended for routine screening because of false positives and negatives. Unlike the PSA made exclusively in the male prostate, CA125 is made by the entire peritoneal lining and can be elevated falsely in many non cancer situations. I will never deny a patient access to this test but discourage its use as a routine as it may prompt unnecessary surgery and tremendous anxiety if elevated. However, if you have symptoms you are concerned about, please share them with me and mention you are worried about ovarian cancer so that we can discuss your concerns fully.
Colposcopy
Colposcopy is a way of looking at the cervix through a magnifying device that enlarges our view by up to 60 times. This is performed to identify abnormal patches of cells that are shedding suspicious cells on a pap smear. We will recommend colposcopy if your pap has atypical cells, mild, moderate or severe dysplasia. It is best done when not on one's menstrual cycle.
A speculum is inserted and a cotton swab is used to apply a solution to your cervix. Most often a small biopsy is taken from any unusual appearing area. This feels like small cramp. The procedure lasts for 5-10 minutes. You may be lightly sore for 1-2 days following the procedure and may have a dark discharge from the solution applied to your cervix. Do not put anything into the vagina until all bleeding and discharge have resolved.
Biopsies are sent to Beaumont and results are available within 7 days. We will call with your results but feel free to call us if you have not heard from us in 7 days. Most often, mild dysplasia can be watched with pap smears being done every 6 months.
I often recommend immune support measures such as avoiding smoke, exercise, healthy diet and Folic Acid 1mg supplements. Careful follow up is mandatory as progression from mild to severe dysplasia occurs in about 15-20% of women. For moderate or severe dysplasia treatment will be customized to the patient.
On occasion in a younger patient, moderate dysplasia can be monitored. Often a LEEP procedure is recommended. (See below). For severe dysplasia, LEEP is usually recommended. Occasionally a laser or cold knife conization will be a considered alternative.
A speculum is inserted and a cotton swab is used to apply a solution to your cervix. Most often a small biopsy is taken from any unusual appearing area. This feels like small cramp. The procedure lasts for 5-10 minutes. You may be lightly sore for 1-2 days following the procedure and may have a dark discharge from the solution applied to your cervix. Do not put anything into the vagina until all bleeding and discharge have resolved.
Biopsies are sent to Beaumont and results are available within 7 days. We will call with your results but feel free to call us if you have not heard from us in 7 days. Most often, mild dysplasia can be watched with pap smears being done every 6 months.
I often recommend immune support measures such as avoiding smoke, exercise, healthy diet and Folic Acid 1mg supplements. Careful follow up is mandatory as progression from mild to severe dysplasia occurs in about 15-20% of women. For moderate or severe dysplasia treatment will be customized to the patient.
On occasion in a younger patient, moderate dysplasia can be monitored. Often a LEEP procedure is recommended. (See below). For severe dysplasia, LEEP is usually recommended. Occasionally a laser or cold knife conization will be a considered alternative.
Endometrial Ablation
The lining of the uterus, the endometrium is shed by bleeding each month during a woman's menstrual cycle. Sometimes the bleeding is too much or too long and treatment is needed. The ablation procedure treats the lining to control bleeding without hormones and does not remove the uterus. Indeed it has replaced hysterectomy in many cases as a less invasive, easy and safe alternative. A pretreatment with a minipill is used for 6-8 weeks prior to the procedure.
The ablation can be accomplished as an outpatient procedure. A short acting anesthesia keeps a patient asleep and comfortable during treatment. Novasure uses an electrical grid to cauterize the surfaces of the cavity. This takes 9o seconds and will be successful for most cases.
HTA or hydrothermablation uses a water bath approach with hot water accomplishing the cautery effect. This is very useful if the uterus has fibroids or any unusual contour. In either case the lining will shed and the patient will note a watery, bloody discharge for a few weeks. Cycles are typically absent or markedly diminished. Please note that one may not become pregnant after ablation and birth control must be used at all times. Although not yet FDA approved, Essure can be performed concurrently with HTA if desired. One theoretical concern with ablation is the difficulty of detected uterine cancer years after an ablation is performed. The uterine lining will be scarred shut in many cases making it difficulty to evaluate abnormal bleeding. Also, occasionally cyclic pain can occur if pockets of untreated endometrium are left near the opening of the tubes. This is less likely with HTA.
The ablation can be accomplished as an outpatient procedure. A short acting anesthesia keeps a patient asleep and comfortable during treatment. Novasure uses an electrical grid to cauterize the surfaces of the cavity. This takes 9o seconds and will be successful for most cases.
HTA or hydrothermablation uses a water bath approach with hot water accomplishing the cautery effect. This is very useful if the uterus has fibroids or any unusual contour. In either case the lining will shed and the patient will note a watery, bloody discharge for a few weeks. Cycles are typically absent or markedly diminished. Please note that one may not become pregnant after ablation and birth control must be used at all times. Although not yet FDA approved, Essure can be performed concurrently with HTA if desired. One theoretical concern with ablation is the difficulty of detected uterine cancer years after an ablation is performed. The uterine lining will be scarred shut in many cases making it difficulty to evaluate abnormal bleeding. Also, occasionally cyclic pain can occur if pockets of untreated endometrium are left near the opening of the tubes. This is less likely with HTA.
Essure Incisionless Tubal Ligation
Essure is a permanent birth control procedure that works with your body to create a natural barrier against pregnancy. It is 99.8% effective, does not involve hormones and requires no incisions. It involves placing a micro insert of nickel in each fallopian tube done hysteroscopically, in an outpatient setting. If your are considering tubal ligation, this may be an excellent option for you. This procedure does require a 3 month follow confirmation test.
Please visit Essure.com or call 1-877-Essure-1 for more information.
Please visit Essure.com or call 1-877-Essure-1 for more information.
Gardasil
An important advancement in women's health care, this vaccine for HPV helps prevent cervical cancer and genital warts. Gardisil is typically given between ages 9 and 26 in a series of 3 shots (initially, 2 months later and 6 months after first dose). We do not administer this in our office, however we do recommend you go to your primary care doctor to get the series.
Please visit www.Gardasil.com for more information.
Please visit www.Gardasil.com for more information.
Healthy Living: Fitness and Diet
It can be a chore to keep your body in shape but the rewards are great in terms of prevention of disease such as heart disease, cancer, arthritis and joint disease, osteoporosis and depression to name a few!
We are famous for our PEP talks which try to motivate you to improve your health through good nutrition and fitness. Don't ever feel embarrassed to ask us about your weight during your annual exam, or for suggestions about diet and exercise. We also know that some women do not want to step on the scale and that's fine with us as well. We are here to help you woman to woman with these challenging issues.
I have had great luck with exercise my entire life. In high school it was tennis, dance and pompoms. In college, aerobics and running and walking all over Ann Arbor kept me fit even if I did gain the Freshman 15. Medical school and residency-not so good about diet but steady exercise with circuit training and running and swimming. By the time I went into practice, I had completed two pregnancies and time was limited but I always put gym clothes in my car and never went home without going to the sports club first. I loved step aerobics and low impact classes and used the stair climber and cross trainer as alternatives on days I missed class. After Nikolas, I took up spinning which was great for a quick 10 pound weight loss. Currently, I like Jillian Michaels from The Biggest Loser's "Yoga Meltdown" (although I can't get passed level 1!). I am also swimming three times a week to help preserve my knees.
I also love, love, love my trainer. She nags me about diet while I sweat like crazy in her basement gym. This is private personalized time that I treat myself to whenever I can so that she can keep my regimen current. Variety makes a lot of sense for exercise.
Dieting is not my strength. You name it and I've definitely tried it to see if I could recommend it to others. I do have great success on protein based diets as do so many women.
When I'm good, I journal every night and count points. Every day is a new day and you have to wake up, eat breakfast and keep trying even if yesterday was a bad day. Never stop trying. I am not usually quick to embrace diet pills or fad diets. Some women will find Metformin (Glucophage) helpful as an "antibuse" for carbs and occasionally the anti-depressant Wellbutrin can break binge eating and provide help for atypical depression and eating. Again, we are happy to discuss this with you at your annual exam.
References:
Laurie Gornbien (My Trainer) 248-736-7271
Beverly Price (Dietician) 248-390-4150
We are famous for our PEP talks which try to motivate you to improve your health through good nutrition and fitness. Don't ever feel embarrassed to ask us about your weight during your annual exam, or for suggestions about diet and exercise. We also know that some women do not want to step on the scale and that's fine with us as well. We are here to help you woman to woman with these challenging issues.
I have had great luck with exercise my entire life. In high school it was tennis, dance and pompoms. In college, aerobics and running and walking all over Ann Arbor kept me fit even if I did gain the Freshman 15. Medical school and residency-not so good about diet but steady exercise with circuit training and running and swimming. By the time I went into practice, I had completed two pregnancies and time was limited but I always put gym clothes in my car and never went home without going to the sports club first. I loved step aerobics and low impact classes and used the stair climber and cross trainer as alternatives on days I missed class. After Nikolas, I took up spinning which was great for a quick 10 pound weight loss. Currently, I like Jillian Michaels from The Biggest Loser's "Yoga Meltdown" (although I can't get passed level 1!). I am also swimming three times a week to help preserve my knees.
I also love, love, love my trainer. She nags me about diet while I sweat like crazy in her basement gym. This is private personalized time that I treat myself to whenever I can so that she can keep my regimen current. Variety makes a lot of sense for exercise.
Dieting is not my strength. You name it and I've definitely tried it to see if I could recommend it to others. I do have great success on protein based diets as do so many women.
When I'm good, I journal every night and count points. Every day is a new day and you have to wake up, eat breakfast and keep trying even if yesterday was a bad day. Never stop trying. I am not usually quick to embrace diet pills or fad diets. Some women will find Metformin (Glucophage) helpful as an "antibuse" for carbs and occasionally the anti-depressant Wellbutrin can break binge eating and provide help for atypical depression and eating. Again, we are happy to discuss this with you at your annual exam.
References:
Laurie Gornbien (My Trainer) 248-736-7271
Beverly Price (Dietician) 248-390-4150
Infertility
The evaluation of fertility should take place any time a couple is trying to get pregnant and has concerns. In general, 20% of couples having unprotected intercourse midcycle will conceive, with 6o% getting pregnant by 3-4 months and 85% by one year. Please do not wait if you have concerns especially after the age of 30 or if you have irregular cycles.
The basic evaluation includes checking for the "seeds" (sperm and eggs) and checking that these seeds can meet (Cervical mucus, uterus and tubes). The amount and order of testing is customized depending on a couple's medical history but may include the following:
Once the basic testing is completed, Clomid/Femara may be tried alone or with insemination for 3-6 months. As an alternative a diagnostic laparoscopy may be suggested especially if endometriosis or adhesions are suspected from your history.
INDICATIONS: Clomid (clomiphene citrate) is indicated for the treatment of ovulatory abnormality in patients desiring pregnancy. Clomid may be used empirically to increase the number of follicles per cycle to improve chances of conceiving. It may help in timing ovulation and treating luteal phase defects by increasing Progesterone in the second half of the cycle.
CONTRAINDICATIONS: Clomid should not be given during pregnancy, in patients with liver disease or those with large ovarian cysts or unresolved bleeding.
RISKS: Clomid side effects are rare and include hot flashes, pain, headache or visual change or ovarian cysts. Ovarian cysts would mandate a cycle off Clomid and observation until the cyst resolves. In one study, among 2369 pregnancies 92% were single, 6.9% were twin, .5% triplet and very rarely higher multiples occurred, Birth defects were 2.4%, a rate about the same as the general population.
PROTOCOL: Clomid requires close monitoring with each cycle.
Please note that eggs can now be stored for women who are not currently ready for children, but are concerned about future fertility issues. Please ask us for a referral.
The basic evaluation includes checking for the "seeds" (sperm and eggs) and checking that these seeds can meet (Cervical mucus, uterus and tubes). The amount and order of testing is customized depending on a couple's medical history but may include the following:
- Temperature Chart. Check upon rising with digital thermometer. Temperature should rise .5 degrees after ovulation. Bring your chart in for us to evaluate at your appointment.
- LH "First Response" Ovulation Prediction Kit. Begin day 10-12 until positive. Try to conceive for 2 days following a positive LH surge. Look for clear mucus at this time. Record your finding on a temperature chart.
- FSH blood test. Day 3-5 of cycle, this checks for ovarian aging and rises to >10 indicate possible decreased fertilization rates and premature ovarian aging. AMH testing also looks for ovarian reserve, is done at Quest labs, and can be done at any time in the cycle.
- Progesterone level Day 24-26 (10 days after ovulation). This test will show progesterone in your system which only occurs if you have ovulated.
- Other blood tests: Testosterone, Prolactin, TSH, DHEAS, LH/FSH ratio These blood tests evaluate your hormones and assess for other conditions which can inhibit ovulation.
Semen Analysis: This tests male fertility including amount of sperm, motility and shapes. If abnormal, suggestions may include a male fertility urology consult to look for varicose veins and hormonal abnormality. Couples with male infertility issues may benefit from intrauterine insemination done in our office or may be referred for ICSI, a special form of IVF-in-vitro fertilization.
A semen analysis can be done by:
Hollander, Mitchell MD 248-539-9036
RMA 248-619-3100
Gago Fertility 810-227-3232
Mersol-Barg 248-593-6990- Post Coital Test: This test is done around the time of ovulation. Please Call us to work in your appointment if your LH kit becomes positive. We will check for cervical mucus and sperm presence in the mucus. Timing is about 2-3 hours after sexual intercourse. We will also do an ultrasound to check uterus shape and evaluate the ovary for eggs. We also check the uterine lining to see if it is prepared for implantation.
- Hysterosalpingogram (HSG) This x-ray of the tubes and ovaries is done at Beaumont on day 5-8 of your cycle. Dye is placed through the cervix using a speculum and small straw and x-rays assess the shape of the uterus and if the tubes are open and spill dye. Surgery may help you if your tubes are block or IVF may be considered. This test can cause cramping so take Motrin 600 mg 1 hour prior. Please remind us if you have a history of PID, Chlamydia or any other STD as you may benefit from antibiotics prior to the test to prevent infection.
Once the basic testing is completed, Clomid/Femara may be tried alone or with insemination for 3-6 months. As an alternative a diagnostic laparoscopy may be suggested especially if endometriosis or adhesions are suspected from your history.
INDICATIONS: Clomid (clomiphene citrate) is indicated for the treatment of ovulatory abnormality in patients desiring pregnancy. Clomid may be used empirically to increase the number of follicles per cycle to improve chances of conceiving. It may help in timing ovulation and treating luteal phase defects by increasing Progesterone in the second half of the cycle.
CONTRAINDICATIONS: Clomid should not be given during pregnancy, in patients with liver disease or those with large ovarian cysts or unresolved bleeding.
RISKS: Clomid side effects are rare and include hot flashes, pain, headache or visual change or ovarian cysts. Ovarian cysts would mandate a cycle off Clomid and observation until the cyst resolves. In one study, among 2369 pregnancies 92% were single, 6.9% were twin, .5% triplet and very rarely higher multiples occurred, Birth defects were 2.4%, a rate about the same as the general population.
PROTOCOL: Clomid requires close monitoring with each cycle.
- Ultrasound is done day 1-5 prior to monthly dose.
- Clomid is given days 5-9.
- Estrogen is given to improve cervical mucus after the last Clomid pill and is often Premarin 1.25mg 2x/day from days 10-16.
- Femara is an alternative to Clomid used in a similar pattern, with improved success rates. It is not FDA approved for infertility, but rather a breast cancer treatment. Care must be taken to avoid Femara if you are already pregnant. Take good notes on all pregnancy exposure while on this medication.
- LH kits begin on day 10. Please call with a positive kit is IUI is to be performed. This is usually done day 14, or the day following a positive kit. If this falls on a Saturday, RMA can preform both the semen wash, and IUI. Please let us know if we can arrange this for you.
- Occasionally HCG is given to simulate LH surge around day 14 to trigger ovulation. Patients must pick this up from their pharmacy and bring it to the office. This is given if a 2cm follicle is seen on ultrasound. IUI or attempts to conceive should occur for the next 48 hours.
- Progesterone supplements begin around day 18 and usually involves Crinone 8% or progesterone suppositories. A pregnancy test is taken 14 days after ovulation and progesterone can be stopped if negative. Call us as soon as your period starts to arrange a follow up visit and the next cycle. If pregnancy is confirmed, continue progesterone until first prenatal visit.
Please note that eggs can now be stored for women who are not currently ready for children, but are concerned about future fertility issues. Please ask us for a referral.
LEEP
Cells on the cervix grow and shed all the time. Sometimes these cells change and become abnormal, usually as a result of HPV infection. Leep uses a thin wire loop that acts like a scalpel (surgical knife). An electric current is passed through the loop which cuts away a thin layer of surface cells. This is done with local anesthesia very comfortably in the office. If you are very nervous, we can prescribe a mild tranquilizer such as valium an hour ahead. Motrin 600mg also will help with cramps. Please eat something prior to your procedure. You will feel a dull ache or cramping after the procedure and resting that day is advised.
Problems are rare and include heavy bleeding, fever, foul-smelling discharge, and severe abdominal pain. Please call immediately with these concerns. A small amount of bleeding and brown-black discharge from the monsel solution is expected and normal. Please avoid sex, tampons or douching until seen in the office in 2 weeks. Results are expected in 7 days. Please call us if you haven't heard from us in 7 days.
On occasion we can do LEEP at the hospital under heavy sedation if a patient is particularly nervous or if her anatomy or bleeding risks are a concern.
Problems are rare and include heavy bleeding, fever, foul-smelling discharge, and severe abdominal pain. Please call immediately with these concerns. A small amount of bleeding and brown-black discharge from the monsel solution is expected and normal. Please avoid sex, tampons or douching until seen in the office in 2 weeks. Results are expected in 7 days. Please call us if you haven't heard from us in 7 days.
On occasion we can do LEEP at the hospital under heavy sedation if a patient is particularly nervous or if her anatomy or bleeding risks are a concern.
Menopause
The severity of symptoms women experience in menopause varies widely and no one knows why some women are asymptomatic and others are absolutely miserable. The approach to menopause has evolved dramatically since I have been in practice especially following the release of the Womens' Health Initiative (WHI) study. This study documented the slight increased risk of breast cancer, heart attack, stroke and blood clot in women in their mid 6os given Prempro comparing them to women given placebo.Much confusion over study results arose from media coverage.
In general our goal has become to use the lowest dose of hormone for the shortest duration (preferably less than 5 years) to treat hot flashes and night sweats surrounding menopause. Fortunately, many products have become available to help meet this goal since the study was released. Unfortunately, it seems doubtful that these products will undergo such intense study as was done during the WHI. Much of the current "new" findings is simply reanalysis of the same data in WHI and does not involve new product or study.
Theoretically, transdermal approach through patch or cream will be less likely to cause blood clotting abnormality and therefore fewer heart attacks and stoke. Theoretically "natural" progesterone may be less likely to cause clotting problem as well. As far as cancer risk, natural does not necessarily mean less risky.
What I do like about "bioidenticals" is the ability to manipulate dose and delivery to meet an individual's needs. This can be ultra low dosing through a skin cream. Again, I make no reassurances about risk being any different than that found in WHI and each patient must assess her own goals of HRT and decide for herself if her symptoms warrant treatment. Each year we review how she is doing and try to decrease dosing or wean off if possible.
Testosterone therapy can be delivered with bioidentical or traditional pharmacy. Women definitely have lower testosterone levels after menopause. Each person's sex drive is affected differently by this decline. Replacement can be useful but also can cause side effects such as weight gain, acne and hair growth. We also have to watch cholesterol and assess for cardiovascular risk when using testosterone. In general I like to avoid higher doses but often give a low dose a try if desired.
Medical alternatives for hot flashes include Clonidine patch, a blood pressure medicine, Bellergal S tabs, an opiate that does help short term, and some serotonin medications typically used for depression such as Effexor or Zoloft. I use these options frequently in my practice and have found them helpful. Brisdelle is another seratonin medication for hot flashes which is FDA approved, and not hormonal.
Many herbal alternatives have been tried for menopausal symptoms. There are no conclusive studies in my opinion on the benefits and safety of this approach. Soy products contain isoflavones, a phytoestrogen or plant estrogen, which acts like a weak form of estrogen hormone in the body. Isoflavone is found in foods such as flaxseed, legumes (peas, beans, peanuts) and whole grains (oats, wheat, corn). However, when soy is processed some benefit is lost.
Healthy Woman's Soy Menopause is one example of a soy supplement by Mead and Johnson which can relieve symptoms. Black Cohosh is a North American plant that may act like estrogen. It is found in Remifemin, an herbal menopause supplement. It may help symptoms for a short while but can cause upset stomach and low blood pressure. Wild yam is available but unproven, Don Quai is the root of Angelica Sinesis and commonly given by Chinese herbal specialists for regularity, dryness and hot flashes. Watch for sunburn and blood clotting issues.
Evening Primrose is a North American wildflower-again unproven. Ginseng is said to boost immunity and help with stress and increase sex chive- unproven. It has not been shown to help with hot flashes. Chasteberry or vitex is the dried ripe fruit of the chaste tree. It is said to decrease dryness and help with depression but is unproven. I say "Beware of all of this stuff." I have doubts about long term usefulness and am somewhat skeptical that anyone knows exactly what is contained in supplements which are largely unregulated. I do, however, like Relizen, which is a swedish bee pollen extract which has no side effects and can be ordered online. Please ask us for samples if you are interested. Please note that Relizen does take up to three weeks to start helping.
In general our goal has become to use the lowest dose of hormone for the shortest duration (preferably less than 5 years) to treat hot flashes and night sweats surrounding menopause. Fortunately, many products have become available to help meet this goal since the study was released. Unfortunately, it seems doubtful that these products will undergo such intense study as was done during the WHI. Much of the current "new" findings is simply reanalysis of the same data in WHI and does not involve new product or study.
Theoretically, transdermal approach through patch or cream will be less likely to cause blood clotting abnormality and therefore fewer heart attacks and stoke. Theoretically "natural" progesterone may be less likely to cause clotting problem as well. As far as cancer risk, natural does not necessarily mean less risky.
What I do like about "bioidenticals" is the ability to manipulate dose and delivery to meet an individual's needs. This can be ultra low dosing through a skin cream. Again, I make no reassurances about risk being any different than that found in WHI and each patient must assess her own goals of HRT and decide for herself if her symptoms warrant treatment. Each year we review how she is doing and try to decrease dosing or wean off if possible.
Testosterone therapy can be delivered with bioidentical or traditional pharmacy. Women definitely have lower testosterone levels after menopause. Each person's sex drive is affected differently by this decline. Replacement can be useful but also can cause side effects such as weight gain, acne and hair growth. We also have to watch cholesterol and assess for cardiovascular risk when using testosterone. In general I like to avoid higher doses but often give a low dose a try if desired.
Medical alternatives for hot flashes include Clonidine patch, a blood pressure medicine, Bellergal S tabs, an opiate that does help short term, and some serotonin medications typically used for depression such as Effexor or Zoloft. I use these options frequently in my practice and have found them helpful. Brisdelle is another seratonin medication for hot flashes which is FDA approved, and not hormonal.
Many herbal alternatives have been tried for menopausal symptoms. There are no conclusive studies in my opinion on the benefits and safety of this approach. Soy products contain isoflavones, a phytoestrogen or plant estrogen, which acts like a weak form of estrogen hormone in the body. Isoflavone is found in foods such as flaxseed, legumes (peas, beans, peanuts) and whole grains (oats, wheat, corn). However, when soy is processed some benefit is lost.
Healthy Woman's Soy Menopause is one example of a soy supplement by Mead and Johnson which can relieve symptoms. Black Cohosh is a North American plant that may act like estrogen. It is found in Remifemin, an herbal menopause supplement. It may help symptoms for a short while but can cause upset stomach and low blood pressure. Wild yam is available but unproven, Don Quai is the root of Angelica Sinesis and commonly given by Chinese herbal specialists for regularity, dryness and hot flashes. Watch for sunburn and blood clotting issues.
Evening Primrose is a North American wildflower-again unproven. Ginseng is said to boost immunity and help with stress and increase sex chive- unproven. It has not been shown to help with hot flashes. Chasteberry or vitex is the dried ripe fruit of the chaste tree. It is said to decrease dryness and help with depression but is unproven. I say "Beware of all of this stuff." I have doubts about long term usefulness and am somewhat skeptical that anyone knows exactly what is contained in supplements which are largely unregulated. I do, however, like Relizen, which is a swedish bee pollen extract which has no side effects and can be ordered online. Please ask us for samples if you are interested. Please note that Relizen does take up to three weeks to start helping.
Urinary Tract Infection
Many women will suffer from an occasional urinary tract infection. Cystitis, a simple bladder infection, will usually cause burning, urgency, painful urination, and frequency. A typical feeling is a strong urgency just after you have already emptied your bladder. We recommend a culture be done prior to treatment whenever possible to document which bacteria caused the problem. Many bacteria are now resistant to treatment and may not be cured by standard regimens. Sometimes the urine is sterile and the problem was not a bladder infection at all. Please do not self treat bladder infections, unless instructed to do so.
Try to call us during office hours and do not wait all day with this problem.
Try to call us during office hours and do not wait all day with this problem.
Vaginal Dryness
Topical Moisturizers There are several topical vaginal moisturizers available without a prescription at your pharmacy. Some examples are Replens, Silken Secret and Lubrin. They come as either a gel with an applicator or as a tablet that melts once inserted. Replens is used daily for 5 days, then 3 times/week. Some patients find them messy. They can relieve daily personal dryness, unrelated to sexual activity and may prevent recurrent vaginal infections caused by pH imbalance.
Vaginal Lubricants are used to help with painful intercourse. Liquid lubricants are usually water-based and seem to work better than gels, but can be messy. Examples are Astroglide Liquid or KY Liquid. Lubrin is also a lubricant that can be inserted ahead of intercourse and may be less messy and more discreet Lubricants should be applied directly to the vaginal area and your partner before and during intercourse. A silicone-based lubricant called Eros is available for order over the Internet. Some patients may find silicone based lubricants more effective but they may stain the sheets as they are not water soluble.
Topical Vaginal Estrogens Oral, patch and transdermal creams will resolve vaginal dryness and painful intercourse due to estrogen deficiency. This problem becomes much more common the further out a woman is from menopause. There is a controversy concerning the safety of estrogen use for women especially those surviving breast cancer or at higher risk for cardiovascular disease. We use Estrace 1/4 applicator full 1-2 times per week with good success, and minimal risk as our main product.
Two topical estrogen products are available with prescription with a low level of absorption into the blood and less controversy. These are Vagifem, a tablet and Estring, small ring insert. These release estrogen onto the lining of the vagina with minimal absorption into the blood.
The Estring is a 2 inch diameter rubber ring with estrogens inside that is placed in the vagina and left there for three months. After insertion estrogens are absorbed into the blood for 2-3 days and on subsequent days there are minimal or no detectable blood levels of estrogen.
Vagifem is a small tablet inserted at night through an applicator for 14 days followed by twice weekly insertion. The tablets are absorbed at night, with some estrogens appearing in the blood for several hours. Both products take about 2-3 weeks to relieve vaginal symptoms.
Definitive research studies in breast cancer survivors to determine if there is a breast cancer risk from Estring and Vagifem have not been performed: however, the theory of safety with both products is good. Indeed, breast cancer prevention research studies through the National Cancer Institute allowed the use of both Estring and Vagifem. Side effects are few and include a slight discharge. The ring is difficult for some women to place and may need to be removed prior to intercourse.
A new product called Osphena (as seen on TV) is a non hormonal, very effective, oral pill for painful sex and dryness. This is a selective estrogen modulator (SEM) and does not increase cancer risk.
Vaginal Lubricants are used to help with painful intercourse. Liquid lubricants are usually water-based and seem to work better than gels, but can be messy. Examples are Astroglide Liquid or KY Liquid. Lubrin is also a lubricant that can be inserted ahead of intercourse and may be less messy and more discreet Lubricants should be applied directly to the vaginal area and your partner before and during intercourse. A silicone-based lubricant called Eros is available for order over the Internet. Some patients may find silicone based lubricants more effective but they may stain the sheets as they are not water soluble.
Topical Vaginal Estrogens Oral, patch and transdermal creams will resolve vaginal dryness and painful intercourse due to estrogen deficiency. This problem becomes much more common the further out a woman is from menopause. There is a controversy concerning the safety of estrogen use for women especially those surviving breast cancer or at higher risk for cardiovascular disease. We use Estrace 1/4 applicator full 1-2 times per week with good success, and minimal risk as our main product.
Two topical estrogen products are available with prescription with a low level of absorption into the blood and less controversy. These are Vagifem, a tablet and Estring, small ring insert. These release estrogen onto the lining of the vagina with minimal absorption into the blood.
The Estring is a 2 inch diameter rubber ring with estrogens inside that is placed in the vagina and left there for three months. After insertion estrogens are absorbed into the blood for 2-3 days and on subsequent days there are minimal or no detectable blood levels of estrogen.
Vagifem is a small tablet inserted at night through an applicator for 14 days followed by twice weekly insertion. The tablets are absorbed at night, with some estrogens appearing in the blood for several hours. Both products take about 2-3 weeks to relieve vaginal symptoms.
Definitive research studies in breast cancer survivors to determine if there is a breast cancer risk from Estring and Vagifem have not been performed: however, the theory of safety with both products is good. Indeed, breast cancer prevention research studies through the National Cancer Institute allowed the use of both Estring and Vagifem. Side effects are few and include a slight discharge. The ring is difficult for some women to place and may need to be removed prior to intercourse.
A new product called Osphena (as seen on TV) is a non hormonal, very effective, oral pill for painful sex and dryness. This is a selective estrogen modulator (SEM) and does not increase cancer risk.
Vaginal Infections
Most women will have occasional yeast infections. Typically the classic symptoms are white "cottage cheese" discharge, external redness and itching. Monistat is available over-the-counter and we advise 3 day regimens as opposed to one day treatment. If your symptoms are not resolved within a few days, you will need to be seen. Cultures will be more accurate if done prior to using over-the-counter inserts. You may also use Domboro compresses made by putting this solution on a warm washcloth and applying 3x/ day for 15 minutes. Recurrent yeast infections could indicate resistant yeast or bacteria, herpes, diabetes, hormone imbalance or immune problems so please see us if this problem is recurrent and come in when symptoms are acting up prior to self treatment.
If your symptoms include external blisters, a yellow discharge or pain or any abdominal pain, fever or urinary symptoms, call us immediately and avoid self treating.
If your symptoms include external blisters, a yellow discharge or pain or any abdominal pain, fever or urinary symptoms, call us immediately and avoid self treating.
Primary Care Referral List
Haller and Hug (H2)
Drs. Haller, Hug, Kakish, Finn, Kemennu, Martilotti, Molnar
hallerandhug.com
27555 Farmington Rd.
Ste. 120
Farmington Hills MI 48334
(248)477-5608
Dr. Lisa Speck
32905 W. 12 Mile Road
Ste. 400
Farmington Hills, Mi 48334
(248)553-0335
Novi Internal Medicine and Pediatrics
Drs. Golden, Einhorn, Leff, Rosenberg, Rakotz
novidocs.com
39475 Lewis Dr.
Ste. 130
(248)374-0502
Drs. Griffin and Weissman
16800 W. 12 Mile
Ste. 210
Southfield, MI 48076
(248)483-5300
Internal Medicine Specialists
Dr. Tammi Cooper
5821 W. Maple Rd
Ste 190
West Bloomfield, MI 48322
(248) 855-0407
Drs. Haller, Hug, Kakish, Finn, Kemennu, Martilotti, Molnar
hallerandhug.com
27555 Farmington Rd.
Ste. 120
Farmington Hills MI 48334
(248)477-5608
Dr. Lisa Speck
32905 W. 12 Mile Road
Ste. 400
Farmington Hills, Mi 48334
(248)553-0335
Novi Internal Medicine and Pediatrics
Drs. Golden, Einhorn, Leff, Rosenberg, Rakotz
novidocs.com
39475 Lewis Dr.
Ste. 130
(248)374-0502
Drs. Griffin and Weissman
16800 W. 12 Mile
Ste. 210
Southfield, MI 48076
(248)483-5300
Internal Medicine Specialists
Dr. Tammi Cooper
5821 W. Maple Rd
Ste 190
West Bloomfield, MI 48322
(248) 855-0407