2013 June

What Is The Scoop With Uterine Fibroids?

June 20, 2013Gynecology

Uterine fibroids are extremely common benign growths that arise in the muscle wall of the uterus. They can occur in any woman but are more common in certain ethnic groups, and up to 40% of African American women have fibroids. For the majority of women, fibroids are asymptomatic and often go unnoticed. In some patients fibroids can cause heavy bleeding, pain and symptoms of pressure, and as they grow they can even cause a bulge in the abdomen and the appearance of pregnancy. We don’t know why some women have them and some don’t, but there is definitely a genetic factor as they can run in families.

When patients complain of heavy bleeding, pelvic pressure or pelvic pain, we usually will order an ultrasound to check for fibroids as this would be a very common cause. Fibroids have a distinct appearance on ultrasound and we are able to measure them and count them, which helps to plan treatment options. Rarely a fibroid will occur by itself but usually multiple fibroids present together. In other cases a patient may have an enlarges uterus on exam when we do our pelvic exam, and this may be the tipoff that fibroids are present.

In general if a patient is not symptomatic we do not have to treat or remove fibroids. Intervention is warranted if symptoms are significant, and generally involves surgical removal. Fibroids can be removed leaving the uterus intact (this is called a myomectomy) in patients who wish to maintain their fertility. In patients who no longer desire fertility the safest way to remove fibroids is to take the whole uterus out, fibroids and all (this is a hysterectomy). After a myomectomy a significant number of patients have a recurrence of fibroids, and the surgery is also more difficult and has a higher risk of bleeding than a hysterectomy, which is why we do not recommend it for everyone. A myomectomy and a hysterectomy can both be approached in many ways depending on the size and position of the fibroids. Sometimes the surgery can have no abdominal incision (such as with a hysteroscopic myomectomy or a vaginal hysterectomy), may have small laparoscopic incisions, or may require a larger open incision. As with all surgery, our preference is always the least invasive possible.

Fibroids generally do not cause problems with pregnancy, unless they are very large or compromise the uterine cavity. Patients with fibroids do not necessarily need to remove them before attempting pregnancy, but ultrasound can help your doctor to advise the patient about her particular case. In some extreme cases fibroids can increase the risk of preterm labor and miscarriage, but this is not common. Fibroids very rarely affect fertility.

A number of non surgical options can also help with reducing fibroid symptoms. “Lupron” is a drug which lowers estrogen levels, and this causes fibroids to shrink. The down side is that the drug causes menopause symptoms (hot flashes, mood swings etc.) and the effect is also temporary. Uterine Fibroid Embolization (UFE) is another option, in which the major blood vessels to the uterus (the uterine arteries) are blocked through a catheter in the groin, resulting in less blood flow to the uterus and shrinkage of the fibroids. MRI Guided Ultrasound (MRGUS) is a procedure in which targeted ultrasound directs heat into the fibroids which also causes shrinkage. Birth control pills have been shown to have no effect of fibroid growth, but can be used temporarily to slow down bleeding. These are all options that your provide can discuss with you.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

What Is Hormonal Balance And How Do I Get It?

June 10, 2013Gynecology

The concept of “hormonal balance” has been so widely misused and abused by marketers that many of us think that there is a mysterious state of balance that we can somehow achieve by taking a single pill or handful of supplements. The truth is that any product that claims to be able to restore hormone balance by itself is nonsense. It was hearing an advertisement on the radio for one of these that spurred me to write this today.

One of the biggest misconceptions about the human body is that we can fix one symptom without causing a series of others. Our bodies are incredibly complex machines, each part dependent on the others, and any change or adjustment to one system leads to changes in the others. Just as in the universe, we can’t change one thing without a trickledown or ripple effect reaching far wider than the initial event. So instead of the concept of “balance”, implying a scale with one thing on each end that needs to be equalized, the concept of “wellness” to me is more like a three dimensional interlocking series of cogs or gears all moving in the same direction. If one cog moves, the others also move, but they all need to be working together and not opposing each other. I equate “hormone balance” with “wellness”, or the state in which our body’s complex systems are working in synchronization, at the optimal level appropriate for our age. “Hormone imbalance” is therefore the state in which our systems are fighting one another causing suboptimal functioning. But feeling like we are in a state of hormone balance involves a whole lot more than just our hormones.

Hormones have become the scapegoat for almost everything that doesn’t feel good, and “hormone imbalance” is blamed for many common maladies such as weight gain, fatigue and mood changes. The media suggests that if we don’t feel great, our hormones are out of balance. If we feel sad/moody before our period, notice weight gain around the middle in our 40s, or lose some of our sex drive with age, we are “out of balance” and need a pill to fix it. In reality, these examples are normal processes that occur in almost every woman. So really nothing is out of balance, things are exactly as they should be according to nature. That does not mean that we can’t seek to fight the aging process and improve symptoms of aging that are natural and normal, but I use these examples to point out that everything that feels bad is not necessarily a symptom of something hormonally wrong. Our sex hormones (those produced by the ovaries) change dramatically throughout our lives. What is normal hormonally for a 5 year old, a 15 year old, a 30 year old and a 50 year old are totally different. Should a 50 year old feel the same as a 15 year old? Thank goodness, no! At least part of the solution is understanding what is normal at our particular time of life and optimizing, but also embracing it.

I am certain that the majority of issues that we ascribe to hormone imbalance are actually problems caused by an unhealthy diet and bad habits such as poor sleep and lack of exercise. While it is much easier to take a pill than to adjust our lifestyle in a more healthy direction, we all know that eating well, sleeping well and exercising will make us feel dramatically better. So why don’t we all do it? After generations of evidence that there is no pill that will make us feel as good as a healthy lifestyle, we still search for it and spend billions of dollars annually on experimenting with alternatives to diet and exercise that don’t work. The most common health complaint I hear from my patients is that they feel tired, moody and can’t lose weight. The vast majority of the time these problems are not due to any hormone issues, but rather to a stressful and hectic lifestyle with little time devoted to healthy eating and exercise. The cure is not a pill or supplement but a lifestyle change.

The concept of “balance” is often used in conjunction with our diet. Not only does balance mean healthy variety, but it also means that any mood altering effect that food gives us will likely come back to us in reverse. Think for example about sugar and caffeine, two of the mainstays of the average American woman’s diet. Many of us use these as “drugs” to achieve a stimulating effect, and wonder why later in the day the stimulant effect is not only gone but we are exhausted and craving more sugar and caffeine.If we push the body in one direction, the body will push back in the other direction to compensate.That is how nature works.

In some cases, hormones that are not functioning optimally can be restored to normal with diet and exercise. Polycystic Ovarian Syndrome, for example is a condition on which too much testosterone (male hormone) is produced, often resulting in irregular periods, hair growth and acne. In many cases (not all) weight loss resolves the problem without the need for any medication. The same can be seen for Type 11 diabetes, which in most cases is preventable reversible with a healthy lifestyle. There certainly are instances in which certain hormones are over or under produced causing the body’s complex systems to function at a less than ideal state. Type 1 diabetics lack the hormone insulin, and need supplementation to stay alive. Autoimmune disease can result in low thyroid hormone production causing serious health consequences for the patient. Rapid estrogen depletion in menopause can cause a number of highly unpleasant symptoms. These are states of hormone deficiency not hormone “imbalance”, and replacement of the deficient hormone to mimic what nature is missing can restore a state of wellness.

So how does one archive the mysterious state of “hormone balance”? Have us check your hormones, and if they are normal for your age, eat moderate quantities of healthy foods (foods found in nature), exercise daily, sleep well, avoid foods/drugs with mood enhancing effects, and practice stress reduction. But please don’t buy those pills they advertise on the radio!

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

What Should I Expect In Early Pregnancy?

June 6, 2013Obstetrics

Some of our patients have mentioned that they would like more information to help them through the first few weeks of pregnancy prior to their initial visit. We know how stressful the first few weeks can be prior to your first visit so here are a few tips to help you to understand what to expect.

If you are like most of our doctors and staff, we generally find out that we are pregnant as soon as we have missed our period, or sometimes even a few days before that! By the time our period is due we have already been pregnant for about 14 days. Modern urine pregnancy tests can pick up a positive pregnancy hormone in the urine even 10-12 days after conception. At this point the fetus is very tiny and not yet visible on ultrasound. By 3 weeks after conception we can often see a “gestational sac” which is a small fluid collection inside the uterus in which the fetus will grow, but the fetus itself and visible heart beat cannot be seen by ultrasound until 4 weeks after conception. Since we can get very limited information by ultrasound prior to 4 weeks from conception, we recommend making the first obstetric visit at or after that time.

Remember the convention for dating pregnancy is to count the weeks from the last period, not from conception. So when you are 4 weeks from conception, the convention is to say that you are 6 weeks pregnant. The best time for the first ultrasound is between 6-8 weeks from the last period (which is usually 4-6 weeks from conception). You can come in for blood work to check hormone levels before your first appointment if you desire, and we especially recommend this if you are having problems such as bleeding or pain.

With blood tests we can follow your pregnancy hormone levels to make sure that they are going up appropriately (the number usually doubles every 48 hours, more or less, in early pregnancy), and we can also measure a hormone called progesterone which is generally high in healthy pregnancies and may be lower if things are not going well. If these numbers are reassuring it is certainly safe to wait until 6-8 weeks from your last period for the first visit.

During the first few weeks you may experience several changes such as breast growth and tenderness, fatigue, constipation and even a small amount of vaginal spotting. As the embryo is implanting into the uterine wall we may experience spotting between 4-6 weeks from the last period. As long as the bleeding is small in amount and not associated with pain, it is safe to wait. Nausea often starts as early as 6 weeks from the last period and usually peaks at 8-10 weeks from the last period. While nausea and occasional vomiting is normal, if you are not able to keep down food and liquids for 24 hours we recommend prompt treatment to avoid dehydration.

A dull campy sensation is common as the uterus grows, even in the first few weeks. Severe pain is never normal and you should call us about this immediately. Prior to your first ultrasound there is a small chance that any patient could have an ectopic pregnancy ( pregnancy outside the uterus) which can be a medical emergency. Your first ultrasound will confirm that the fetus is in the uterus, but severe pain and vaginal bleeding prior your first visit is always a warning sign for a possible ectopic pregnancy.

About 15% of diagnosed pregnancies end in miscarriage, which is devastating but unfortunately is rarely preventable. The vast majority of miscarriages occur due to abnormal fetal development, usually from a major chromosomal abnormality caused by a division error early in fetal development. Usually in these cases we never see a heartbeat, but sometimes miscarriage occurs after a heartbeat has already been seen. The good news is that if the fetus has a heartbeat 8 weeks after the last period, then the chance of miscarriage is only 5%. Since miscarriage can occur very early, a common experience is to have a very heavy and crampy period a few days or a week late.

If you have had a positive pregnancy test then experience heavy bleeding and cramping, the chances are high that this is what is going on. Although there is nothing we can do to stop the natural process, we recommend being seen as soon as possible in the office to confirm that everything has passed naturally. If you are experiencing an early miscarriage we do not recommend going to the emergency room unless the bleeding is extremely heavy or the pain is not manageable.

Your first prenatal visit to confirm pregnancy and establish your due date will likely be with one of our Nurse Practitioners or our Physician Assistant. These ladies are highly experienced providers with advanced training in Women’s Health and ultrasound. They will go over your history and risk factors, answer any questions that you have, perform an exam and ultrasound, establish your due date and order our standard blood work for pregnancy. If all is well, we will then schedule an appointment for you to see your physician 2 weeks later.

At any time in early pregnancy if you have non –urgent questions, email your doctor’s nurse (the email directory is on our website in the CONTACT section) and we will advise you what to do. Also don’t forget to read the FAQs for pregnancy in the FORMS section of our website.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

Are Vaccines Safe In Pregnancy?

June 3, 2013Obstetrics

There is a lot of confusing information in the community about the safety of vaccines in general and specifically during pregnancy and breastfeeding. The development of safe vaccines has been one of the most incredible advances in modern medicine and vaccines have prevented millions of deaths from diseases that we rarely think about any more. We urge our patients to follow the standard of care when it comes to vaccinations and here are some important facts:

Most vaccines do not contain live virus, and in general these are safe in pregnancy. Exceptions are the MMR (measles, mumps, rubella) vaccine and chickenpox vaccines which do contain live virus and are not recommended during pregnancy as they have a theoretical risk of transmitting disease to the baby. The type of influenza vaccine given by nasal spray also contains live virus and is not recommended in pregnancy. Both MMR and nasal flu vaccines are safe for breastfeeding but there is no data on chickenpox vaccination in breast-feeding so we generally do not recommend it.

Other common vaccines including the injectable influenza vaccine, hepatitis and tetanus, diphtheria and pertussis vaccines are not only safe in pregnancy but can convey benefit to the baby. Since newborns are not fully vaccinated and immune to these diseases in the first year of life, some of the protection from vaccines given in pregnancy is transferred across the placenta to the baby and can help to protect the baby during the first year of life. Also, preventing mom from getting these diseases keeps the baby safe in the uterus, as a sick mom can lead to a sick baby. Women with influenza in pregnancy, for example, can get very sick with serious conditions including pneumonia which can be life threatening for both mom and baby due to lack of oxygen.

Prior to pregnancy we recommend making sure that you are immune to varicella (chickenpox) and rubella since these diseases can cause birth defects if a pregnant woman is affected. While the risk to the fetus of these vaccinations this theoretical, both rubella and chickenpox vaccines should be given before or after pregnancy as they contain live virus. Checking your immune status with a blood test prior to pregnancy will give you an opportunity to get vaccinated if necessary. It is recommended to wait three months after both of these vaccines prior to becoming pregnant.

Pertussis or whooping cough is a potentially life threatening disease for babies and young children so we recommend that all parents as well as caretakers and other family members of newborns get vaccinated themselves so they will reduce the risk of passing the disease to the baby after birth. The best time to get vaccinated is during pregnancy so the vaccine has time to take effect before the baby is born. We recommend vaccination in the third trimester of each pregnancy. Your pediatrician will recommend that the baby get vaccinated but the vaccination will not be fully effective until about 1 year of life.

A common myth is that vaccines cause autism. This idea was perpetuated about 10 years ago by a British physician who has since lost his license as it was exposed that his data was falsified. No link between autism and vaccines has ever been established outside of these false claims which have been disproven. It is true that there is a type of mercury in some vaccines called Thimersol. Pregnant women do not have to ask for Thimersol-free vaccines as Thimersol has been proven to be safe for pregnant women and unborn babies.

Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to shs@cwcchouston.com.

Month: June 2013

What Is The Scoop With Uterine Fibroids?

What Is Hormonal Balance And How Do I Get It?

What Should I Expect In Early Pregnancy?

Are Vaccines Safe In Pregnancy?

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