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Starting or choosing a birth control method can be an overwhelming decision for many women of reproductive age.  There are currently various options of birth control available. Women base their decision on their desire for permanent vs. reversible birth control, ease of use, cost, and gynecological and medical history and hormonal vs. non-hormonal options.

Some methods of birth control may be more effective than others, but all forms of birth control have higher rates of success when taken as directed. The choice thereby needs to be made in accordance with one’s lifestyle, work and schedules etc.

Some of the most commonly asked questions are…

1) “Is it dangerous to be on birth control for a long period of time?”
2) “Do oral contraceptives cause an increased risk of breast cancer?”
3) “Does hormonal birth control make me infertile?”

Our short answer is “No”.  There is no significant evidence showing that there are negative long-term effects of being on birth control and we are comfortable prescribing it to patients from menarche (onset of your menstrual cycle) until menopause. A common myth is that long-term oral contraception use may increase the risk of breast cancer.  According to The Journal of Family Practice (2014), oral contraception does not increase patient’s risk of breast cancer, even those with a family history of breast cancer.  The myth comes from contraception pills that were used before 1975 that contained higher doses of hormones, which showed an slight association to a risk of breast cancer. With all reversible forms of birth control, patients are able to conceive as soon as they stop using it (as it can happen even if you miss oral pills or take it incorrectly!).

Some reversible birth control options include combined oral contraceptive pills, a skin patch, a three monthly injection, a vaginal ring or an IUD (intrauterine device, which can be hormonal or non-hormonal).  Low cost birth control options are available and your gynecologist can help you choose the right fit for you. If you have high co-pay or do not have insurance, there are plenty of cash discount options available. You can discuss these in details during your visit with your gynecologist.

Permanent birth control options include tubal sterilization methods like Essure and laparoscopic sterilization.

It is very important to remember that while being on birth control, one still needs to use condoms to prevent transmission of STD’s. For women who do not desire to “put hormones in their body” or have had side effects or are not the right candidate for hormonal pills also have various options to select from. A great reversible non hormonal option is copper intra-uterine device (IUD).

The link below contains more details and may help you choose the right fit.
http://www.nytimes.com/health/guides/specialtopic/birth-control-and-family-planning/print.html

Please discuss with your OBGYN or women’s health expert as to which option is the best for you. Our team of women’s health experts at Expert GYN is available late evenings and weekends if you are a busy professional woman.

Betty Krechmer, PA-C

Endometriosis is most commonly diagnosed in women in their 30’s and 40’s.  It occurs in about 1 out of 10 women of reproductive age.

Endometriosis explained simply is a condition when tissue or blood deposits that are normally found in the lining of the uterus, called the endometrium, are found outside of the uterus.  Areas of endometrial tissue may be found on the peritoneum, ovaries, fallopian tubes, bladder, ureters, intestines and the rectum.  There are many conflicting theories regarding the origin of endometriosis. There is some evidence that retrograde menstruation ( the blood passing backwards through the tubes instead of all of it coming down and out through the uterus and cervix).

The most common symptoms that occur with endometriosis are chronic pelvic pain. The pain may be dull or sharp shooting pain located in the lower abdomen or lower back. The periodic pain is most common before and during menses. Painful sex may be presenting feature as well. Women may also experience a black-brown discharge before menses. In some cases of severe Endometriosis, the endometrial or blood deposits may also be present on the bowel. This can lead to severe bowel symptoms like painful bowel movements, constipation and constant bloating etc.

The endometrial tissue responds to changes in estrogen in the body.  The deposits grow and bleed similarly to how the uterine lining does during the menstrual cycle.  This may irritate the tissue, causing it to become inflamed and swollen.  When this occurs every month, it can cause formation of scar tissue.  The bleeding, inflammation and scarring can cause severe pain, especially before and during periods.

The diagnosis of Endometriosis is not easy. It is based on clinical symptoms as described previously. The gynecologist will perform a pelvic exam which may be painful and give your doctor an indication of endometriosis. Further evaluation may include pelvic sonogram ( ultrasound) to check for any ovarian cysts ( also called chocolate cysts).  The only way to accurately diagnose endometriosis is through a procedure called a laparoscopy where a small camera in inserted through your abdomen to look for tissue around your organs.  A biopsy, or a small sample of the tissue, may also be taken at that time.

About 40% of women who have endometriosis may experience difficulty in getting pregnant.   Inflammation from endometriosis may or interfere with the movement through the fallopian tubes and/or affect implantation in the uterus leading to infertility. Family history of endometriosis may play a role. Women with first degree relatives who have endometriosis are at a 7-10 times increased risk of developing the condition.

The treatment of endometriosis depends on symptoms and desire to have children.  Medications such as anti-inflammatory drugs ( Ibuprofen/ Advil etc) and birth control pills are first line treatment options. Birth control pills help prevent new endometrial tissue from forming but are unable to destroy the already existing patches of the endometriosis.  More advanced anti-hormonal treatments may include Lupron, Depo-Provera or progesterone releasing hormonal IUDs.

Surgery for endometriosis should be reserved as the last option in case of failure of response to the previously described medical measures. Many women who have surgery to remove endometriotic implants may experience pain again within 2 years after the surgery.  These women may need birth control pills after the surgery to help prevent new tissue from forming.  For severe endometriosis in women who have completed child bearing or do not desire to have children, a total hysterectomy (removal of uterus, tubes and ovaries) may be performed.

Endometriosis can be lifelong and debilitating condition. It does not always lead to severe problems like infertility or hysterectomy. The diagnosis should be made with care. Compassionate care in management of endometriosis goes a long way.

Adeeti Gupta MD, FACOG

In the United States, 42% of adolescents aged 15–19 years have had sexual intercourse. Although almost all sexually active adolescents report having used some method of contraception during their lifetimes, they rarely select the most effective methods. Adolescents most commonly tend to choose contraceptive methods with relatively high failure rates such as condoms, withdrawal, or oral contraceptive (OC) pills.

Short-acting contraceptive methods, including condoms, oral pills, the contraceptive patch, the vaginal ring (Nuvaring), and depot medroxyprogesterone acetate (DMPA or depo) injections, are mainstays of adolescent contraceptive choices. However, these contraceptives have lower continuation rates and higher pregnancy rates than LARC methods.

IUDs are placed by a healthcare provider into the uterus through vagina and the cervix. Most are made of molded plastic and have a string that you can feel in the vagina, but does not extend outside the body. IUDs currently available in the United States do not increase a woman’s risk of ectopic pregnancy, infertility, or long-term risk of infection.

Two types of IUDs are currently available:

• Copper-containing IUD (brand name: Paragard) prevents pregnancy by preventing sperm from reaching the fallopian tubes. The copper-containing IUD lasts for at least 10 years and is highly effective in preventing pregnancy.
• Levonorgestrel-releasing IUDs or hormonal IUD’s (brand names Mirena and Skyla) prevent pregnancy by thickening the cervical mucus and thinning the endometrium (the lining of the uterus). They also decrease menstrual bleeding and pain. The Mirena IUD lasts for at least five years, and the Skyla IUD lasts for three years. Both are highly effective in preventing pregnancy.

Common concerns

1. Are Intrauterine devices are safe to use among adolescents?

Current evidence demonstrates the safety of modern IUDs. They have a very low complication rate and no toxic or poisonous effects.

2. Do Intrauterine devices increase an adolescent’s risk of infertility?

There is no increased risk of Infertility after discontinuation of IUD. In a large case–control study that examined determinants of tubal infertility, the presence of past or present chlamydial infection was associated with infertility irrespective of IUD use.

3. Is it difficult to introduce Intrauterine devices in adolescents and/or women who have not given birth?

Little evidence suggests that IUD insertion is technically more difficult in adolescents compared with older women. Appropriate counseling regarding pain and provision of pain relief during IUD insertion helps in alleviating the discomfort. Your doctor may recommend taking a NSAID (non steroidal anti-inflammatory drug like ibuprofen or Aleve) to minimize the pain at insertion. Your gynecologist may give a local anesthetic injection to minimize the pain at insertion (like a dental anesthetic injection before a tooth extraction).

4. Should girls be should be routinely screened for STIs (eg, gonorrhea and chlamydia) at the time of IUD insertion?

Women aged 15–19 years have the second highest rates of chlamydia and the highest rates of gonorrhea of any age group. Thus, all adolescents should be screened for STIs at the time of or before IUD insertion.

5. Do Intrauterine devices cause heavy periods?

Women using either copper IUDs or the levonorgestrel intrauterine system can expect changes in their menstrual bleeding especially in the first months of use. The copper IUD may cause heavier menses that can be treated with NSAIDs.

Women using the levonorgestrel intrauterine system (Mirena) will have a decrease in bleeding over time that will lead to light bleeding, spotting, or amenorrhea.

6. How effective are IUD’s in preventing pregnancy?

Intrauterine devices and the contraceptive implant are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in women across all age groups. The risk of pregnancy with an IUD is below 1%.

7. What are the risks or complications expected with an IUD?

There is a small risk that the IUD will come out, sometimes during your period. You should check your IUD once per month, after your menstrual period, by finding the strings inside the vagina. If you cannot feel the strings, use a backup method (eg, condoms) until you can see a healthcare provider to be sure the IUD is still there. There is a very low risk of developing an infection after placement of the IUD, and of improper placement.

8. What if I get pregnant with an IUD?

If you become pregnant while using an IUD, you need an ultrasound of the uterus to be sure that the pregnancy is inside the uterus, rather than in the fallopian tube (called an ectopic pregnancy). The IUD should be removed, if possible, when the pregnancy is discovered.

9. How often do I need to get checked if I have an IUD?

You need to see your gynecologist at least once a year to make sure that the IUD is still in place. Your doctor may do an ultrasound to locate the IUD if there are any doubts.

10. What is the best time in the menstrual cycle to insert an IUD?

The best time for insertion of an IUD is right after periods. Your doctor may ask you to come in towards the end of the period to get the IUD inserted. This is to make sure that you are not pregnant at the time of insertion and also allow easier insertion because the cervix is softer and allows easy insertion at that time.

11. Is IUD also a method of emergency birth control?

Yes. It can be inserted within 5 days of unprotected intercourse. It does not cause an abortion.

If you have any further questions or concerns, please consult your gynecologist or feel free to see us at “Walk IN GYN Care”.

An ovarian cyst is a sac or pouch filled with fluid or other tissue that forms on the ovary. Ovarian cysts are very common in women during their reproductive years. There are multiple types of ovarian cysts and most are noncancerous. The most common type of cyst is a functional cyst, which may form on a monthly basis as a result of ovulation. These cysts will almost always disappear on their own in about 6-8 weeks. These cysts most commonly do not cause any symptoms, and if any, they are very mild.

Sometimes, however, they may continue to get bigger and start collecting fluid or blood inside them. If they get really big (more than 7-8 cm) then there may be a risk for rupture (burst cyst) or torsion (twisting around the base of the cyst). In that case, you may suffer from severe sharp shooting pain in the abdomen associated with nausea, vomiting, sweating etc.

The pain may be constant or may be intermittent. Sometimes, the pain is so severe that you need to go to the emergency room. In the ER, you will be checked out by a sonogram and blood tests to see if you are losing blood. In most situations, if your blood pressure and heart rate is stable, you will be observed for a few hours and then discharged to follow up with your doctor. Your gynecologist may prescribe birth control pills to prevent the cyst from coming back in the next menstrual cycle.

Polycystic ovaries are also a commonly seen finding. Women with polycystic ovaries may present with symptoms of irregular periods. They may also have a tendency to gain weight, have excessive hair growth and have a pre-disposition to developing diabetes during pregnancy or later on in life. For women who are not ovulating, the ovaries may be enlarged and contain a large number of small cysts. About 4-7% of all women may present with polycystic ovaries.

Polycystic ovarian syndrome (PCOS) is a more complex condition, which includes hormonal imbalance and other symptoms. Your gynecologist can help you diagnose and manage the condition on an ongoing basis.

Another common type of cyst is an “endometrioma, or “chocolate cyst”. These types of cysts result from endometriosis. With endometriosis, endometrial tissue that is usually seen in the uterus grows outside the uterus, in places such as the ovaries. These cysts form as the tissue bleeds with each menstrual cycle, therefore filling the cyst with dark, reddish brown blood. Endometriosis is a complex condition with varying severity and presenting symptoms (Watch out for a more detailed blog coming up on endometriosis!).

Many women are not even aware that they have a cyst and don’t experience any symptoms. If they do experience symptoms of endometriosis, they may include abdominal or pelvic pain. More concerning signs may include bloating, constipation, extreme abdominal or pelvic pain, early satiety, nausea or vomiting.

Ovarian cysts may be found during a routine pelvic exam. If one is found, your provider will likely do an ultrasound of the uterus and ovaries to look closer at the cyst. You will also need sonogram if are experiencing abdominal pain or any other symptoms to rule out any other conditions in the lower abdomen that may be causing pain.
The treatment depends on the size and type of cyst found on ultrasound and your symptoms. With small functional cysts that are not causing the patient symptoms, watching and waiting is the usual course.

If the cysts are bothersome and growing, some treatment options may be birth control pills, which will help new cysts from forming. Your gynecologist may recommend removal by laparoscopic surgery if the cyst is getting bigger, painful or looks concerning on certain ultrasound findings.

Adeeti Gupta MD, FACOG

Most women have suffered from at least a single episode of urinary tract infection at some point in their lives. They constitute some of the common reasons for seeking out a gynecologist of family physician on an urgent basis. Urinary tract infections occur most commonly from bacteria that live on the skin near the anus or in the vagina. The bacteria may spread and enter the urinary tract from the urethra (urinary tract opening) that lies in front of the vagina. The bacteria may move up the urethra to the bladder causing an infection. If the infection spreads further up the urinary tract to the ureters and ultimately to the kidneys, the infection is called pyelonephritis.

Women with urinary tract infections may experience a variety of symptoms. Common symptoms include urinary urgency, frequent urination and/ or pain and discomfort with urination. The urine may appear cloudy or may have an odor or even some blood in it. You may also experience fever, pain or pressure in the lower abdomen, lower back or sides.

Some of the common factors that may make some women more prone to get UTI’s more frequently than others include low immunity, not drinking enough water, irritation of the vagina by rough sexual intercourse, wiping from back to the front etc. Since the opening of the urethra lies in front of the vagina, fingers or the penis may spread bacteria from the vagina. UTIs tend to occur more commonly in women who are having intercourse more often or just beginning to have intercourse. Women who have had UTIs in the past, are obese, have diabetes, are menopausal or have had several children are more prone to UTIs.

Women who experience UTIs frequently may need an evaluation by a gynecologist to zero down on the possible causes and help provide useful tips on prevention of further infections.

UTIs are diagnosed based on one’s symptoms and a urine test, which includes dipping the urine to check for leukocytes (pus cells). If the dipstick reveals pus cells, then the urine may be sent for a culture and sensitivity to the type of antibiotics. The treatment is either a 3-day or a 7-day course of antibiotic depending on the frequency and the type of UTI. If you have any other co-existing medical problems such as diabetes or other chronic conditions, you may need a longer course. Some people suffer from UTI’s every time after sexual intercourse. This may be due a short urethra or sensitive vaginal lining that may transfer the vaginal bacteria (normally harmless) to the blood stream and cause UTI. If this happens frequently, some women may need to take a single dose of an antibiotic pill after sex (Post coital prophylaxis). Most women will not need to be on this regimen lifelong if they introduce lifestyle and dietary modifications etc. These infections may be common during puberty and menopause due to certain hormonal changes happening around these periods in life cycle of a woman. An open discussion with your gynecologist can help you fix these problems in a safe manner.

Commonly recommended life style changes are drinking at least 10-15 glasses of water, avoiding very spicy irritant foods, wearing cotton underwear, showering with mild no irritant soap after going to the beach or working out at the gym and avoiding douching. Recent studies have shown that taking daily probiotics prevents recurrences of urinary infections. If you are traveling and develop symptoms of UTI, please visit a nearby walk in women’s health center to get the right diagnosis and treatment before spending time and money on the non-prescription treatments for urinary infections.

Dr. Gupta shares the scientific evidence of benefits of probiotics.

Please follow the link for details http://www.health.harvard.edu/fhg/updates/update0905c.shtml

It is sad to see that cervical cancer screening by a test as simple as a pap smear is still not widely utilized by the American women. The duty is upon us health care providers to spread awareness and make the test easily accessible to women in above the age of 21.

ACOG released a statement this month stating that, “It is disappointing that millions of American women – more than 11 percent – have not been screened for cervical cancer in the last five years. Data have demonstrated that widespread cervical cancer screening leads to a reduction in cervical cancer incidence and mortality. In fact, most cervical cancer occurs in women who have never been screened or who have been inadequately screened.

“The impact of cervical cancer screening on women’s health is dramatic. Widespread screening has decreased the incidence of cervical cancer in the United States by more than 50% in the past 30 years. In 1975, the rate was 14.8 per 100,000 women. By 2008, it had been reduced to 6.6 per 100,000 women. Mortality from the disease has undergone a similar decrease, from 5.55 per 100,000 women in 1975 to 2.38 per 100,000 women in 2008”, as per data from ACOG.

A well woman visit includes a pap smear, STD testing and counseling, contraception counseling and prescriptions. This is covered without co-pay by most insurances. For women who do not have insurance, at Expert GYN we have highly affordable fee schedule to facilitate women practice preventative care.

Betty Krechmer, PA-C

Expert GYN