A Is for Adenomyosis

Of all the words, terms, and phrases you have heard us utter, adenomyosis may sound the most foreign—and if you think it’s hard to say, try spelling it! It’s likely that, unless you have it or know someone who has it, you will close the chapter (or computer) on this piece pretty quickly. But Bear with us for a minute; push past the A to C of what this Diagnosis is really all about and why it’s something worth learning about.

In many ways, adenomyosis is sort of an Enigma. If you don’t look for it, you won’t Find it. And Getting the diagnosis right can be Hard. Unless you have surgery or an Individual who is really skilled at his or her Job looking at your ultrasound or MRI, you may not Know that you are suffering from adenomyosis. It can often masquerade itself as a Leiomyoma (medical term for fibroids). Although adenomyosis also forms Masses in the uterus, they are no fibroids.

In many ways, adenomyosis is like the first cousin of endometriosis. Both pathologies arise from endometrial tissue that has gotten lost (a.k.a. made its way out of the uterus) and is Not sure how to get back—uh Oh. While in endometriosis this lost uterine tissue can go pretty far (think lungs and even skin), in the case of adenomyosis, the endometrial tissue Prefers to stay much closer to home. In adeno (the medical nickname for adenomyosis), the tissue inside the uterus has taken up residence within the muscle of the uterus. So although that trip may be small in distance, the impact of this unwanted visitor can be big.

And unlike those distant cousins that you never knew you had, adenomyosis is not so unknown or removed. In fact, nearly 10% of all women suffer from adenomyosis. The number is much higher in women with infertility. And while many might not know they have it, they will be aware of the heavy bleeding, the dysmenorrhea, the abdominal pressure/bloating, and the infertility that often accompanies adenomyosis. The symptoms can be pretty severe and often send women (usually in their 30s and 40s) to the GYN in a Quandary (a.k.a. not the best of physical and mental states…we needed a Q!).

Historically, the only way to diagnose adeno was in the operating Room with a piece of tissue that was sent off to our pathology friends. Oftentimes, women were incorrectly diagnosed with fibroids (for years), and until the uterus came out Surgically, they didn’t really know what was causing their unpleasant symptoms. Nowadays, due to huge improvements in our imaging Techniques (cue Ultrasound and MRI), we can see adeno before women walk into the operating room.

Although there is much crossover between the treatments for fibroids and adeno, surgery for the latter can be much less successful and much riskier. The division between normal healthy uterine muscle tissue and adenomyotic tissue can be harder to find. With fibroids, the distinction between the two is pretty clear. Thus, there can be a loss of healthy tissue and, in some cases, loss of the uterus.

The treatment for adenomyosis, like its cousins the fibroid and endometriosis, Varies based on the severity of a woman’s symptoms as well as where a woman is in her fertility plans. For Women who have said sayonara to their baby-making days, a hysterectomy is usually their best bet. Goodbye, uterus, means goodbye, symptoms. For women who are not ready to make their uterus their eX, hormonal treatments (oral contraceptive pills, IUDs, aromatase inhibitors, and Lupron are also pretty good at getting you back to a Zen state. Whatever path You choose, it’s super important to go hand in hand with a physician who can recite the ABCs of adeno as he or she catches some Zzzzs (that is, in his or her sleep). Trust us. This is a song that you don’t want to “sing” alone.

My Teenager Is in Terrible Pain…Could It Be Endometriosis?

The teenage years are tough—for both parents and teens. Figuring out who you are, what you want, and how you want to get there can be tough, to put it mildly. Peer pressures, raging hormones, and discoveries can be overwhelming. From alcohol to boys and cars to clothes, your teenage daughter is riding a seemingly never-ending rollercoaster of emotions. The ups and downs can make anyone vomit, even those with an iron stomach.

Adding the debilitating “take you out of the game and sideline you from school”-type of pain can make matters a whole lot worse. It can be frightening, confusing, and exhausting. And while getting your period is a rite of passage, severe pain is not. It is important for both mothers and daughters to recognize this—you should not blow off blow-your-socks-off pain every month. Endo can affect teens just as it affects women in their 30s. Here’s the deal on endo in adolescents.

Interestingly, if you ask most women who have endo as adults when their pain started, most would say under the age of 20. Although initially we thought it took years for endo to develop, we now know it can start right after the first period (and in very rare cases, before). Just like their adult female counterparts, we don’t really know exactly why endo forms. The big four include retrograde menstruation (when blood goes backwards into the tubes, ovaries, and pelvis as well as forward), the spread of endometrial cells through the blood vessels and lymphatic systems, the differentiation of undifferentiated cells, and an alteration in the immune system. And like everything else in life (thanks, Mom, for those bunions!), genetics plays a big role in who gets endo and who doesn’t. Girls whose moms or sisters or grandmothers have endo are more likely to have endo themselves.

It’s important to recognize or help your daughter recognize that intense pelvic pain and debilitating menstrual cramps are not normal. You don’t need to just toughen up and take it. You need treatment. Adolescents with endometriosis are more likely to complain of both cyclic and acyclic pain (a.k.a. pain during menses and pain throughout the menstrual cycle—pain all the time). Young girls are also likely to complain about GI stuff (constipation, pain with defecation, rectal pain, and bleeding) as well as urinary discomfort (pain, urgency, and blood in urine). The only way to make the diagnosis is to see a doctor who you can “dish” to.

A thorough history can crack the code. While a physical exam and blood tests are also a must, they definitely come second and third. While ultrasound and other “picture-taking” tests are key in diagnosing adult women with endo, they are less so in the adolescent population. We almost never see ovarian cysts (a.k.a. endometriomas) in adolescents, and therefore, the ultrasound is less helpful. However, it can be helpful in excluding structural abnormalities of the pelvis, which can go hand in hand with endo. Bottom line, make sure you or your daughter are seeing a doctor she is at ease with. These conversations, especially when they are the first of their kind, should be had in a comfortable environment.

After the diagnosis has been made, the first choice of treatment is medical. The go-to medical option is nonsteroidal anti-inflammatory agents (a.k.a. NSAIDS; Advil, Motrin, and the like). In most cases, we recommend giving NSAIDS plus hormonal therapy (oral contraceptive pills, implantable devices, or injectable medications). The dynamic duo has a way of keeping pain at bay (without any harm to yours or your daughter’s future reproductive abilities). If this pair does not work (most GYNs recommend at least a three-month trial), we suggest a more thorough investigation before amping up the treatment; that usually includes a surgery (laparoscopy) to look inside and confirm endo is what we are dealing with. At the same time that a diagnosis is made, surgical treatment of the disease (if the bad guy is, in fact, endo) can be performed. Our words of wisdom when it comes to surgery are limited to one sentence: Make sure the surgeon who is operating on you or your daughter specializes in this! Look for a pediatric GYN or a pediatric surgeon or an adult endo surgeon with experience treating adolescents. Therefore, if surgery is needed, they should be the ones to do it.

If surgery is needed, it often doesn’t end here. The after party is often just as important as the pre-party—we recommend that adolescents who undergo surgery for endometriosis receive medical treatment following the procedure. Those endo areas are making a lot of unpleasant substances (a.k.a. prostaglandins and cytokines), which are no one’s idea of a good time. Even the best of surgeons can’t get every last bit out. To keep those angry areas quiet (and prevent them from growing from small problems to big problems), GYNs generally start hormone therapy—think oral contraceptive pills.

By turning off your system, we can keep whatever is left (as well as all the good that the surgery did) silent. Although there are other ways to keep things quiet (both pre and post-surgery), some may be too much for a young girl’s bones to take. Lupron is very good at shutting things down. However, in its zest to keep the ovaries quiet, it can have a negative impact on bone density. As a result, we are hesitant to prescribe it to young girls.

We certainly don’t recommend labeling all pelvic pain in teenage girls as endo. There are other processes that can cause pain, including pregnancy, appendicitis, pelvic inflammatory disease, GI issues, and structural abnormalities of the GYN system. Pelvic pain can also be the result of sexual abuse. Although endo is not uncommon in adolescents (about 30% of adolescent girls with chronic pelvic pain have endo), we have to keep our eyes open for other possible problems. We remember being teenage girls—those years can be tough, to say the least. Make sure to talk about what’s going on with someone you trust. It can make all the difference in early diagnosis. This is one place where “no pain, no gain” does not apply!

Post-Menopausal Bleeding: A Drop in the Bucket?

Month after month, year after year, we are running for the bathroom searching for the tampon or pad that we keep buried in our purse for an emergency. After realizing that we used the emergency supply last month and never restocked, we seek out help from one of our bathroom mates who smiles and says, “Don’t worry; I’ve been there.” The truth is, we all have at some point; the monthly mess is just a part of a woman’s life. It can be so unpleasant—the cramps, the moods, the pimples, and of course, the endless bleeding—that it’s hard to imagine ever missing this. I mean, if your 20-year-old self could talk to your 50-year-old self, what a conversation that would be! When you are in the thick of those reproductive years, a little irregular bleeding here or there often goes unnoticed: what’s a little more bleeding? You probably don’t make much of it and maybe even forget to mention it to your doctor. It is, so to speak, just a drop in that much larger bucket. However, when bleeding arises post-menopause, it can be serious and should never be shrugged off, ignored, or go unnoticed.

Menopause is the end of a very, very, very long race; “miles” of menses ultimately come to an end. While this race is long, its end is gradual and is preceded by a major “spacing” out of rest stops. All regularity and predictability are lost, and irregularity and the unknown take the lead. Medically, this time of irregular periods is known as perimenopause; perimenopause and the haphazardness that it brings (both physical and often emotionally) can (oh joy) last for years.

It isn’t until a full year from the last period that you receive your official medal (a.k.a. menopause). From this point on, the flood gates are closed. No more bleeding should occur. Without the ebbs and flows of estrogen and progesterone made by the ovaries, the stimulus for a uterine lining to be produced and shed monthly is lost. The uterine lining becomes thin (no diet required!) and in most instances remains that way indefinitely. If it starts to receive mixed messages (um, no way, that’s not what she told me!), it can thicken and bleed. But let’s cut the game of telephone ASAP. This is not evidence that you are once again fertile. It can hint at a seriously serious situation, such as endometrial cancer, which requires immediate attention. Endometrial cancer is the most commonly diagnosed gynecologic cancer; about 55,000 women will be diagnosed in the US each year. Luckily, most endometrial cancers give you a heads up: a “get out of the way; the bus is about to hit you”-type of thing. For most women, bleeding, long after the days when there was bleeding, will happen.

Bleeding is an obvious and often early sign that something is off. Because it is so visible, endometrial (uterine) abnormalities are often picked up early in the game. In fact, in many cases, they are not even fully cancerous but rather precancerous (about 70% of endometrial cancers are stage I when diagnosed). The precancerous condition is called endometrial hyperplasia. Basically, the cells are becoming a little hyperactive and if untreated could be on their way to some serious Ritalin-requiring behavior. There are four types of endometrial hyperplasia, with some being more in line with cancer and others just slightly out of line with normal. As a common precursor to endometrial cancer, endometrial hyperplasia in a post-menopausal woman often leads to a hysterectomy.

Not all postmenopausal bleeding is bad. Some is just a reflection of a thin uterine lining or thin vaginal wall (medically termed atrophic). Think of dry hands or lips in the winter…they get dry, chapped, and cracked. This can lead to bleeding. There is no medical problem that caused the bleeding (it’s your lack of lotion and chapstick!). And while it can be unsightly, it usually doesn’t require medical treatment. The same goes for what we call endometrial atrophy. With years of low estrogen, things can sort of thin and shrivel. One such thing is your uterine lining. It can become so thin that it bleeds. Last, in certain cases the answer is C: neither of the above. Often, a benign structure like an endometrial polyp (an overgrowth of glandular tissue) can cause postmenopausal bleeding.

Our job is to sort out which type of bleeding you are having—the “I need some chapstick bleeding” or the “I need some surgery bleeding.” We don’t have eyes in the back of our head (even though our kids think we do), and we can’t diagnose endometrial pathology just by looking at your abdomen. In order to make a diagnosis, be it a cancer, hyperplasia, a polyp, or just a really thin lining, we need to perform an ultrasound and possibly even an in-office biopsy.

Sometimes, if more information is needed to make the appropriate diagnosis a D&C is required. The thickness of the uterine lining on ultrasound serves as sort of the gatekeeper for what should be done next. In this case, the line in the sand is 4mm. When the lining is less than or equal to 4mm, you pretty much have the all clear. No further testing is required unless the bleeding continues to occur because the risk of uterine cancer is so low. When the uterine lining is greater than 4mm, you have entered the no-fly zone, and further evaluation is required.

Luckily, the warning signs are fairly bright, so most endometrial cancers are diagnosed and treated early (making survival rates quite high). While most women with endometrial hyperplasia and cancer will require a surgical procedure (hysterectomy), it is a small price to pay to be cancer free. While seeing red again can be alarming, it is not always bad. However, you do need to sound the sirens (a.k.a. call your OB/GYN) and police the situation. Even the smallest drops in the bucket matter. When you are postmenopausal, every spot matters.

Step on a Crack and Break Your Mother’s Back?

While most of us can vividly remember playing this game as kids, aimlessly wandering up and down the sidewalk, we never really had any idea what this saying meant. It served as the impetus to jump over every crack, to yell at our friend whenever she landed on one, and to drive our mother crazy as it took us double the amount of time to walk down the street. Unfortunately, as we age, breaking our backs (medically speaking, our vertebrae), our hips, and our wrists becomes a reality. Osteoporosis, a bone disorder characterized by loss of bone mass, a decrease in bone quality, and a breaking down of the bone structure, affects 54 million people in this country; one in two women over the age of 50 will break a bone from osteoporosis. While you would want to play the lottery with those odds, you wouldn’t want to gamble with your life. And osteoporosis is a lot more than a cosmetic problem (broken bones, deformed spine, and hip braces). This disease not only has a significant impact on a woman’s quality of life but also her quantity of life. Approximately 3–6% of women will die in the first few weeks after being admitted to the hospital for a hip fracture and about 20% within the first year of after the fracture. Simply stated, fractures are no joke, and we should do all that we can to avoid them.

So osteoporosis is thin bones…Who gets thin bones and why? Are thin bones just a natural part of aging like grey hair and wrinkles? The answer is somewhat grey (no pun intended). While age is the most important determinant of bone quality, not all postmenopausal women will have osteoporosis. Genetics, race, and ethnicity are also key players. Caucasian women have the highest rates of osteoporosis, and African American women, the lowest. Other important risk factors include smoking, prolonged periods of no period (no period = no estrogen, no estrogen = no “water” for the bones), weight, excessive alcohol consumption, inactivity (a.k.a. couch potatoes!), poor nutrition, family history, and certain medications or medical conditions.

Another important piece to the bone jigsaw puzzle has been locked in for years and years. While it may be hard to believe, most of what will happen to our bones as adults is determined by how we lived as adolescents. During our late teens and 20s, we achieve what is called our peak bone mass. Our peak bone mass is mostly influenced by things like genetics and ethnicity (inherited factors). But even if the cards had you slotted for some good bone numbers, lifestyle, health, and environmental factors during your formation and oh-so-fun years can hinder what you can achieve (in the words of your parents…you aren’t living up to your potential!). This is why it is so important for young women to get that milk mustache, a good steady dose of estrogen, a good amount of exercise, and a good daily complement of vitamins.Even if you failed to live up to your bones’ expectations, any time you make a change is helpful: basically, better late than never.

Diagnosing osteoporosis is fairly simple, painless, and pretty quick. If done in women with some serious risk factors or at a specific age, it can be picked up years before really bad stuff and bad breaks happen. A DEXA (dual-energy X-ray absorptiometry) makes the call. A DEXA takes a picture of the lumbar spine and the hip and provides the necessary information to make the diagnosis of osteoporosis. Additional pictures are often taken of heel and wrist; these images are not as useful for making a diagnosis or for monitoring treatment (if you need it) but can provide helpful information about the extent of the underlying process. Through the DEXA, something called a bone mineral density score for each site is calculated. The numbers at each site are then compared to a young and healthy female to produce another number (ugh, math, math, and more math!). Once you get to the end of this very long equation, you can answer the question: do I have osteoporosis?

When your T score is ≤ -2.5 at ANY of the sites, you have got yourself a diagnosis.

If the T score is ≥ -1, you are in the clear.

For those between -1 and -2.5, you have what is called osteopenia.

Osteopenia is sort of like a yellow light. Your bones are slowing down, but they have yet to stop. This information can be incredibly powerful because lifestyle and medical changes can keep the road ahead clear. DEXA screening should begin no later than 65. However, for some women with any of the previously mentioned risk factors, screening should be initiated even earlier.Bottom line, this issue is fragile and needs to be handled with care! If your doctor doesn’t bring it up, you should!

We all knew milk was good for us, but who knew it was this good? Get that milk mustache ready, because a few glasses a day can help keep the cast away. Good lifestyle decisions such as calcium and vitamin D, exercise/activity, and healthy eating habits can all make a big difference. Currently the recommended daily dose for ALL women is:

1,000–1,300mg/day of calcium and 600–800 IU of vitamin D/day (specific dosing based on age). Postmenopausal woman (51–70) need 1,200 mg/day of calcium and 600 Vitamin D/day. Bottom line, milk really does do a body (and bones) good!

Lifestyle modifications and changes in your surrounding environment can also have a major impact on both on your getting osteoporosis and preventing fractures. Weight-bearing exercises (e.g., walking) and muscle-strengthening exercises can not only make you look good and feel good but also bulk up your bones (i.e., prevent osteoporosis and decrease the risk of fractures). And while we don’t want you to start moving your furniture around, it might not be a bad idea to call some friends over to help you. Modifying your living environment and adopting ways to prevent falls can reduce your risk of falls and subsequent fractures. Some other suggestions include installing better lighting (including nightlights), removing throw rugs and junk from the floor, moving cords/cables, storing items at your height (throw away the stepstool!), putting nonskid strips in the shower, and installing handrails on the steps. While we are not in the business of redecorating and love what you have done with the place, these changes can be very beneficial for your bone health.

Unfortunately, sometimes even our best efforts can’t stave off a disease. You can drink gallons of milk and eat cartons of yogurt and still get osteoporosis. But don’t get all sour; there are excellent medical treatments that can help rebuild your bone and stop future bone destruction. While many options exist, your doctor will tailor the appropriate medical treatments to your lifestyle, the extent of your disease, and your personal needs. Bisphosphonates (Fosamax) are often the first line (inhibit the cells that break down bone); while they have gotten some negative press lately, when taken under the guidance of an experienced physician, they are safe and often quite successful at keeping the damage at bay.

Just in case you were wondering where that saying, “step on a crack and break your mothers back” actually comes from (no, it has nothing to do with osteoporosis!), it is rooted in some serious old-school superstitions. It seems to have originated in the late 19th century when racism was rampant. The original verse was “step on a crack, and your mother’s baby will be black.” Pretty terrible stuff. Somehow, from that we got to the mid-20th century where the saying took some “alternative” paths. Some said that the number of cracks equaled the number of china dishes you would break, while others told children that the number of cracks equaled the number of bears around the corner waiting to eat them for lunch (that’s one way to parent!). While all beyond ridiculous, for some reason the saying has stuck. If for nothing else, use it to remember to be mindful of where you walk and to watch out for bumps in the road. Try to avoid cracks. Let’s face it; you don’t want to trip. Then you may really break some bones!

Peeing in Public: Female Incontinence

When you are afraid that your friend will make you laugh and both you and your bladder will lose it, it’s not a good situation. The inability to hold your urine (medically termed incontinence) is not anyone’s idea of a funny situation. It can be incredibly embarrassing and isolating. While you certainly won’t kick the can because of incontinence, it may kick the quality of your life. Women often report depression, anxiety, and isolation because of it. Admitting it out loud can be difficult; but once you say the words, you will probably see several of your friends nodding in agreement. You are certainly not alone.

You may be asking yourself: how the heck did I find myself leaving the pharmacy with Depends? I used to buy tampons and pregnancy tests, and now I am buying Depends! How did this happen? Well, despite your love for your little ones, they are usually somewhat to blame. And the larger your brood, the better the chance that you will experience incontinence. Furthermore, if you avoided a C-Section and pushed those kids out, you are even at greater risk. Wow, being a woman is so much fun!

While pregnancy and delivery are big players in the incontinence game, obesity is also one of the biggest risk factors for urinary incontinence. Believe it or not, obese women are three times more likely to suffer from incontinence. It’s a real risk factor. And not surprisingly, rounding out the top four is age; age is the A-number-one risk factor for incontinence. While about 4% of women age 20 to 29 report incontinence, this number jumps to 40% in women older than 80 (getting old is not easy!)

Incontinence comes in many shapes and sizes (as do the women that it affects). Close your eyes, and imagine four drawers—one that holds your bras, one that holds your T shirts, one that holds your tanks, and one that holds your long-sleeved shirts. Now, if you live in New York City, you may be thinking: I only have space for one drawer, and all that stuff is mixed together. However, the rest of the country is digging the metaphor. Each drawer is a part of a dresser that holds something that you wear on your top. Incontinence is similar; there are four main types of incontinence, all which hold their own “drawer.” There is stress, urgency, overflow, and mixed. It is important to identify which type you have so that you can get the right treatment.

Ah, stress…the big S impacts us on a daily basis, from morning to night, from work to home, from friends to spouse. And much like the pressure it causes in our daily lives, stress incontinence results from increases in intra-abdominal pressure. Think cough, sneeze, laugh, push—all of these actions increase pressure in your abdomen and can lead to the leakage of urine. It is more common in younger women (40s) and generally occurs because the urethra (that’s the hole from which your urine comes out of) changes position. It becomes hypermobile (or uber flexible); this change results from poor support in the pelvic floor (pregnancy, deliveries, obesity, chronic coughing, high-impact activity).

Moving right along from the T- shirts to the tank tops, we have urge incontinence. Think gotta go, gotta go, gotta go right now…and that’s urge. The need to go right now is called urge. This usually happens as we age and often occurs alongside other medical conditions. The urge to urinate comes whether the bladder is full or basically empty. Due to bladder contractions, you are always on the go, searching for a bathroom.

The next drawer down is overflow incontinence. In an overflow situation, the urine is always flowing; whether it is a stream or a dribble, it never stops coming. In general, it results from an inability to completely empty the bladder, and it can be a real bummer.

Putting it all together, or choice A + B (stress and overactive), you get mixed incontinence. The combination effect makes treatment slightly more difficult and diagnosis definitely more clouded. You will likely need a specialist to help you solve this problem. To figure out if you have it and what you have, we need to do some tests. After a thorough history and exam (focused on the pelvis and pelvic organs), we will likely check your urine for infection. Believe it or not, bugs in the urinary system can lead to incontinence, so this is one of the first places we look.

Usually, we will ask you to keep a diary (Dear John…I think I may be in love with Tom…no, not that kind of diary) documenting when you urinate, how much you urinate, and what you drank before you urinated. It is also likely that we will schedule you to undergo something called urodynamic testing. While totally different than any test you have ever gone through (think sitting in a chair with catheters coming out of all orifices below your belly button), it will shed a lot more light on why your urine is making unsolicited appearances throughout the day. Furthermore, if surgery is in your future (and we are not saying that is where you are headed), this is super helpful in planning the procedure.

Before any medical treatment is initiated, be it pills or surgery, we ask you to look at your life and see what, if any, changes need to be made (and to get a second opinion!). If you are smoking, you need to quit. If you are overweight, you need to lose weight. If you are suffering from constipation (chronic pushing is not good), you need to take a stool softener and eat more fiber, and if you are drinking tons of caffeine, you need to cut back. While basic, these can be the biggest beasts to tackle (we know; we have some habits that would be nearly impossible to break).

We will also suggest learning and implementing daily Kegel exercises. No, we’re not kidding. Strengthening your pelvic floor muscles can help reduce incontinence. We also take you back to those magical days of potty training your toddler (“Sammy, do you have to go pee-pee?”) over and over again until they finally get it! Retraining your bladder to void frequently and keep bladder volumes low can be quite helpful. Despite our best efforts, many times, lifestyle changes ≠dry underwear. We may need medication and/or surgery to get us there. It’s not a bad thing; it’s just a slightly bigger deal. But with new advancements in medicine and surgery, we can find the right treatment to tame your bladder.

Whatever you call it, the ladies room, the bathroom, the loo, or the potty, the bathroom is a pretty essential part of all of our days. You stumble in bleary eyed in the middle of the night without giving it much thought. However, when you start to experience incontinence, everything to do with it—the bathroom, where it is, how long it will take you to get there, and what you will do if it is full—becomes a big, big deal.

Unfortunately, it is not an uncommon problem. Millions of women experience it, and most do it in silence. While we don’t suggest updating your Facebook status to reflect “incontinent,” we do recommend sharing it with your doctor and those who are near and dear to you. Their support will make a difficult situation easier and will guide you to get the treatment you need. Don’t suffer in shame; it’s so not worth it!

How to Stop a Drought: Vaginal Dryness in Post-Menopausal Women

When it’s dry as the Sahara Desert down there, you are in need of some major water. In the case of the vagina, water doesn’t come from a bucket or a well but from estrogen. Think of estrogen as a hose. Without a hose, you have no water, and without water, you are going to face a drought. And as we have all seen on the news or lived through in real life, droughts are not fun. As a result, vaginal dryness is not just a pesky problem but rather a major pet peeve. It can cause pain, bleeding, itching, daily discomfort, and urinary symptoms (infections and incontinence). Here’s how to get the water flowing again.

Vaginal dryness is best treated with vaginal estrogen…seems intuitive, right? If you have a fire, pouring water on it is the best way to put it out. Vaginal estrogen comes in creams, rings, and tablets. They are placed, in one of these three forms, into the vagina and deliver a low dose of estrogen directly to the vaginal tissue. While the doses and composition may vary, most of the vaginal estrogens function in a similar way. Going back to our fire reference, when you pour water on a fire, the water doesn’t typically spread. It does its job on those flames only. Vaginal estrogen is not absorbed into the bloodstream (like oral estrogen); therefore, the hormonal effects on other parts of the body (think breast, ovarian, uterus, etc.) are very small. The limited spread of vaginal estrogen makes it appealing too many.

On the flip side, if you are experiencing both vaginal dryness and hot flashes you should start searching for a wider and bigger hose. Vaginal estrogen can’t put out those fires, and they can be hot! In these cases, oral estrogen or an estrogen patch is the better way to go.

While vaginal dryness is no joke, it’s particularly unfunny in women who have or have had a history of an estrogen-sensitive cancer. In such situations, using estrogen, be it oral or vaginal, can be risky and somewhat taboo. Therefore, OB/GYNs usually like to start twisting the faucet by using non-hormonal approaches. Some of these include vaginal moisturizers, vaginal lubricants, and topical anesthetics. And while they are not estrogen, they are pretty good at temporizing the torrid situation. When they don’t and the dryness is debilitating, we must look for other options. In select cases, even in women with estrogen-sensitive cancers, we will give vaginal estrogen a go for a short period of time.

Anything that impacts your quality of life should sound the sirens. You shouldn’t live in pain. We may not put the fire out on the first try, but we have many other firehouses and engines that we can call for back up. If you sound the sirens, we will find a way to put it out!

Fibroid: What to Do When Fertility Is No Longer on Your Mind

If you have fibroids, you are probably saying a choice curse word every time you think of your little (and in some case) big uterine friend (s). They can be a big pain in the rear. They can cause bleeding, pain, pressure, and infertility. Bottom line, they are not fun.

Unfortunately, this un-fun party is very well attended; nearly a quarter of reproductive-age women have fibroids. Simply stated, you are not the only person who RSVPed yes to the fibroid gala. While there are many ways to treat them, not everything works for everyone at every point in their life. Women at different stages of their lives (a.k.a. reproductive “stages”) and symptomology warrant different procedures. For those of you whose fertility ship has long since sailed and you are done and done, here’s what we recommend.

When babies are no longer on the brain, your options with regard to fibroid management (as well as where to go to dinner) are way more expansive. It no longer matters if they have crayons and serve you fast. You can do a lot with or to your uterus, if you don’t care if it functions for fertility purposes ever again. While you still have both medical and surgical options if you are totally fed up, going down the surgery path is a way to be totally done.

You still have medical options, and those include: oral contraceptive pills (a.k.a. “the pill”), the intra-uterine device (a.k.a. “the IUD”), Lupron (a.k.a. “I feel like I am in menopause with these hot flashes and vaginal dryness”), progesterone receptor modulators (mifepristone or ulipristal acetate), SERMs (raloxifene), aromatase inhibitors (letrozole), and anti-fibrinolytics. While some of the medical options are better at improving some of the symptoms (for example, OCPs will improve heavy bleeding but not the pressure symptoms), they very rarely fix it all.

Just like when selecting the OCP you want to “marry,” you may have to shop around the medical options before you land at your symptom-free spot. While Lupron (GnRH agonist) will do it all, it will cost you in the side effect department. Hot flashes, sleep problems, vaginal dryness, muscle and bone pains, and even changes in mood/thinking often come in conjunction with the reduction in fibroid bleeding, pain, and pressure. It’s because of the side effect profile that we don’t go with Lupron as our first medical treatment (and very rarely for women who are ready to wave goodbye to their fertility). It’s reserved for the fibroids that we don’t like in women who still want to give fertility a chance!

If having kids is no longer a consideration, surgically, you are no longer boxed into the myomectomy corner. While you can certainly elect to retain your uterus and just remove the fibroids (a.k.a. myomectomy), you can also go for broke and remove the whole uterus. By undergoing hysterectomy, you ensure that the symptoms are sayonara (even if you are not yet in menopause).

The approach for both a hysterectomy and a myomectomy can vary; the procedure can be performed abdominally through a bikini cut incision, laparoscopically through a camera, robotically through a robot (and small incisions), or vaginally (no explanation needed!). The approach depends on the size of the uterus and fibroid (s). If you are going for a myomectomy, the location and number of the fibroids also play a role. Lastly, your surgeon may have a bias and a preference. Make sure you are comfortable with all of the above before you commit to anything or anyone.

Just as there are minor and major life decisions (dating vs. marriage, contraception vs. babies), there are minor and major surgeries. The majors, we described above; they require the big guns: anesthesia, intubation, hospital admission, and everything in between.

Minor procedures are still procedures but are much less involved. They can often be done in an office and under less paralyzing anesthesia, that is, no breathing tube. When it comes to fibroids, the minors we talk about in a major way include uterine-artery embolization (UAE) and endometrial ablation.

Our radiology friends perform UAE; they use some fancy catheters and particles (threaded from the groin to the uterus) to block off the uterine arteries (the blood supply to the uterus). By starving the uterus, they starve the fibroids. The fibroids shrink, and symptoms in most cases will resolve. While the uterus is not removed, we don’t recommend performing UAE in women who want to keep using their uterus. It can impact ovarian function and egg quantity. Endometrial ablation is also an option, particularly for women whose biggest gripe is bleeding. There are various devices and mechanisms to ablate the uterus (burn, freeze, microwaves, radio frequency), but essentially in all cases, the endometrium (uterine lining) is destroyed.

As with most things, there are pros and cons to all options. If you like lists (we love them!), here are the important points to note…For most women who have closed the kid chapter, the options are endless. You are not thinking with your fertility hat anymore! You can do whatever necessary to halt all symptoms. Based on your symptoms, the size of your fibroids/uterus, and your medical/surgical history, your OB/GYN will decide which route is the best to go.

Give their opinion a lot of thought, and seek out another one if you are on the fence so that you feel more than fine with your decision. News flash. If menopause is in the very near future, you may not need to do anything. Without postmenopausal hormone replacement therapy, fibroids will shrink, and symptoms will subside. Just make sure that your reproductive timeline matches up with your treatment timeline; in some cases, time will be on your side!

Fibroids are pretty pesky for most of us, but some women are completely unaware of their presence. They find out totally by accident during an ultrasound, a pelvic exam, or pregnancy. And just like if it isn’t broken don’t fix it, fibroids that are causing no symptoms are really no big deal. They can hang with you for as long as you both shall live. No divorce in sight. If they don’t bother you, don’t do anything with them until you have to. Prophylactic or preventative therapy to avoid future problems is not recommended (no pre-nup here!). Fibroids need to be fixed only if you can’t take them anymore. Otherwise, do your best to forget they even exist!

The Big O: Cysts, Solutions, and All the Steps in Between

Your mind probably went somewhere we don’t want to know about after reading that title, and you are likely thinking, So this is where they are going to tackle the sex thing. And although, yes, we will, no, it is not here. In this debriefing or girl talk, we will begin an extended conversation on ovarian cysts. We want to demystify their presence and debunk many of the myths. So let’s get gabbing!

The second you hear the word cyst your mind starts racing—and not to the same places the “big O” takes you. You think surgery, cancer, and possibly even death. It’s beyond overwhelming.

The good news is that, in the large majority of women who are diagnosed with an ovarian cyst, the pathology will be benign. In fact, a good proportion won’t ever even need surgery—the cyst will resolve on its own, like magic (take that, David Blaine!). Ovarian or adnexal (as we doctor types like to say) masses are very common. In many ways, they are the bread and butter of gynecology. Luckily, only about 15% will be cancer. The overwhelming majority are benign. The odds of it being something bad are pretty low. A woman’s lifetime risk of developing ovarian cancer is 1 in 70 compared to breast cancer, which is 1 in 8. Nevertheless, you never want to ignore something that could be serious.

What determines what sort of pathology cards you are dealt is usually age. Think of age as the worst Vegas blackjack dealer; when it comes to ovarian masses, he is not your friend. After that, the others who are lining up to take your chips include those with a family history of breast or ovarian cancer and BRCA carriers (a genetic mutation that increases your chance for breast and ovarian cancer). How we determine who has what is through a good medical history, a thorough physical exam, comprehensive imaging studies, and a couple of tubes of blood (e.g., CA-125).

If it looks like a duck, swims like a duck, and quacks like a duck, then it probably is a duck. When it comes to ovarian cysts, you want to make sure all of your ducks are in a row, that is, you have confirmed that the “ovarian” mass is not a something else (diverticular disease, appendicitis, pelvic kidney, etc.). This is where a really complete and comprehensive check-up comes in—every stone should be unturned before you step foot into an operating room. If all fingers point to the ovary, then you are in the right place. How we determine who needs treatment and who needs time is based on age, size, and cystic features (blood flow, septations, and fluid).

First up in the lineup for what matters is age; unfortunately, yet again, time does not heal all wounds. When comparing premenopausal women to postmenopausal women, cancer is way more frequently encountered in postmenopausal women. In fact, nearly all pelvic masses in pre-menopausal women are benign. What matters most for the “young-uns” is what brings you into the office. Those who come in with pain, fever, and lots of symptoms usually need immediate treatment. Whether this is surgery or antibiotics or a little bit of both, it always warrants something ASAP. The “this” we are talking about are things like tubo-ovarian abscesses, ovarian torsions (ovaries that twist), and ruptured benign cysts. Never say never, but it is almost never that a woman with acute symptoms has cancer—that’s just not how cancer comes on.

Premenopausal women are also affected with the chronic stuff. Think endometrioma, dermoid, hemorrhagic corpus luteum, and serous and mucinous cyst adenomas (two types of benign cysts). While you may not know every name we just rattled off, you likely have heard of one or two.

Bottom line is that there are a lot of different things that can call your ovary home. Some are more welcome visitors than others. Although at some point we would like all of these houseguests to leave, the urgency with which we kick them out is varied.

Women who are postmenopausal are way less likely to present with acute symptoms and are way more likely to present with those “nagging, persistent” sort of symptoms. To differentiate the bad stuff from the benign, we take a lot of pictures, get a couple of tubes of blood, and start our workup.

In most cases (except for the simplest of simple), postmenopausal women will require surgery to figure out what’s up with their ovary (s). The ovary is also a common site for cancer metastases. Therefore, it’s important to look at the breasts, the uterus, and the GI tract of postmenopausal women with cysts before calling it a wrap.

How a cyst looks on ultrasound is a big deal for how anxious we get about its pathology. If the cyst has a thin wall, has smooth, regular borders, and appears empty (think of a black hole) then there is a very, very good chance (no matter how old you are) that it is benign. In fact, it’s okay to play the waiting game with (repeat exam/ultrasound in six months) even those that are big (up to 10 cm) but appear super simple in patients that are post-menopausal. In fact, about two out of three of these cysts will resolve on their own without us doing anything! So in most cases our answer to these is patience, time, and lots of deep breaths. They will go away!

Next comes size, and guess what? It does matter, at least when it comes to cysts. How big they are has a big impact on how likely they are to be something bad. The bigger the cyst, the more likely you are to need it out and need it evaluated. Additionally, the bigger it is, the less likely it is to resolve on its own. Last, those that are big may cause the ovary to twist (ovarian torsion) and require immediate evaluation.

When we think things don’t look good (a.k.a. concern for cancer), most of the time we general OB/GYNs turn things over to our oncology colleagues. They are trained in surgery and cancer and are the ideal people to treat any cysts that appear worrisome. Studies show that women who start with a GYN ONC (as we have affectionately nicknamed them) do better overall, with longer survival rates. Never be afraid to ask your doctor to consider asking for help.

While there are innumerable things to stress about, most ovarian cysts, even in postmenopausal women, are not it. You can usually stick to a good follow-up schedule and cross the bad stuff off your list. And just like if you see something, say something, if your symptoms change or you don’t feel right, tell your doctor. Although we usually have some tricks up our sleeves, we are not magicians and need to hear from you if something seems different. Together, we can usually make things disappear!

Get Out Your Checklist…It’s Screening Time!

One thing we can never stop or change is aging. And while it may bring us increased confidence and accomplishments, it does have some unwanted side effects: the aches, the pains, the wrinkles, and the grays. The maintenance alone can become a full-time job. And the cosmetic side is the least of it. Doctor’s visits go from twice a year to twice a month and, in some cases, twice a week. Arthritis sets in, blood pressure creeps up, weight becomes hard to shed, and hearing goes downhill. Sounds like a ball of laughs.

But the reality is that we women are kicking aging’s behind. We are living longer and longer, and today, the life expectancy for a woman in the US is 81. Go, girls, go! One of the ways to make sure you make it to 80 and beyond is to maintain good preventative care (a.k.a. see your doctor when you don’t feel sick) and follow health screening recommendations, as outlined by the ACOG (American Congress of Obstetricians and Gynecologists) and the U.S Preventative Services Task Force.

Here’s what is on our list of things to do for women who are over 40 each year.

  1. Talk
    The majority of what we as MDs do is talk (wait, all those years of training, and we mostly talk?). In all seriousness, we can make a pretty good assessment of a woman’s overall health just from chatting with her. It’s all about knowing which questions to ask and how to listen.
  2. Physical Exam
    Although no one likes the check-up part, it is a must. Getting into that gown and being weighed, poked, and prodded are no one’s idea of a fun day off. However, it is important that someone gives you a good onceover at least once a year to make sure nothing is out of place.
  3. Breast Exam
    An annual breast exam (a.k.a. the clinical breast exam) should be performed each year. It might surprise you to know that we, as MDs, can feel lumps and bumps that are really tiny and may go undetected by your monthly self-breast exams. While our exam does not replace a mammogram, it is definitely an important yearly checkpoint.
  4. Mammograms
    Recently mammogram screening has become more controversial than if you’re going red or blue during an election year. The U.S. Preventative Task Force changed their recommendations and no longer recommend that mammograms start at age 40 or occur every year—they now recommend a screening mammogram (in a woman with no personal or family history) at age 50. If all is ok, they want to see you back two years later. The every-two-year schedule (as opposed to the traditional every one year) will stay as long as nothing notable is noted (say that five times fast!). However, many, such as the ACOG, are going old school and recommend you start at 40 and go every year to your friend the mammographer. We tend to side with the ACOG on this one and still advise our patients to follow the more traditional screening protocol. Of note, family histories matter big time on this one. You may need to be screened even before 40 if your sis or your mom had early breast cancer. So be certain to share this info with your MD!
  5. Colonoscopy
    Once you hit the big 5-0, it’s time to get cleaned out and checked out! Colorectal cancer screening in the form of colonoscopies should begin at age 50 (unless you have a family or personal history that requires an earlier exam). In most cases, the intestines are inspected every five years.
  6. Bone Mineral Density Test
    In many ways, our bones resemble our ovaries—time is not on their side! As women age, their bones are prone to breakage and fracture. This condition is called osteoporosis, and it is fueled by low estrogen, low vitamin D/calcium, and age. Most women start getting bone mineral density testing (a.k.a. DEXA) starting at age 65. However, women with risk factors (think a family history of osteoporosis, history of fractures, or an elevated risk assessment on what is called the FRAX test) need to dial up the DEXA testing.
  7. Cervical Cancer Screening
    Pap smears are like the never-ending story—they just keep on going. However, the good news is that, due to a revamping of Pap smear guidelines, at some point most women can close the chapter on Pap smears. Women between the ages of 30 and 65 can hold off on Pap smears for five years if both cytology and HPV testing are done together and are negative. If you have passed the 65 mark, you may be done with Pap smears. What dictates where your finish line is, is your Pap smear history. It’s important to keep track of your tests (especially if you switch GYNs) and stay in touch with your GYN so that you know when you can throw in the cervical cancer-screening towel.
  8. Cholesterol Testing
    No matter how much you weigh, how much you eat, or how much you exercise, it’s important to check your cholesterol. Although obesity and a diet high in fats make you more prone to high cholesterol, there are genetic conditions that can predispose even the healthiest of us to cholesterol abnormalities. We have a whole slew of good medications to manage cholesterol, and therefore, the sooner you know, the sooner you can start treatment. Anyone who is above the age of 45 (or younger than 45 but with risk factors for heart disease) needs to sit in the blood-draw chair for a cholesterol check at least once every five years.
  9. Blood Pressure
    When it comes to blood pressure, higher is not better. Here, less is more. Elevated blood pressure is a predictor of heart disease and many not-fun medical conditions. It should be checked at the least every two years, if not every year. Don’t let the white coat scare you; it’s all good!
  10. Diabetes
    Diabetes is no joke. If untreated, it can have some of the most devastating medical complications, from blindness to limb loss. Being checked for diabetes should be at the top of everyone’s list. A simple blood test checking your glucose level will give us a hint as to how “sweet” things are. It’s important to be screened diabetes in a regular fashion (particularly if you have a family history of diabetes, elevated blood pressure, and obesity).
  11. STDs (a.k.a. gonorrhea and chlamydia)
    Just because you are not 23 does not mean you can’t acquire a sexually transmitted infection! For this reason, women who are sexually active should have STD testing (gonorrhea and chlamydia).
  12. HIV
    All women should have HIV testing at least once in their lifetime. If you are in a high-risk category (certain behavior patterns), the testing should be done more than once.
  13. Other
    We are not all the same. Our genetics and our environments differ big time. Your doctor will decide based on your past (and your family’s past) what tests should be done yearly to maintain your present. However, the only way this will work well—and allow your GYN to tailor a treatment plan to prevent what may lie in your path—is to be honest with your GYN. We need to know it all to know what tests need to be run.

The list may seem long, but checking the boxes can be pretty quick. We can tackle a lot of the issues at once at your yearly visit. Don’t brush us off because it seems like no big deal. Yearly checkups, preventative care, and screening can be the key to longevity. You’ll take that 81 and see you 10 more!

Compounded Bioidentical Hormones…Are They Really the Best Fit?

Thanks to Samantha on Sex and the City and Oprah, compounded bioidentical hormones have gotten a whole lot of press. They have been billed as the best thing since sliced bread. They have become the good guy, while the prescription drugs (a.k.a. conventional hormone replacement therapy, or HRT) have become the bad guy. Bioidentical hormones have been called “natural,” “organic,” and everything in between.

Unfortunately, most women are being sold snake oil, and what they are getting is far from natural. They are victims of false advertising and in most cases are unaware of what compounded bioidentical hormones actually are and how they differ from standard hormone therapy, if at all.

The public and medical opinion on hormone replacement therapy for post- and perimenopausal women has run quite the gamut. The pendulum has swung further on this issue than almost any other topic in gynecology. Before the results of the Women’s Health Initiative (a large study initiated in 1991 to examine estrogen and progesterone’s impact on postmenopausal women) were released in 2002, HRT was lauded as the fountain of youth.

Estrogen and progesterone in the postmenopausal woman were not only believed to improve the nagging symptoms of menopause (hot flashes, vagina dryness, etc.) but also to improve a woman’s overall health. The results of this large study showed almost exactly the opposite. This led GYNs to turn their HRT-writing prescription pads in ASAP and caused women to quickly trash their stash! However, a closer examination of the study and the study population over the past 10 to 15 years has called into question a lot of the initial findings and negative hype.

It now seems that HRT in the right woman (again, the right woman) is no longer the devil and actually can be pretty helpful. While it is no longer believed to improve overall health and prevent things like heart disease, stroke, and breast cancer, it can be useful for women with beyond-bothersome menopausal symptoms.

So if HRT was good, then bad, and now sort of good, what is all the hype about compounded bioidenticals? Did they, too, follow this trend? What are they, and what makes them so different? Bioidentical hormones are plant-derived hormones similar to those produced by our bodies. They include both products that are and are not approved by the FDA.

Think of the FDA as the FBI; they are there to keep you safe when it comes to anything drug- or medicine-related. They test products, procedures, and techniques and make sure things look kosher before you use them. However, the FDA does not oversee the production of compounded bioidentical hormones. They have not checked these drugs for safety, efficacy, potency, purity, or quality. Basically, the inmates are running the asylum. Overdosing and underdosing are both more than possible, and you can’t be sure that what you took on Monday is going to be the same thing you take on Tuesday.

You might now ask, what is compounding? Is it just a fancy way to say “mixing”? Basically, yes. Compounding is creating an individualized product based on the prescription written by the health care provider. Given that the product is custom made, there is no regulation over what is put into that “cocktail.” While you may think your vodka cranberry drink tastes better with a little more vodka, it might not be good for you. And unfortunately, given that it has deviated from the traditional vodka cranberry, no one will be checking to make sure it’s safe.

Now don’t get us wrong; compounding has its place in medicine. It has traditionally been used when specific products are not available or if different preservatives, routes, or ingredients are needed to deliver a medication. An example is the following…you need to take progesterone but it traditionally comes mixed in peanut oil—but you are allergic to peanut oil. Therefore you can’t take the medication UNLESS it is compounded with something else (aka sesame oil). Changes like this are what compounding was meant for!

But give me a little of this, mixed with some of that, and a splash of something else (a.k.a. blending) is not what compounding is or was intended to do. However, this blending concept is how it is often sold and marketed when used to describe hormone replacement therapy. When we were all down on HRT, compounded bioidenticals gained foot traffic because they appeared, and were billed to be, a safe alternative. They were marketed as the same good but no bad. The story was bought by many hook, line, and sinker and led many women to have a false sense of security about what they were putting into their bodies.

Many practitioners who prescribe bioidentical hormones tout them as personalized or tailored. They sell them as a perfect fit (sort of like those jeans that you are always trying to find!). But in reality, you don’t really know what you are buying, ingesting, or drinking. They are free from warning labels and any information on risks. But while ignorance can certainly be bliss, in many cases, this is not one of them! For example, if you are not taking enough progesterone in comparison to estrogen, you can put yourself at risk for uterine cancer—it’s just not a good situation.

And let’s take it one step further. Those that tout compounded bioidentical hormones will tell you they can check your levels through your saliva and can further tailor your treatment according to what they find. There is no evidence that hormone levels in saliva have any biological meaning; while we can pick up some things from your spit, we cannot pick up the level of your circulating hormones. So chew on this: don’t put yourself in danger because you want something natural. Compounded bioidentical hormones are not necessarily the answer.

The specific medications, the dosage, and the way the medications are delivered (oral, patch, vaginal) should be made to order for you. However, this should be done with FDA-approved medications where your doctor knows exactly what they are writing for you and you know exactly what you are ingesting. So while, yes, medicine should be tailored to you, the tailoring should not come in how the medication is mixed but rather how it is administered.

While we all agree that you need a good designer, some designs are not meant to be worn (think midriff shirts). So while you can look, please don’t buy. If the salesperson tells you it looks good, don’t believe it…just like bioidentical hormones, it’s not necessarily the best fit!