PMS, Contraception, Pap smears and Pregnancy
The best in gynecological and obstetrical care is a partnership between you and your doctor. In her office, Dr. Pollycove provides the full spectrum of gynecological care, from the early onset of your menstrual period with all of its potential symptoms, to understanding causes of irregularities in menstrual cycles. Most of the time these irregularities are part of the “normal” spectrum of menstrual patterns throughout our lives but can become bigger issues as we pass from “peri-menopause” and the transition to full menopause. Routine general health screens, female hormone evaluation including thyroid screening and treatment are available. Many options for treating PMS, including menstrual migraines, are available. With a careful clinical history and discussion of treatment options, significant improvements in life quality are possible. Gentle and thorough breast exam, pelvic exam, pap smear, including screening for HPV and bacterial or yeast infection (vaginitis), and other diagnostic evaluations are also offered routinely. The experience of pelvic pain or painful intercourse (dyspareunia) also affect many women, with many potential causes which can be explored with Dr. Pollycove, using an integrative approach. Frustration with weight management is a frequent area of concern for all ages of women, especially in menopause. Understanding potential hormonal contributions to this aspect of your health can be valuable, as well as inquiry into life style, nutrition, stress and addressing each of these factors. Pregnancy is a world of care unto itself. Being in good overall health prior to getting pregnant enhances the likelihood of a healthy gestation and the best outcome of pregnancy—a healthy baby. Normal healthy blood pressure and average blood sugar in the optimal range contribute significantly to lowering risk of problems during and after pregnancy for both mother and baby. Avoiding toxins, such as alcohol and cigarettes, are also important in pregnancy. So if habits include frequent wine/alcoholic beverage consumption, smoking cigarettes or cannabis use in any of its forms, it is important to address these life style patterns and institute cessation practices prior to conception. Simple advice is sometimes not enough to help us quit a bad habit. Dr. Pollycove networks with excellent life style enhancement programs for her patients who require this assistance.
Modern contraceptive choices are divided into reversible or permanent. Reversible contraception can include hormonal options, birth control pills being the most common, followed by the vaginal-delivery system of a ring (Nuva Ring® is the only one available in the US). These can be prescribed to result in monthly cycles or extended cycles, with only 4 periods a year. Both methods are safe and very effective. Implantable progestin-only methods are also available and offer benefits for some women (“set and forget”) yet the skin incision/scar aspect deters many women. One progestin-only pill resembles these implantable progestin-only methods (sometimes called the “mini-pill,” brand name NorQD, with many generic names for the 0.35 mg norethindrone pill) as well as the long-acting injection, Depo-Provera. Positive and negative aspects of each choice can be explored should you be interested. IUD’s or intrauterine systems, IUS in more current language, include a 10-year copper-wrapped T shaped (Paragard) or the 5- or 3-year systems (Mirena or Skyla respectively) that contain a low dose of levonorgestrel progestin that lightens menstrual flow and usually decreases cramps. For women desiring permanent sterilization, less common today, elective tubal ligation or removal of fallopian tubes (salpingectomy). Salpingectomy is a permanent sterilization option that may be worth considering especially if one has a family history of ovarian cancer and does not desire the possibility of pregnancy. Removing the fallopian tubes does not cause hormonal changes or menopause, as the ovaries usually continue to function normally afterward. Removal of the uterus, hysterectomy, is another permanent sterilization option which may be considered should other problems with abnormal bleeding, pain or interference with bowel or bladder function be present.
Gynecology Concerns about Pap smears
Comprehensive gynecological services with the latest and most advanced diagnostic ultrasound, complete hormone evaluation, hormone therapy, cervical cancer screening are routine services in our office. Colposcopy, the microscopic examinations of the cervix to carefully evaluate abnormal pap smear results, is another area of special expertise. Some women consult Dr. Pollycove for a “second opinion” regarding abnormal pap smears obtained by other clinicians. Anxiety decreases with better understanding of what exactly a pap smear is assessing. Knowing the many contributing factors that can cause abnormal cell changes, sharing a more thorough discussion, including clinical evaluation and curative treatments, supports greater self-confidence in the privacy and comfort of our office. Dr. Pollycove is a strong advocate for HPV immunizations to protect all ages of women from cervical cancer and can discuss details of evolving medical literature with newly revised recommendations since 2017. Women over 60 with a history of abnormal pap smears and high risk subtypes of HPV may be offered anal pap smears along with routine vaginal exams to further reassure that no detectable virus may be increasing risk for abnormal cells in the anus and rectum.
Whether you are young or approaching or past menopause, abnormal bleeding, painful cramping with bleeding, or non-cyclic pelvic pain are among Dr. Pollycove’s broad expertise. Pain or abnormal bleeding due to fibroids, endometriosis, infections or other conditions require careful assessment. A thorough review of prior experiences, surgeries, infections, any previous lab tests helps focus attention to understand the cause and find a cure. A thorough exam by Dr. Pollycove is included in this evaluation to help understand and explain likely causes/contributions to bleeding. The many options for treatment may include natural approaches such as vitamin or mineral supplements, progressing to medications: over the counter non-steroidal anti-inflammatory pain medications (NSAIDS, such as aspirin, advil® ibuprofen, Naproxen), prescription longer-acting NSAIDS, and contraceptive hormones (birth control pills, ring or patch. The progestin-eluting IUD can in fact control abnormal bleeding even with abnormal anatomy issues that fibroids can create. A more recently developed, non-hormonal medication that helps stabilize the mechanism for blood clotting that involves the uterine lining. Fibroids, also called myomata uteri, are a frequent benign cause of abnormal bleeding. ). The progestin-only birth control pill is yet another option for abnormal bleeding due to fibroids, though less commonly used. Hormonal suppression therapies, called reversible menopause, can temporarily stop ovaries from making the hormones that stimulate bleeding and fibroids. Lupron is the most widely known of these treatments but more GNRH-agonists, cycle inhibtors, are available as of 2018.
Uterine artery embolization, UAE, is an option in selected situations, but can also yield months of post-procedure pain and abnormal bleeding issues as the fibroids shrink. Risks include bleeding during or after the procedure at the arterial entry site, prolonged fluoroscopic radiation exposure, and long moderate sedation times, many women are deterred from this choice. The fact that fibroids do not go away entirely is another sub-optimal aspect of UAE.
Sometimes surgery is the best next step, with minor surgery through hysteroscopy, D and C and sometimes polyp removal if that is the cause. Occasionally a small fibroid lies close to or projects inside the uterine cavity and can be removed during hysteroscopy if it is safely accessible through the cervical canal-endometrial cavity approach. Laparoscopy or major surgery defined as “open laparotomy” are frequent choices for optimal resolution of bleeding problems due to fibroids. Controversy over use of a “laparoscopic morcellator” has resulted in more open laparotomies and greater complications world-wide. These important aspects of therapeutic plans and choice of management options are common discussions with Dr. Pollycove.
PMS and Premenstrual Dysphoric Disorder (PMDD)
PMS and the wide variety of physical and mood symptoms some women experience with their periods is a special area of Dr. Pollycove’s expertise and concern. She shares current knowledge on symptoms as they create a picture of PMS or PMDD, and offers various options for improvement, including natural and integrative approaches. You can link to a PMS symptom calendar to help yourself be more aware of timing of onset of symptoms as they may relate to onset of your menstrual period. These types of prospective, ongoing, detailed observations can be made and recorded every night at bedtime. Awareness of timing of onset and severity of a wide variety of symptoms can be very helpful in guiding choice of optimal treatments. Headaches, acne skin changes, bloating, pelvic pain, menstrual irregularities, heavy periods can often be improved or completely resolved with insights gained using a symptom calendar and designing treatments appropriate to individual needs.
Major mood difficulties that are worsened at or after ovulation can be helped by simple awareness and nutritional supplements. But when low mood associated with the menstrual cycle is truly a depressive disorder, PMDD, it requires our thoughtful attention. Many prescription medications have been proven to be of significant value in helping to decrease or prevent these depressive mood changes. There is no shame in experiencing these mood changes, yet many cultures place blame on women who “confess” to these symptoms. Awareness of quietly carried negative thoughts and feelings about PMS-low mood revealing a “weakness of character” is all too common in our communities. Dr. Pollycove has a highly developed skill set in all modalities of diagnosing and treating PMS as well as PMDD, and presents expert continuing medical education to doctors and allied mental health specialist-clinicians in these areas.
My Approach to Healthy Aging
I often ask 45 year old women what motivates them to seek better health for the second half of life. And after this discussion their
“homework assignment by next visit” is to name 5 women over 80 in whose bodies they would be happy to dwell. Thus far not a single patient has had 5 role models over 80! I am fortunate, as a gynecologist, to have observed amazing women age beautifully and be attractive, energetic, healthy and physically very fit. What they all have in common is moderation! Not exactly an American tradition. We are a culture of competition, youth-veneration and superlatives. The steady pace of moderate exercise, moderate drinking of alcoholic beverages (not heavy or binge use), mostly good foods, lowering glycemic index of the foods we regularly consume, and ample enjoyable social connections to friends, family and colleagues over the years. The social network is as important to our vigorous old age as our nutrition, exercise and hormone balance.
And as millions of women enter the last third of life, the multitude of years after 60, profound questions of aging arise. Often called upon to care for elderly family members, concerns turn to what our own path might be like 20-30 years hence. These years demand of us greater awareness of the “sand grains of time filling the hour glass.” The best approach is “baby steps to better health, one committed better self care moment after another.” So many organizations devoted to helping people reach a long desired goal use this same formula: now is new, this moment is for me, one day at a time (weight loss, smoke cessation, less alcohol intake, less marijuana use, less time on social media, less cell phone use, decreased preoccupation with 24/7 news , setting limits of shopping …the list is long).
As might be important to individual women, these conversations are typical in discussions at annual visits that also include a thorough physical exam and hormone balance (estrogen and testosterone sex steroids as well as thyroid). For most women we also focus on cholesterol, blood pressure, liver and kidney health, immunizations, average blood sugar measures and bone density/colon cancer screening as indicated.
Dr. Pollycove’s care includes approaching yourself and personal care with love, not with an unbridled inner critic that chatters away inside your head. Getting our hormones right, changing our diets to promote lower oxidative stress on every organ, (including our brains!) at every age results in better health. Nutrition education in the context of your gynecology visit helps women appreciate the negative impact of “high glycemic* loads” on increasing total body inflammation. This is part of the basis of the likely optimal health that is supported by the “Paleo Diet.” [For more information about “glycemic index of foods” look up Dr. Robert Lustig (UCSF diabetes prevention doc) on You Tube for a series of valuable lectures about the impact of hidden sugars and the important concept of glycemic load.]
Frequent health concerns are gynecological infections (sexually transmitted diseases as well as frustrating yeast and bacterial imbalances). Diet, lifestyle and partner exposure may all play a role in achieving and maintaining vaginal health. Although very common, HPV, the human papilloma virus, can increase our risk for cancer of the cervix. Pap smear guidelines need to be assessed on an individual basis and explained in terms that make sense. Individualization of care, with the patient’s decision of great importance, allows you to be alerted to many subtle early abnormalities beyond simple cervical cancer screening.
Pelvic Pressure, Pain or Urinary Symptoms
Some women, especially in menopause, experience a sense of pelvic pressure with a bladder infection. For many reasons, typical obvious symptoms of burning pain with urination, urgency and frequency may not appear with a urinary infection. A simple urine test is important in thoroughly evaluating such symptoms. Most urinary tract infections are treated with antibiotics, though some may be resolved completely with cranberry extract, high doses of vitamin C and ample water drinking. Treatment is individualized according to severity as well as personal choice. A follow up urine test to be sure the infection is completely gone is essential and can be performed directly in Dr. Pollycoves’ office.
Non-infection enlargement of the uterus or ovaries can create such symptoms. Although almost always benign, not cancer or even pre cancer, it requires evaluation by a clinician. The uterus can increase in size due to expanding fibroids (smooth muscle bundles that look like a concentric circle of fibers when cut open) or a process called adenomyosis, thickening of the muscle wall due to the presence of nests of endometrial lining tissue, normally confined to the uterine cavity (endometrium) but can “burrow” into the wall extending beyond the typical edge of the cavity’s lining. Often these benign growths appear as firm rounded lumps within the wall of the uterus. They can get quite large, create pressure or even restrict the bladder from being able to fill, to hold large volumes of urine. Fibroids or myomas, are easily seen on pelvic ultrasound (sonograms) and appropriate early management can often avoid surgery. Adenomyosis is a bit more difficult to diagnose but is often an underlying cause of pain and bleeding.
Or fluid filled enlargements of an ovary, are more common than solid tumors of the ovary. In normal menstrual cycles a cyst of ovulation is formed each month, typically up to 2 cm (almost an inch in size). These have defined appearance on ultrasound and can sometimes leak fluid that is irritating and causes enough pain to urgently see a doctor or even go to an emergency room. Typically these normal, cyclic cysts (corpus luteum, progesterone-synthesizing cysts) appear at mid-cycle and resolve on their own with each cycle. In normal cycles they may cause a small discomfort that resembles a gas pain or minor tugging feeling. Sometimes that cause severe transient pain during intercourse if compressed. Slowly growing ovarian cysts can get quite large and may be diagnosed simply because of expanding waist size. Such concerns are best addressed as soon as they arise. Excellent non-invasive tests are available to reassure there is a benign cause for the pressure. But since ovarian cancer can cause similar symptoms, seeing a doctor early can be life-saving.
A change in bladder or even bowel symptoms is a good reason to have a gynecological exam. Modern management of pelvic growths (fibroids, ovarian cysts, uterine or cervical polyps) varies according to severity and persistence of symptoms, concerns regarding possible malignancy and pain patterns. Surgery is a frequent necessary choice for relief of these types of symptoms that are common when a tissue has grown beyond normal size. Although most often benign, it is important that women see a clinician, have a through pelvic exam, possibly also an ultrasound to more accurately assess size, to understand such symptoms and resolve them before potentially causing complications.
Libido, Responsiveness and Comfort with Sex
Multiple factors contribute to how satisfying or enjoyable a woman’s sex life may be. The health and enjoyment of the relationship lies at the heart of most sexual interest and experiences, positive or negative. These are important aspects of our whole life health and hormone deficiencies can make significant impact in this intimate part of life. In younger ages of women, women on contraceptive hormones, women with very irregular periods or no menses for over a year, hormone imbalance or deficiency can interfere with sexual desire, responsiveness and orgasm quality. These topics are important and can be addressed with education, lab tests and hormone adjustment and additional medical therapies when needed. In the past two years new FDA-approved libido/sexual desire enhancing medications have become available in the US. Your gyn visit with Dr. Pollycove is the right place to discuss this aspect of your personal experience as well.