Dr. Matt Lee is an OB/GYN with Wheaton Franciscan Medical Group.

One of the more common reasons for abnormal bleeding in women ages 20-40 is anovulation (not making an egg).  The mechanism for anovulation is slightly different from the adolescent.  The culprit is usually too much androgen (a male type hormone that women normally have in small amounts).  This can be a genetic predisposition, excessive weight, or an androgen-secreting tumor (rare).

Other hormonal reasons can be thyroid abnormalities and/or over secretion of a hormone called prolactin.  Besides hormonal causes there can be anatomic causes like fibroids.  This is usually more likely at the upper end of this age group.

By looking at the above causes for abnormal bleeding, the evaluation might include thyroid testing, prolactin testing, physical exam and possible ultrasound.

For women in the upper range of this age group or those with higher risk medical problems (hypertension, diabetes, obesity) consideration should be given to endometrial cancer or hyperplasia (precancerous condition).  This is usually evaluated with an endometrial biopsy done in the office with minimal discomfort.

A recent study has shown that many practitioners in the US are doing pelvic exams unnecessarily.  To view the full article: http://www.liebertonline.com/doi/pdfplus/10.1089/jwh.2010.2349.

The gist of the article is that many of the routine screenings offered by an OB/Gyn are not helpful and may lead to more aggressive and unindicated testing.  To be perfectly clear, this does not apply to women who come in with a complaint that needs to be evaluated, this only applies to the annual screening exams that are currently performed in the United States.  A pelvic exam consists of two components, a speculum exam and a bimanual exam.  The annual speculum exam should have fallen by the wayside with the advent of urine testing for STIs and the new pap smear guidelines which greatly diminish the number of pap smears a healthy woman needs.  I have heard many of my colleagues say that they still do an annual speculum exam to look for prolapse and bacterial vaginosis.  I myself do not do an annual speculum exam unless my patient has a specific complaint that needs to be evaluated.  My philosophy for most things in medicine is "if it is not bothering the patient, it is not bothering me". The annual bimanual exam will be harder for me to give up.  While I know that studies have indicated that it is not helpful in an asymptomatic patient, I still feel like I have to do something to justify my presence in the exam room.  The reality is that a bimanual exam is useless as a screening for ovarian cancer, will not alter any plans the patient and I have made with regards to contraception management and hormone replacement therapy, and frequently finds abnormalities that are not problematic; but, that I am forced to evaluate further, causing undo stress to the patient and increasing the already sky rocketing costs of health care in this country.

It would be helpful if the American College of OB/Gyn would come out with a definitive statement about this as they did for the revised pap smear screening guidelines.  Many of my colleagues, particularly those practicing in highly litigious areas, are reluctant to make such a major change in practice without some backing from our governing body.  Will I change my practice any time soon?  I am sure that I will.  I will probably do the same thing that I did when I changed my practice with regards to pap smear screening.  I will obsess about it for several weeks, then I will try to come up with a detailed plan for changing my practice, then I will give in, come to the office one day and announce that, from that day forward, I will be changing my practice pattern.  (My staff loves it when I do this!) I have heard many people ask how OB/Gyns will get people to come in every year if we stop doing annual pelvic exams.  In an ideal world, I would prefer to see us go to a more European model for gyn care.  Routine gyn care would be provided by a patent's primary care doctor and I would function as a consultant for patients with problems.  This would certainly be a more cost effective use of my skill set and keep patients from having to see one provider for an annual physical and another for a well woman exam.  Many of my colleagues still operate under the delusion that, as OB/Gyns, we can function as a primary care provider for women.  Until that mindset changes we will probably not be able to make such a drastic change.  In the interim, I have found that patients will still come in to see me every year for medication management and problem focussed visits, even if I do not do a full annual exam.

Dr. Matt Lee is an OB/GYN with Wheaton Franciscan Medical Group.

Adolescents are usually defined as a woman from the age of menarche (the starting of her cycle) to about age 21.  Most of the bleeding irregularities in this age group come from anovulation (not making an egg).  The normal menstrual cycle is in response to a mature hypothalamus, pituitary, and ovary working together to produce an egg for conception.  When pregnancy is not achieved each month, the progesterone level falls and the uterine lining is shed, producing a bleeding episode.  In some women in this age group, the brain is not mature yet, and even a year or more after menarche, there is no egg produced (or it is produced infrequently).  If there is no ovulation, no regular cycle can follow.  This sets up a situation of “anovulatory bleeding” where the lining of the uterus bleeds intermittently and unexpectedly due to noncyclic hormonal environment.

As long as the bleeding is not too severe or disabling, waiting for the brain to mature is a reasonable course of action.  Occasionally, if the bleeding is causing problems, combined oral hormonal medications can be used to regulate the cycle.

I have just mentioned the most common reason above.  Of course, there are a whole host of possible reasons including pregnancy, blood clotting issues, leukemia, and others.  If you are or know a young women that is having difficulty with excessively long, heavy, or painful cycles, have her see her pediatrician or gynecologist.

Dr. Matt Lee is an OB/GYN with Wheaton Franciscan Medical Group.

“Is my cycle normal?”  This is a common question asked by women coming into my office.  Not all women’s menstrual cycles are the same, and not every woman will have a precise 28-day cycle.  It is true that 28 days is the average, but the normal can be anywhere from 24 to 34 day cycles.  The menstrual flow is usually 4-7 days in length. 

Cycles may be different at different times of a woman’s life.  At menarche (the beginning of menstrual cycles) periods may occur from 21 to 45 days.  Cycles can certainly change in the mid-40s as well as become very irregular just prior to menopause.

Bleeding between cycles, very short or long cycles, or very heavy bleeding all could be normal or abnormal depending on many factors. 

Over the series of the next few post I will look at bleeding abnormalities of women at different ages – adolescents, women 20 to 40, women 40-50, menopausal women.  Stay tuned!

 Here's a good resource from the American College of Obstetricians and Gynecologists.

Dr. Michelle Douglas is an OB/GYN with Wheaton Franciscan Medical Group - Franklin.

Kimberly-Clark has recalled  several lots of the Natural Balance Security Unscented Tampons.  These tampons were accidently contaminated during the manufacturing process with E. Sakazakii.  This bacteria can cause UTIs, pelvic inflammatory disease and vaginal infections.  There is no need for mass panic.  These lots were sold in a limited geographic area (IA, KS, MO, NE, NM, TX, AZ and UT) through two distributors, Walmart and Fry's.  If you are concerned that you may have used one of these tampons, remove it immediately and check the box to see the Lot Number and the SKU code.  The full list of contaminated lot numbers and SKU codes can be found on http://www.fda.gov/safety/recalls/ucm279588.htm.   Contact your physician if you have used the tampons, especially if you experience any signs or symptoms of infection (headache, unusual vaginal discharge, rash, fever, abdominal pain).  You will also want to contact Kimberly-Clark so that they can make arrangements to retrieve your unused product.

Another important thing to remember is that tampons in and of themselves do not cause infections unless they are contaminated.  Tampons provide bacteria with a place to grow in a nutrient rich environment, menstrual blood.  This is what happened in the 80's with the Rely tampons, people left them in for too long, giving the bacteria time to grow and spread.  It is important not to leave tampons in for prolonged amounts of time.  Always remove the last tampon before you insert a new one.  Remember to remove the last tampon that you use with any given menstrual cycle.  If you use two tampons at once, be sure to tie the strings together so that you remember to remove both of them.

Dr. Matt Lee is an OB/GYN with Wheaton Franciscan Medical Group.

Many women commonly ask, “How often do I need Pap smears?”   This is a great question, although one with difficulties.  Most women have heard recommendations from organizations like American College of OB GYN.  These recommendations state: Cervical cytology screening is recommended every 2 years for women aged 21–29 years, with either conventional or liquid-based cytology. Women aged 30 years and older who have had three consecutive cervical cytology test results that are negative for intraepithelial lesions and malignancy may be screened every 3 years. Certain risk factors have been associated with CIN in observational studies; women with [certain] risk factors may require more frequent cervical cytology screening.

The trouble lies, however, in that many women hear that Pap screening needs only to be every 2 or 3 years and think that they don’t need other gynecologic care.  Many women in this age group are on medications like oral contraceptive that need to be monitored like any other medication.  Many women only see their gynecologist and are therefore not getting other health screening that the gynecologist provides. 

So for reproductive age women on hormonal contraception, yearly visits are best even if cervical cytology screening (ie Paps) are not done.  For women at low risk and not needing other health screening, every other to every third is reasonable.  I recommend discussing the frequency of visits with your gynecologist so that you can both come to agreement about your individual risk and need for screening.

Dr. Margaret Hennessy is a Pediatrician with Wheaton Franciscan Medical Group - All Saints.

Back in 1992, the American Academy of Pediatrics (AAP) issued a statement that all infants should be placed on their backs to sleep.  This change in American infant sleeping habits dramatically decreased the risk of SIDS (Sudden Infant Death Syndrome).  That recommendation still holds for today.  But that is not the only thing that you can do to help prevent infant death.  New recommendations have come out from the AAP this month.  Here is a summary of these recommendations.

Back to sleep for every sleep.  Putting an infant on the side is not a safe alternative.  Healthy infants do not choke or aspirate while sleeping on their backs.  Even infants with reflux disease will not choke.  They have sophisticated swallow mechanisms that protect them.  There are rare conditions when an infant should sleep on his or her tummy and only a specialist would recommend it.   So you ask, “What if my baby rolls over in his or her sleep?”  Once they can roll on their own then you can leave them but still start on the back.   Give infant some tummy time every day while awake to work on the upper body strength. 

 Use a firm surface for infant’s bed.  Skip the pillows and bumper pads.  Make sure that mattress fits bed tightly.  Do not use cribs that are missing parts or broken.   Avoid comforters, sheepskins, and soft mattress covers.  Car seats, strollers, and swings are not recommended for sleeping routinely because the infant may roll or slump over and cut off their airway.    Also avoid elevating the head of an infant’s bed because they tend to roll to the bottom of the bed. 

Room-sharing with young infants is recommended.  In fact, room-sharing has been found to decrease the risk of SIDS up to 50%.  Bed-sharing, however, is highly controversial.  Adult beds can be very risk for young infants because of heavy bedding and pillows.   It is very important to avoid bed-sharing always with someone who is a current smoker or if mother smoked during pregnancy, with someone who is excessively tired, with someone who is on a medication or who uses alcohol/drugs that impair alertness, with someone who is not the parent, with multiple persons, and on waterbeds, couches, armchairs, or beds with heavy bedding.

Avoid smoking exposure during pregnancy and after birth.  Smoking both before an infant is born and after birth does increase the risk of SIDS.  Alcohol and illegal drugs also should be avoided during pregnancy for the same reason. 

Watch the temperature of the room.  Keep the room comfortable and do not pile on the blankets.  Overbundling can lead to overheating in a young infant.  This is a risk factor for SIDS.  If you are not sure if the infant is too warm, then place your hand on the chest to check.  I like the idea of sleep sacks or sleeping gowns for infants when sleeping.

Pacifiers may help decrease the risk of SIDS but do not try to force a pacifier.  Also for breastfed infants, you will want to wait on the pacifier until at least 4 weeks of age.   Do not attach pacifiers to infants clothing or hang around their necks while sleeping.  Skip the wedges, positioners, and special devices that are marketed for safe sleeping.  There is no evidence that they protect and can actually put infant at risk of suffocation. 

Breastfeeding has been shown to be protective against SIDS.   AAP recommends breastfeeding for at least a year and avoiding any other foods until age 6 months of age.

I feel compelled to write this article after a patient interaction I had in the office the other day.  I was counseling a teenager about gynecologic health and I asked her if she had received the HPV vaccine.  She replied that she hadn't.  When I asked her mother why she had not started the series, she told me that her primary doctor had told her that she did not need the vaccine because she was too young to have sex.  Her mother then added that she had thought that advice was strange because she had read that the vaccine works better when given at a younger age.  I realized that if there was such a huge misunderstanding about the vaccine among my physician colleagues that there is probably an even bigger amount of false information on-line that might be confusing my patients and their parents.

First of all, this is just a vaccine.  This vaccine is not a commentary your daughter's morals or your ability to be a good parent; it does not give your daughter a free pass to go out and have sex with multiple partners.  It is just a vaccine, a vaccine that can prevent your daughter from acquiring an infection that kills approximately 4000 American women each year.

Allow me to answer a few of the questions I hear most frequently.

When is the best time to get the vaccine?  The best time to immunize your daughter is before she initiates sexual activity.  The vaccine is not going to cure HPV once your daughter contracts it, the vaccine is for prevention.  In addition, the younger your daughter is when she gets the vaccine, the better immunologic response she will have to it.  Getting the vaccine does not mean that your daughter is sexually active now, it is an acknowledgement that most women eventually become sexually active.  The vaccines are 93 - 100% effective against HPV 16 and 18 (the types most commonly associated with cervical cancer) if they are given before your daughter is exposed to the virus.  Currently the vaccine is recommended for women between the ages of nine and twenty-six.

I am 22 years old and I am married, why should I get this vaccine?  You should get this vaccine because people's lives change in ways that we don't anticipate.  What if your husband is in a serious accident or develops a fatal illness and you find yourself back on the dating scene when you are thirty-five years old?  Wouldn't it be better to protect yourself now?

Most HPV infections clear on their own, what good will this vaccine do if my body is just going to clear the virus itself.  This is true, most of the time your body will suppress the virus down to undetectable levels within six to twelve months, unfortunately we have no way of predicting who will progress to pre-cancer or cancer and who will not.

Why can't I just get a pap smear every year instead of getting the vaccine?  Pap smears have a known false negative rate of up to thirty percent.  Getting the vaccine is not a substitute for pap smear screening.  The primary reason for this is that while the majority of cervical cancer is caused by HPV 16 and 18, there are several other strains that can cause cervical cancer and they are not covered by the vaccines.  With the new screening guidelines, if you are HPV negative you can decrease the frequency of your pap smear screening.  You are also much less likely to have to come back to see me for additional testing and biopsies for false positive pap smears if you are HPV negative.

Why should my daughter get this vaccine, she would never date, have sex with or marry a man who would give her HPV?  As a general rule, we only know where we have been and none of us walks around with a name tag that says "Hi, my name is ..... and I am HPV positive".  Most HPV positive men do not know they are HPV positive.  Also, as I said before, this vaccine has nothing to do with morality.

Why do women have to get vaccinated, if men give it to us why shouldn't they get vaccinated?  The vaccines have recently been approved for use in men primarily to prevent genital warts and to prevent transmission to their female partners.  Acceptance among men is low and it is always better to protect yourself if at all possible.  As women we need to be proactive when it comes to our health.

Have you gotten the vaccine?  No I haven't, I am too old.  I have recommended that my nieces get it and they have.

Michelle Bachman says that the vaccine is dangerous and caused some girl to become mentally retarded, is this true?  Michelle Bachman is not a physician and should save her political commentary for things she is qualified to talk about.  The most common side effect of the vaccine is soreness at the injection site.  Approximately 6% of recipients have reported severe adverse reactions, upon investigation none of them were found to be vaccine related.

My family doctor says that I don't need this because I am low risk, why do you think I should get it?  You are only low risk if you have not had sex and are never, ever planning to do so.

How often do I need to get a booster shot?  This is unknown at this time.  Current studies show  protection lasting at least five years, this information will be updated as new follow up studies are published.

And finally, I would like to leave you with a few facts to ponder while you make this important decision.

Studies have shown that:

Seventy five percent of sexually active adults will acquire an HPV infection before the age of fifty.

As many as thirty percent of women who have sex with women will acquire an HPV infection.

Four percent of virginal women are HPV positive.

Twenty-nine percent of female college students who had only had sex with one partner acquired HPV over the course of twelve months

The lifetime probability of acquiring cervical cancer in the US is 1:142. Greater than ninety-nine percent of these cancers will test positive for HPV and seventy percent of these are covered by the vaccine.

Ask your doctor about this vaccine.  If S/he tells you that you or your daughter does not need it, tell them to call me.

Dr. Matt Lee is an OB/GYN with Wheaton Franciscan Medical Group.

Pertussis is still a deadly problem for infants here in the United States.  Of the 194 pertussis deaths in the US from 2000 to 2099, 90% were infants 3 months or younger.  These are children too young to be immunized.  In a previous post, the concept of a “cocoon” strategy was discussed where parents were immunized after the birth against pertussis. 

According to the Center for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP), this strategy has not been as effective as hoped.  They now recommend administering tetanus diphtheria acellular pertussis (Tdap) vaccine to pregnant women after 20 week’s gestation.  This vaccination will result in the passage of pertussis antibodies from the mother to her unborn baby, helping protect newborns against pertussis until they can get the first dose of vaccine at 2 months of age.  The remaining 4 doses are given between 4 months and 6 years.  CDC Director Thomas R. Frieden, MD, MPH, has to approve the ACIP recommendation before it becomes official, but infectious diseases experts say his approval is likely.

Dr. Matt Lee is an OB/GYN with Wheaton Franciscan Medical Group.

Pregnancy can be a time that women become more health focused, and part of discussing overall health is vaccinations.  There are some vaccines that are safe during pregnancy and some that can only be given when not pregnant. 

The difference boils down to how the vaccine is made.  Some are made of small amounts of the live virus.  These cannot be given during pregnancy due to risk to baby.  However, some vaccines are made of inactive parts of a virus and are safe in pregnancy.  Still another group are made of toxoids and are also safe during pregnancy.

Live Virus (not in pregnancy)

--Measles
--Mumps

Inactive Virus (OK in pregnancy)

--Influenza
--Rabies
--Hepatitis B

Toxiods (OK in pregnancy)

--Tetanus
--Diphtheria

Even though we all would agree that vaccination prior to pregnancy would be best, pregnancy also represents a good time to become up-to-date on certain vaccines.