I know this post has nothing to do with late breaking medical news; but, several patients and colleagues have recently asked me how I ended up being an OB/Gyn, why I do what I do.  I thought this post might make a nice change of pace from my usual posts.

I went to medical school knowing that I wanted to be an OB/Gyn, then I started frantically searching for a specialty that I liked better because I was afraid of the life style issues that are common in OB/Gyn.  I never found anything else that even came close to making me want to switch specialties.  I will admit to being briefly led astray by Emergency Medicine and I actually worked in an Emergency Room part time while I was in medical school.  One day I realized that if I never went back to the ED I would not miss it at all; but, if I never delivered another baby I would always feel like something was missing.  My mind was made up at that moment.

When patients ask me what drew me to OB/Gyn, I usually tell them that I hate taking care of men because they are a bunch of weenies when they get sick.  While this is certainly true, the full answer has many more levels than this.  I enjoy the mix of primary care and surgery, although I do not consider myself to be a primary care physician.  As a surgeon, I like being able to focus on one organ system.  I also enjoy the actual work itself, it is very fulfilling and intellectually stimulating.  On a more political level, I am proud to be an advocate for my patients and for women in general, after all, women compose more than half of the world's population; but, our healthcare issues frequently get pushed aside or politicized until our healthcare needs are no longer even recognized.  On a personal level, I enjoy the relationships that I have formed with my patients.  The downside to all of this, as I stated before, is the lifestyle issues.  No-one goes in to OB/Gyn because they like to sleep, and I really like to sleep.  Fortunately OB/Gyn is a fairly broad specialty and there are opportunities to build the sort of practice that best suits an individuals personal and professional needs.

So, why do I do what I do?  Because I can't even imagine doing anything else.

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

This time of the year the trees are blooming and my first thought is “Oh, no, it is a new allergy season.”  It is a common issue but also there are still plenty of respiratory viruses still circulating too.  So how do you know the difference?  With a cold virus, you may see a fever 100.5 or higher for the first 3-4 days and then the runny nose and cough.  (A temperature of 99 degrees is not a fever no matter what.)  Runny noses, congestion, headache, and body aches are all part of it.  The normal upper respiratory infection (also known as a “cold”) will last anywhere from 1-2 weeks and will not respond to antibiotics no matter how many that you take.   Treatment really consists of saline drops in the nose, watching fluid intake, and getting plenty of rest.  Good hand washing will help limit the spread of the viruses.

On the other hand, allergies will give you runny nose, sneezing, itchy nose, itchy throat, watery and itchy eyes.  It will likely linger more than a week.  It does not cause a fever, but  you may feel very tired.   For older children, you will see them rub their nose often (called the allergy salute) and they may get dark circles under their eyes (called allergic shiners).  Allergies will not respond to antibiotics. 

Allergies are very unlikely in young children.  Most of us have to be around for a few years before we develop allergies.  I do not recommend a cough syrup or over-the-counter decongestants for colds or allergies as there is no evidence that they help and they have many side effects.   We usually will use an anti-histamine medication for treatment or even a prescription nose spray.  These children should see us for diagnosis and treatment.   A primary care clinician can usually handle many cases of allergies.

Sometimes, the runny nose can be something else too.  Non-allergic triggers such as cigarette smoke, perfume, pollution, and dry heat in the winter can cause chronic nasal irritation.   Try to limit these triggers as possible, but saline drops to the nose can help.  For smokers, we recommend that you keep it out of the house.  If your child can smell the smoke (even on your clothes) then they are inhaling the harmful chemicals. 

Regardless of the actual trigger, a good first line treatment can be saline nose drops.  Give each family member their own bottle.  Sharing nose spray can spread illness.  If there are signs of serious illness such as increasing fever (>100.5) for more than 3 days, ear pain, trouble breathing, or troubling feeding call your primary care physician for an appointment.

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

As I have commented in previous entries, the guidelines for screening tests in the US are constantly changing.  The latest pap smear screening guidelines were released just last month and will probably be even more popular with women than the last set of guidelines.  Here they are:

WOMEN SHOULD NOT BE SCREENED ANNUALLY AT ANY AGE, BY ANY METHOD.

Aged < 21 - no pap smear screening regardless of perceived risk factors.  This has not changed.

Aged 21 -29 - pap smear every three years with HPV testing reserved for ASCUS (atypical cells of unknown significance) triage.  HPV testing should not be used as a cotest in this age group.  This is a change from the previous guidelines which recommended a pap smear every two years with HPV testing reserved for ASCUS triage.

Aged 30 -65 - pap smear with HPV cotesting every five years (preferred) or pap smear with HPV for ASCUS triage every three years (acceptable).  This is a change from the previous recommendations for a pap smear with HPV every three years.

Aged >65 - no screening following adequate negative prior screening

After hysterectomy - no screening

These guidelines are based on an analysis of the benefits of screening vs the potential harms of screening.  Cost was not used to determine benefits in the USPSTF screening recommendations.

For those of you who are wondering why this is considered to be safe when you had always been taught that every woman should have a pap smear every year, I would like to touch upon the rationale for these changes.  We now know what causes cervical cancer, the HPV virus.  We also know how to test for the virus and how the virus behaves.  This knowledge has led to these new guidelines.  For the most part the virus is slow growing and is cleared by the body before it causes any problems.  The persistence of the virus is the second step in cervical carcinogenesis (there are four steps in total).  If you leave my office and immediately go out and acquire HPV, you will not have cancer before your next pap smear.  Most likely, your body will have cleared the infection.  The goal of these new guidelines is to maximize the detection of pre-cancerous and cancerous lesions while minimizing possibly harmful interventions for infections that the body would be able to clear on its own.

As always, no rules are hard and fast, and screening guidelines may not apply to you if you have had positive pap smears in the past.  We are expecting revised screening guidelines for these women to be released later this year.  Stay tuned for further details!

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

This is an update to two of my previous posts.

In a recent post, I discussed the use of progesterone gel to help prevent preterm birth.  The FDA has opted not to approve the product for the reduction of preterm birth in women with a singleton pregnancy and a shortened cervix at mid-trimester.  The FDA has encouraged the manufacturer to continue to study the product and to compare it with other products that are commercially available.  They have also been asked to include more women in private practice (not just academic practices) and to analyze why compliance was low in the US.  The FDA panel indicated that the effect of this intervention was not robust overall and did not have a beneficial effect on women in the US trial.

A study supported by the National Institute of Health, the Study of Osteoporotic Fractures, has recommended the following screening intervals for bone mineral density screening.  For women who have normal bone mineral density or mild osteopenia, repeat screening should occur fifteen years after the initial screen.  Screening should occur at five year intervals for those with moderate osteopenia and annually for those with advanced osteopenia.  Patients with a change in risk factors may need to be evaluated sooner.  At last, evidence based screening guidelines!

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

The term molar pregnancy refers to a group of conditions known as Gestation Trophoblastic Disease (GTD).  Basically this condition is the result of the new growth of baby going wrong.

Usually when a fertilized egg implants, the baby and the placenta develop roughly at the same time.  Molar pregnancy is characterized by the placenta growing abnormally due to abnormalities in fertilization.  There can be several different types.

Complete Mole

• Has the normal amount of chromosomes, but both sets are from male
• 15-20% rate of persistent disease

Partial Mole

• Fetal development may occur – usually abnormal as well
• Abnormal amount of genetic material (three set of chromosome instead of usual two)
• 3-5% risk of persistent disease

Invasive Mole

• When tissue begins invading the uterus and growing out of control.  Can metastasize quickly.

Treatment

Treatment  can vary depending on the clinical situation.  Sometimes by the time the diagnosis is made (after D&C or completed miscarriage) all tissue is out of the uterus and all bleeding has stopped.  If not, sometimes a D&C is needed.

The main role for the gynecologist is to watch for the development of persistent disease and the risk of invasion (also called Gestation Trophoblastic Neoplasia).  Serially B-hCG values are observed.

Post Molar Follow-up

Following diagnosis of molar pregnancy, close monitoring must be performed.  Increasing or plateauing levels of B-hCG could be indicative of cancer, so it is very important not to conceive during the observation period.   Patients should be watched via weekly hCG levels until three in a row are normal.   Monthly levels are also usually suggested for a period of 6 months.  There has been some recent thought that shorter follow-up might be OK for women with certain factors. 

Depending on which of the above you are dealing with, your care might be given by a general OB/GYN, a GYN oncologist, or a medical oncologist.  Due to the more rare nature of some of these diagnoses, a second opinion is very reasonable, especially before chemotherapy or surgery is undertaken.

 The American Pregnancy Association offers some good information on this topic.

A recent article in the New York times addressed the issue of osteoporosis screening. 

There seems to be some confusion about when to start screening for osteoporosis and how often to screen once the initial screen is performed.  This is due, in part, to the fact that, for many years the screening guidelines were not clearly defined so individual practitioners were just making them up as they went along.

Unless a woman is 65 or older, or meets other criteria, she should not even have bone mineral testing done.  In addition, if the test shows osteopenia (bone density that is lower than normal but still not showing osteoporosis) she should not be treated.  A recent study done in PA showed that 40% of woman who were tested for osteoporosis should not have been tested because they did not meet the current testing criteria.  Of the tested patients approximately 1/6 met the criteria for treatment and many were not being treated appropriately.  Of those who did not meet the need for treatment, slightly less than 1/5 were being treated needlessly.

Currently, Medicare will pay for bone mineral density testing every two years; however, this does not mean that bone mineral density testing is necessary every two years.  If you do not have osteoporosis or severe osteopenia, the chances of developing osteoporosis over the next five years is very small, negating the need for frequent screening unless some other risk factor is identified.

Screening for osteoporosis became much more common after the development of medications to prevent fractures in osteoporosis patients.  With a treatment available, it makes much more sense to start aggressively screening patients.  Doctors began prescribing treatment for women who had osteopenia even though osteopenia itself was of doubtful clinical significance;  now these medications been shown to increase the risk of rare but serious side effects such as bone loss in the jaw forcing everyone to step back and take a look at who needs to be treated and how long they should be treated. Generally speaking, people with osteoporosis, not osteopenia, should be treated.  Patients should be treated for five years followed by a drug holiday to prevent serious side effects.

With regards to screening, I use a tool called FRAX in my office.  This tool is a very quick computer generated questionnaire that calculates the risk of a major osteoporotic fracture over the next ten years.  For patients fifty and over, I use this test to determine if early bone mineral density testing is indicated.  If it is not, I order an initial test at age sixty five.  After that initial test, the above study indicates that additional screening is not necessary for the vast majority of patients for at least five years and probably not even for as long as fifteen years.

If you are currently being treated for osteopenia, ask your doctor if these treatments are really necessary given the paucity of evidence supporting them and the unpleasant side effect panel.  If you are being treated for osteoporosis, ask your doctor when you are due for a drug holiday.  If you are under sixty five and your doctor recommends a screening test, be sure to ask what your risk factors are and how they have influenced his/her decision to screen, ask what your FRAX score is.  Remember, unnecessary screening is the primary cause of unnecessary treatment!

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.