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GENERAL questions

Q. Do I a need a referral to come to your office?
A. Most insurance companies consider OB/GYNs to be direct access. No referral is necessary.

Q. What is the office policy for treating a patient under the age of 18?
A. While a minor does not need a parent or guardian to accompany her to her appointment, she must bring a completed form entitled Consent for Care of Minors with her. See our page Preparing for your Appointment to download this form.

Q. What is the difference between a doctor and a nurse practitioner?
A. Nurse practitioners work collaboratively with physicians (in the private office setting) to provide comprehensive health care to women throughout their lifespan. Nurse practitioners will take detailed health histories and perform physical exams; they will also diagnose and treat a woman’s individual health care needs. They focus on in depth health education and counseling. The nurse practitioner will consult and refer to physicians for complicated gynecological and health care problems based on individual needs.

Q. I’m moving and leaving the practice, how do I get a copy of my records?
A. Send a written request with a check for $20 to our office. Your records will be ready for pick up within one week. If you need them sooner, please call the office and leave a message for Judy.

 

Q. How much weight should I gain during my pregnancy?
A. The average weight gain during pregnancy is 25-35 pounds. If you are overweight when starting the pregnancy, 10-15 pounds is within normal range of weight gain. Remember, you only need 200 extra calories/day when pregnant over your normal dietary requirements. This is not eating for two!

Q. Is there anything that can be done to alleviate PMS symptoms?
A. Diet, exercise, and vitamin supplementation have been found to be very helpful for many women. Vitamin B6, evening primrose oil, and calcium are what we recommend. Exercise releases the endorphins in the body to help alleviate the emotional highs and lows. A diet low in caffeine, soda, and sugars has also been helpful.

Q. Is leaking of urine a normal part of aging?
A. Age increases your risk for urinary leakage but the symptoms are treatable.

Q. Is surgery the only treatment for bladder control problems?
A. No. Behavioral techniques are commonly used and very effective. Over 50% of patients with incontinence can notice improvement or cure with behavioral techniques. Medication is also another option.

Q. Is leaking urine with exercise or after childbirth normal?
A. No. This is usually caused by the weakening of the pelvic muscle. Special exercises with biofeedback often will cure this problem. The longer you wait the harder it is to strengthen the muscle.

Q. If I have a bladder control problem will my insurance pay for treatment other than surgery?
A. In general, yes. Each plan has different coverage and a referral is necessary from all HMOs. Contact the office for referral information.

Treatment, including behavioral techniques for bowel and bladder control problems is offered through the Continence Program at the Center for Women's Health.

Q. At what age should I schedule my first gynecological visit?
A. Your first visit should be scheduled around the age 21 unless you are sexually active or have a gynecological problem. It is also best to see a doctor or nurse practitioner prior to the onset of sexual activity.

Q. How old should I be when I have my first mammogram? What if I have a history of breast cancer in my family?
A. A baseline mammogram is offered between the ages of 35 and 40. Most professional health organizations recommend yearly mammograms after age 40. If your family history includes a mother or sibling with the onset of breast cancer prior to menopause, some experts would recommend beginning screening mammograms starting 10 years prior to the onset of the cancer in your first degree relative.

Q. Can I have a Pap test done while I have my period? What if I am just spotting?
A. When blood is present in the Pap smear specimen, cells from the sample may be obscured by the blood. This results in a less than optimal Pap smear. Due to scheduling difficulties and the demands of your job you may decide to have the Pap smear performed when there is just light bleeding despite the fact that it will not be an optimal specimen. Sexual activity, vaginal medications and douching should also be avoided for 48 hours prior to a Pap smear.

A. Although much less common, precancerous or early cancer of the vagina can be detected by a Pap smear even after a hysterectomy. Certainly if the indication for the hysterectomy was for precancerous or cancer of the cervix or uterus, regular Pap smears are indicated.

Q. What is an abnormal Pap smear?
A. Abnormal Pap Smears and Precancerous Changes of the Cervix.

The purpose of the Pap smear, in a patient who comes for regular visits to the gynecologist, is not meant to find cancer. Our hope is to pick up precancerous changes of the cervix, changes which occur before a cancer ever starts. The beauty of cervical cancer is that there is a gradual change from normal to cancer; it does not develop over night. While the Pap smear is not perfect (it can miss abnormalities 3 out of 10 times), if it is done frequently enough it will pick up the precancerous changes years before the cancer ever starts. And if these changes are severe enough, they can be treated with minor surgery, called a conization, so that cancer never develops. This makes it possible to have a normal life without affecting fertility, child bearing or the need to remove the uterus.

Precancerous changes of the cervix and, in some cases, eventually cancer, are caused by a virus called HPV (Human Papilloma Virus). HPV is nearly always sexually transmitted. Since up to 7 in 10 women between the ages of 18 and 30 carry HPV virus, it is a very common diagnosis. But in the vast majority of cases it will never be detected. HPV can express itself in 4 ways.

New technology allows us to look for the presence of HPV virus in the Pap smear specimen if a Pap smear comes back with findings that show a minor abnormality. One in 10 Pap smears will show “atypical cells of undetermined significance” or cells that look a little funny but the doctor cannot tell if they are precancerous or just affected by the normal vaginal environment. This is the case where this new technology is most often used. If HPV is present in the Pap smear specimen or the cells look sufficiently abnormal, a colposcopy will be recommended.

A colposcopy is when the doctor looks at the cervix under a microscope. Just like a Pap smear, a speculum is inserted into the vagina so that the cervix can be seen. The vagina and cervix are washed with vinegar (this may burn a little) and then looked at under a microscope (or colposcope). Most often biopsies (very small pieces of cervix) are taken and sent to the laboratory. The pathologist can then prepare the biopsies and look at them under a microscope to tell us if there is a significant problem. Based on the seriousness of the biopsy results, we will recommend either observation with repeated Pap smears and/or colposcopies or minor surgery called a conization.

You might be wondering why we would not treat all people with precancerous changes of the cervix, and that is a very good question. When the biopsies reveal mild precancerous changes (also known as cervical dysplasia or cervical intraepithelial neoplasia for those of you who are internet aficionados), this basically means that they see very minor effects of the virus but no significant precancerous changes. These changes are likely to go away without treatment in 8 out of 10 cases. If the changes are moderate or severe, then the conization procedure is performed because the chances of developing a cancer are much higher. Even though the conization will prevent a cancer from starting in the short term, it does not eradicate or remove the virus from the body. Therefore the precancerous changes can return. For this reason in cases of mild changes there is most often no benefit to treatment.

If you have mild precancerous changes of the cervix it is very important to follow up with the observation plan recommended by your doctor. If this is not done, and years go by without follow-up, true cancer can develop. This would be a shame since cervical cancer is a preventable disease.

Q. What is maternal serum screening?
A. For many years obstetricians have offered pregnant women a blood test, between 15 and 19 weeks of pregnancy, to look for Down syndrome and neural tube defects (anencephaly and spina bifida). The test does not tell whether the baby has or doesn’t have either of these two problems. It predicts the risk, odds, or chances that the baby might be affected. If the risk is above a certain level, the patient is informed of the results and asked if they want additional testing. Five out of every 100 tests results will come back in this higher risk range and will result in a call to the mother. This test is still offered.

More recently a new test to predict the risk of Down syndrome has become available. There are two ways this new test can be used. The test combines the results of an ultrasound done between 9 and 11 weeks with a blood test. The results of these tests can be used in one of two ways:

1. The chances that the baby may have Down syndrome can be calculated using only these two tests. The advantage of this test is that the information can be obtained earlier in pregnancy than the original test. It is no more accurate than the original test; and 2. The second way the new testing can be used is to do the earlier test but not get back the results. The original test is then done at 15 weeks. The results of both tests are then used to calculate your risk of having a baby with Down syndrome. This test also tests for the risk of neural tube defects. The advantage of doing both tests and waiting for the result is that only 1 or 2 in 100 tests will show a higher risk of the baby having Down syndrome (instead of 5 out of 100 like the other tests).

Both tests can be performed and the results of each will be given when they are performed. This will allow further testing based solely on the first test if it is abnormal. If the first test is normal, the second test can still be performed, and if abnormal, further testing can be done. This testing sequence will result in the highest number of abnormal tests.

All three tests will pick up 8 out of 10 babies with Down syndrome. All three tests will fail to predict 2 out of 10 babies with Down syndrome and, therefore, these mothers will not be offered additional testing. All of these tests are offered to all mothers regardless of age.

The original test can be done at the laboratory you ordinarily use. If either of the new tests is desired, a special ultrasound is required that only certain centers are qualified to perform. At the present time not all insurance companies pay for the newer first trimester screening

Q. I have recently heard a lot about HPV testing? What exactly is HPV? Who needs to be tested?
A. HPV, or Human Papiloma Virus, is the cause of genital warts, precancerous cells, and cancer of the cervix. The present recommendations for testing are for those people whose Pap smear results show abnormal cells of undetermined reasons. In other words, the cells appear abnormal but not quite cancerous or precancerous.

The other recommendation is to use the test in woman over age 30 that have no history of abnormal Pap smears and are low risk for cervical cancer. If the test is negative, Pap smears need only be performed every three years. This does not mean that yearly visits to the gynecologist are not necessary. Because this is new technology and our personal experience with it so far is limited, the physicians at the Center for Women’s Health are not ready to completely trust this method of testing. We do believe that it can serve as another tool in determining the correct treatment for our patients on an individual basis.

Q. If I miss a birth control pill should I take 2 the next day?
A. Yes. If you miss more than one pill or start the pack of pills later than you should have, you will not be protected against pregnancy. Missing a pill may cause bleeding in the middle of the cycle. This does not indicate something is wrong. The best way to keep from missing a pill is to place the pill pack in a location that is used every day, even on weekends and vacations, such as next to your toothbrush.

Q. If I am on the pill and I start bleeding what should I do? Continue taking the pills? Make an appointment?
A. Occasionally when you are on the pill there will be what is called “break through bleeding”, bleeding which occurs other than the time it is expected. This happens most frequently during the first month or two after the pill is started. It also occurs in most women at least once a year, especially if a pill is missed. It is not harmful, but sure can be a nuisance.

Q. If I am 40 years old, do I still need to use birth control?
A. Yes. Until your cycles are completely over and you have gone through menopause, there is still a chance of pregnancy. This chance can exist until the age of 50 or older. Consult your healthcare provider for appropriate options.

A. Hormone replacement therapy is substituting man made hormones that are very similar to the ones the ovaries made prior to the time they ceased to function, known as the menopause. At the present time the only indication for hormone replacement is for vasomotor symptoms, or hot flashes. Half of woman will experience only minor flashes if any at all. However, for many women these symptoms can be quite uncomfortable. They can interfere in the workplace or prevent adequate sleep at night. Sleep deprivation can lead to depression and loss of function during the day.

Some women will get relief from these symptoms with over the counter preparations containing soy products, which themselves contain estrogen like compounds called isoflavens. Since these preparations are not standardized, their safety and effectiveness has been difficult to determine. There are many studies presently being performed to answer these questions.

Another treatment for hot flashes is a class of medications called Selective Serotonin Uptake Inhibitors, or SSRIs. While these medications were originally developed to treat depression, a beneficial side effect that many women noticed was the relief of hot flashes.

A. A yeast infection can cause an abnormal vaginal discharge and/or vaginal irritation and burning. One in seven women carries yeast in her vagina. When conditions permit the yeast to overgrow and out number the normal bacteria in the vagina, symptoms develop and it is now considered to be an infection. Many studies reveal that when women self diagnose their condition and buy over the counter yeast medication, up to 80% of the time the symptoms are caused by something other than yeast. That is why the physicians and nurse practitioners at the Center for Women’s Health recommend an accurate diagnosis before treatment of any suspected infection. This can only occur with a thorough examination and testing.

Q. What is a urinary tract infection (UTI)? How is it treated?

A. A urinary tract infection occurs when bacteria pass through the urethra into the bladder and multiply. The bladder is normally free of any bacteria. Symptoms of a urinary tract infection can vary widely among women and may be different in the same person during different infections. Some of the more common symptoms include burning or lower pelvic pain with urination, going to the bathroom frequently and never feeling quite empty, or the presence of blood in the urine. While drinking cranberry juice between infections has been shown to possibly reduce the number of infections, it has not shown to be an effective treatment once an infection has been established. UTIs are best treated with antibiotics. It is important to flush the bladder with as much fluid as possible during treatment to help the antibiotics eliminate the bacteria from the bladder.

Q. I’m pregnant and I read in a book that I should lie on my left side but I wake up on my back. Am I hurting my baby?

A. Over my 20 years in practice, this is one of the most common questions I have been asked. Certain publications such as “What to expect when expecting” advise a woman not to lie flat on her back. The problem with this advice is that we have no control over our position while we are sleeping. In fact, the average person changes position every 20 minutes while they are sleeping. I believe the advice that the book is attempting to impart is that while you are lounging around the house, and say watching TV, it is best not to be flat on your back. This can reduce blood flow to the uterus by compressing the large blood vessels returning blood to your heart which lie next to the spine. A more upright position or inclining toward the left or right side allows better blood flow to the uterus. But if you wake up in the middle of the night or in the morning and find yourself on your back, you needn’t worry that you have harmed your baby.