Placenta Previa 

After I finished my shift at The Valley Hospital as the "Doc in Box" I did my rounds and went home. My shift ended at 7 am. I signed out and handed the phone over to the next on call Obstetrician, and came home around 8:30 AM or so. Then I tried to get some sleep. I did some reading, and finally did fall asleep. 

Later in the morning I got a phone call. 

I have a full term pregnant patient who has a suspected placenta previa. What does that mean? 

A human embryo is created about day 14 of a 28 day cycle. This is called ovulation. Once the egg pops out of the ovary on day 14, the sperm will start looking for it. If there are sperm there, they will all swim to the egg. The egg is surrounded by a protective covering called the zona pellucida. One sperm by itself is unlikely to get through the zona. Instead, about a hundred sperm need to be there. But usually only one sperm will penetrate the egg membrane. This process is called fertilization.  The egg once fertilized becomes an embryo and starts floating down the Fallopian tube. A week after fertilization, about day 21 of a normal 28 day cycle, the embryo will float (or be propelled by tubal peristalsis) into the uterus. By day 21 the uterine wall is covered with a sticky secretion that is ready for the embryo to come along.  The embryo floats around until it comes into contact with the uterine wall. Once it does, it sticks on, and starts to burrow into the uterine wall. This will frequently cause a day 23 spot of blood called an implantation bleeding. Any women who is trying to get pregnant should welcome the day 23 spot of blood. It is really great news. The problem with implantation is that it can happen almost anywhere. Ideally it can happen in the fundus, or body, of the uterus. Sometimes the embryo implants in the fallopian tube. This is called an ectopic pregnancy and may be a life threatening emergency. Sometimes the embryo is just a few millimeters short of making it into the uterine cavity. This is an even worse spot called a cornual ectopic. This means the implantation is in the "corner" of the uterus, in the part of the fallopian tube that is within the muscle of the uterus. Nowadays, some ectopics can be treated with cancer chemotherapy, and therefore avoid surgery. Obviously there are risks with chemotherapy as well. And sometimes the ectopic can take forever to dissolve. But is is there as an option. 

But for a placenta previa, the implantation occurs very low in the uterus. It is then very near the cervical opening. When this happens the placenta grows very low. The placenta itself grows over the cervical opening. Since the baby needs to come out the cervical opening, and the placenta is in the way, there will be a life threatening hemorrhage when the women goes into labor. The baby will not survive losing the placenta's function while still inside the mother. When the placenta disconnects from the mother, there will be a hemorrhage, and the baby will suffocate from lack of oxygen. 

There are many different types of previa. If the baby implants in the cervix, instead of in the uterus, it is called a cervical ectopic. This is a bad event that needs to be managed quite urgently. 

If the placenta only edges up to the cervix, it will be called a marginal previa. This can go either way. If the placenta is low, but not up to the cervix, it will be called a low placenta. These women can try for a vaginal birth if they want, but they are subject to abnormal bleeding. If they bleed a lot in labor, then a C-Section might be safer. 

My patient today was told she had a previa early on in the pregnancy. We watched  the baby and the placenta very carefully for many months. The placenta seemed to move away from the cervix a bit as the uterus grew up to full term size. This is not unusual. Many previas resolve themselves as the pregnancy grows. We had at first scheduled her C-Section, but then unscheduled it because the placenta appeared to be in a better spot. 

As a pregnancy grows, the uterus grows with the baby. The uterus and the baby grow about a centimeter a week. The placenta, if it is stuck sufficiently to the uterine wall, can move up with the uterine growth. But, on the other hand, the placenta and the baby are growing. The placenta, if it is stuck near the cervix but continues to grow, it can grow back over the cervix. This can make a marginal previa worse, so that it can become a total previa again. 

So, it is best to follow the previa clinically. Analyze its growth pattern. Follow it with the sonogram. Try to make predictions about what might happen with time. Don't examine it with the hands, because that may cause severe bleeding. Only examine it with the sonogram. And if there is a lot of bleeding, then deliver the baby by C-Section. The delivery can be elective at term, or at any time if there is a lot of labor contractions or bleeding. 

But today, she was 39 weeks and waiting for labor, when she started having a bloody show. The bloody show was normal, and a good sign that labor might be beginning. But then she broke her water, and the water gushed out and was very bloody. She called and I advised her to go to the hospital. At the hospital she kept on bleeding and ultimately passed a softball sized clot. Obviously this is risky for both the baby and the mom, so I advised a Cesarean after all. She couldn't keep bleeding to that extent and expect a happy outcome. So we did it. And everybody is fine now. At the C-Section we did find that the previa was close to or over the cervix, so labor would have continued to be very risky, and the bleeding would have gotten much worse with time. 

She didn't get her vaginal birth. But she did get a healthy baby at 39 weeks. Everybody is fine. Maybe the next baby can be a vaginal birth if she wants to try for it, and there is no previa. We will have the discussion about the benefits and the risks of a VBAC. VBAC means vaginal birth after Cesarean Section. 

Thank you all for reading today's blog. I appreciate all of the readers from around the world. 

Sincerely, 

John Marcus MD Ob/Gyn FACOG

89 North Maple Ave

Ridgewood, NJ, 07450 

201-447-0077 

Preconceptional Counselling

Hello Everybody. Thanks for coming.  I really appreciate all of you reading my blog. This blog has expanded much faster than I imagined. I now have readers from about 10 different countries all over the world.

Today was a busy Obstetrics day in my office. Since we have just finished a long weekend, a lot of the pregnant patients came to the office today, to catch up from yesterdays holiday. So my office hours were filled up with pregnant patients, and had just a few gyn patients in for checkups.

After my office hours, I've delivered two babies, and I assisted at one more. The babies are beautiful and healthy. One baby was a Cesarean Section.

I am now taking my shift in the hospital. Our hospital, The Valley Hospital in Ridgewood, New Jersey, has elected to always have an Obstetrician present on the unit. We stay here to cover the unit for emergencies. There are about 14 of us Ob's that share that particular duty. I am one of them. I am on duty now. We call ourselves the Doc In Box. The hospital's official title for us is the "Valley On Call Obstetrician". The official title is too hard to say over and over, so we just shorten it to Doc In Box. As in "am I Doc in Box tonight?"  We take 12 hour shifts, or two in a row for 24 hours. When here, we consult with the nurses whenever they ask, we assist in complicated deliveries, we examine laboring patients whenever we are asked, and we occasionally save lives of new moms and babies. Particularly we save lives when there is a placental abruption. We can try to get some sleep in between the calls. Some of us try to get some of our boards done. We all need to get about 30 hours of boards work done every year, to maintain our board certification.

But I promised I would write about preparing a women for pregnancy, so that someday, she can herself be here in labor and having a baby. What does a women need to do in order to be safe for the pregnancy, for optimal chances of health?

Sometimes a woman will make an appointment for a "preconceptional consult". Other times, a woman will be in for her annual checkup and in the course of that checkup I will determine that she is trying to get pregnant, or will be soon. Either way, we have to help her prepare for the pregnancy. This is what we should do:

First , we will review her history to determine if there are any health issues that need to be addressed. All medical issues in the past will need to be analyzed to make sure that whatever the problem was, it will be optimally managed. For instance, one in twenty people have a misbehaving thyroid gland. It could be either hyper- or hypo-thyroid.  These women will need their thyroid gland examined and her TSH checked to make sure it is optimal. A properly adjusted thyroid hormone will make it easier to get pregnant, and will keep the baby safe and growing well. Another example is if she has high blood pressure, we will need to change her pill to one that is safe for the fetus, and get her BP under good control. Virtually all medical problems in the past will need an analysis. Many young women will have no medical problems in the past, so this part will be easy for them. Many people have multiple mild issues. Everything is on the table here. More examples: Seasonal allergies, with or without allergic asthma. Yeast infections. Urine infections. Back pains. Sciatica. Palpitations. And on and on.

Second , she will need a complete checkup and an exam to make sure nothing obvious is wrong.

Then, I will ask her to get a dental checkup and cleaning. Proper dental care is important for the pregnancy. believe it or not, gingivitis is a cause for preterm labor. In fact, any infection anywhere in the body is bad for the pregnancy. Infections can spread into the baby. But even if it doesn't get into the baby, it can still release toxic substances that make the uterus and the placenta irritable and threaten preterm labor.

Then, we will discuss the diet. Special dietary needs will need to be discussed. Many women are vegetarian, or even vegan. It is possible to keep the baby healthy as a vegan, but we will need to make sure she is getting proper proteins from the veggies. Right about now, I will discuss the "fish rules". There are five fish that women should not eat in pregnancy. Many times I will write this down for women, because it hard to remember everything from this visit. So I will take notes for the women, and make sure that she gets this note when she leaves the office. The 5 fish that women cannot eat are: shark, swordfish, tilefish, monkfish, and tuna. They cannot eat these fish because they are all too high in mercury. Then, I will explain that salmon has no mercury and is therefore the best fish for pregnant women. Salmon also has very high DHA, which is an essential fatty acid and is great for the babies brain development. I blogged about salmon before in one of my prior posts. All of the whitefish varieties are healthy. This will include cod, flounder, tilapia, sea bass, etc. And shellfish is good, too. Unfortunately, some women still have the mistaken opinion that all fish is bad for pregnancy. Many times it takes a lot of discussion to explain to women why that opinion is incorrect.  Fish is so good for the baby that this discussion is worth having, if I can convince the women to actually eat it.

I will usually explain that hamburgers that are under cooked red or over cooked black are not good for her or her baby. Hamburgers and cheeseburgers must be medium only. Black burgers have toxic burned black material on them. This is the food equivalent to smoking. Red hamburgers are infectious with E.Coli and Salmonella. Eggs must be cooked through with no runny yolks.

If she has ethnic food requirements, I will try to address those requirements here.

All cheeses and juices must be pasteurized.

Now is a good time to discuss recreational habits, and exercise. All high impact exercise will have to be toned down to low impact only. Running is ok, but elliptical is just a bit safer because it is low impact on the baby and placenta. Skydiving, bungee jumping, and motorcycle racing are examples of activities that will have to stop. Any illegal or recreational drugs should stop before pregnancy. Alcoholic drinks should stop while pregnant, although a few glasses of wine near the end of the pregnancy will not likely hurt anyone.

I will explain to women that heat can damage fetuses. How can a women get overheated? Most commonly, it is hot tubs. Hot tubs are forbidden to pregnant women, or even women that might be pregnant. Incidentally, hot tubs damage sperm as well. A fever higher of 101F or so is dangerous to the baby. A fever can be reduced with a dose of acetaminophen and a cool shower. There are other ways to get overheated. Examples are: hot days outside, such as at Disney World, hot exercise, hot sex for a long time, hot waterbeds, hot baths, saunas, etc. So we will try to keep a woman's body cool during her pregnancy.

I might ask a woman to buy a pregnancy book. "What to Expect When Your Expecting" is a famous and good book.

Finally, I will ask a woman to call me anytime there is a question or a problem. Keeping the phone lines open can help keep the pregnancy safe.

I will ask a woman to call whenever there is a medical problem in pregnancy.

I will try to explain to women that the phrase "you can't take anything because you are pregnant" is commonly said, and frequently well intentioned,  but is actually a very dangerous notion. It is dangerous because it means that a woman will be tempted to ignore her medical needs. Since the baby and the mother are one, it is not possible to allow a pregnant woman to get sick, and have the baby better off by ignoring the illness. All medical illnesses need to be managed properly to keep the baby safe. All medical issues have pregnancy safe alternative management options.

All of the above is a 15-20 minutes or so discussion. I will many times keep notes as I go, and give her a copy of these notes. Because of the time required, this discussion is best done on a separate visit from a checkup or a problem visit. Women will commonly request preconceptional counselling at the time of a checkup. If there is time on the schedule, I might do this at a checkup. But sometimes, there is just not enough time. I may have to ask a woman to come back to have this discussion. Other times, I may convert the visit to a preconceptional consult, and delay the checkup or whatever reason she is there.

Remember, this is not medical advise. Please see your doctor for medical advise. This is just general information. 

Thank you for reading.

Sincerely,

John Marcus MD FACOG PC
Ridgewood, NJ, 07450
201-447-0077

Good Deeds Come Back 10 Fold 

Welcome back to my Blog everybody. It is Saturday night, on Memorial day weekend. There will be parades tomorrow, on Sunday. Many of the firemen will parade around town on their fire trucks, blowing off their sirens. There's going to be barbecues and backyard parties. Memorial day is also the unofficial beginning of Summer. Lucky for me I have this weekend off. It is nice to have some time off. I can take time off call because I have a cross coverage arrangement with Dr. Fred Rezvani. When he takes time off, I cover him, and when I take time off, he covers me. On average, that works out to about two weekends a month off duty, and the same for him. This means that I am on duty for almost two weeks straight. These work hours, which are common in the medical practice of Obstetrics, are a continuing source of controversy  in Obstetrics and Gynecology around the world.

My covering doctor, Fred Rezvani,  is a good doctor. And he is a good friend to me. Our practices are similar. We are both solo Ob/Gyns. Both Fred and I were once Chairman of the Department of Obstetrics and Gynecology at our hospital, The Valley Hospital in Ridgewood, New Jersey.

Before Fred and I worked out this present coverage arrangement, we were both on call all the time, 24/7. I like this practice style because I really wanted to "be there" for my patients. I felt that if my patients trusted me with something as important as their health and their lives, then the least I could do was to honor them  by being there when they needed me. Fred and I worked all the time, 24/7. This 24/7 practice made taking time off for vacations difficult. On duty means getting calls and taking care of patients. On duty usually means that we can still get at least some sleep, but most nights there will be at least a phone call from a nurse or a patient.

Eventually, though, reality forced us to realize that nobody can work 24/7 forever. It is just too hard. And it is unhealthy to work so many hours. Sleep deprivation is unhealthy.

So now, Fred and I have this weekend coverage arrangement. And it is really great.

Back when I was picking a career, I knew the work hours were long. All the Ob's knew this in med school. Nevertheless, many people still pick this career and this specialty. For the people who have the stamina to make it through the stress, it really is a fantastic job.

I make my living by battling the forces of nature that cause mayhem in women. I fight against pain, misery, discomfort, dysfunction, disease, depression, infertility, and all of those awful things. And I try to help create a state of health and happiness. I feel that I am really good at my job, and despite the long hours, I really like my job.

A mentor once told me that a good deed comes back 10 fold. So, I try to do good deeds, by doing a good job. And I do feel that these good deeds reflect back on me.

So the long hours are worth it, no doubt about it.

Sure, sometimes it is hard to get out of bed, if I am sleep deprived. But once I am up and moving, I can be totally awake and on the job when I need to be.

I haven't decided on my next post yet. Maybe, how to prepare a woman for a pregnancy?

Disclaimer: none of this is medical advise. This is just general information. Please see your doctor for medical advise. 

Thanks for reading. Please share it around.

Sincerely,

John W Marcus MD FACOG
Ridgewood, NJ, 07450
201-447-0077

Post edited on 5/28 at 1 am. I tightened up some poor pronoun references.

Urinary Incontinence and Prolapse

Today in my office I gave Kegel instructions about 20 times. Admittedly, it was a busy day, but there was nothing unusual about that number.

What is the problem? The problem is that about a billion dollars a year are spent on adult diapers in USA alone. And there are about 16 billion dollars a year spent on incontinence, it's control, and it's correction. Most of the incontinence is urinary, but some is fecal as well.

And, much more important than the money spent, is the awful discomfort of being incontinent. Women are unnecessarily filled with shame. They feel like they cannot go outside the home. They cannot go on trips. They are mortified when or if they might wet their pants. They are mortified when the have to buy giant pads, or even worse, adult diapers. And they are ashamed and discomforted with the thought of having sex.

The solution to getting diapers discretely is easy. Just buy them online, maybe from Amazon. No one will have to face the clerk. The clerk that fills the order will be very far away. And someone might get a very good deal. Although, they will have to be forevermore targeted by Amazon with adult diaper ads. Most likely even I will be targeted just because I wrote this blog.

What do Kegel instructions have to do with it?

There is a giant muscle that exists in women and men that elevates the structures in the pelvis, and keeps everything from falling out of the bottom of the pelvis. This muscle has a bunch of different names. Doctors like to call it the Levator Ani, and the bulbocavernosus muscle, along with some smaller muscles with different names. We can just call the whole thing the pelvic floor. This pelvic floor muscle acts like a sling under the pelvis. But it has some other very important functions. It also wraps around the external urine carrying tube. In both women and men this tube is called the urethra. In men, it extends through the penis. In women it is very short, and goes from the bladder, just under the pubic bone, and ends externally anterior to the vagina, and about 2 cm below the clitoris. So, this muscle wraps around the urethra, vagina, and rectum. And, when it is tight, it closes these openings tightly. And when it is tight, it blocks the flow of urine, it holds the vagina together, it keeps fecal material inside the rectum until it is time to defecate, and keeps the structures near the vagina from falling out the vaginal opening. When this muscle is loose, the urine leaks. The uterus falls into or out of the vagina. The rectum falls out of the vagina. The bladder falls out of the vagina. Even the intestines call fall out. These problems are called incontinence, uterine prolapse or procidentia, rectal prolapse, cystocele, and enterocele, respectively.

Most women do not ever exercise this muscle. I might have a menopausal women patient who runs marathons, and is fitter than any 20 year old, who never exercises this muscle. This is not uncommon at all.

Most women are told to exercise this muscle when they are pregnant. It is fine to do this, but the real problem begins later, when they are older. The muscle atrophies from lack of use, and these problems I noted above begin to show up.

This is where I come in. During a regular checkup, I will many times ask the patient to do a Kegel. Many times they are reluctant because they aren't sure they are doing the right muscle. With coaching, almost all women are able to contract the right muscle. It is the same muscle that can be used to stop a urine flow if the doorbell rings, or the phone rings, or the baby screams for attention. If the women can close off the urine mid flow, then she has the right muscle. Some women do not have the option of shutting off the flow, because they don't know how. With encouragement, I can teach them how. I don't advise women to routinely stop the urine flow, because that can lead to some urinary retention or infections. But it is fine to do this as a test of learning once in awhile.

In my experience, some women have such a strong muscle that they can break fingers. Some women have such a tight muscle that they cannot release it. This, if symptomatic, is called vaginismus. Vaginismus, if bad, can make exams impossible, and even sex impossible. Vaginismus is curable with proper stretching exercises, sometimes muscle relaxers, and sometimes pain meds.

But many more women have such a weak muscle that there is no detectable contraction despite full effort and coaching. These women are at high risk for incontinence and prolapse symptoms.

The good news is that I have seen women who could not hold a drop of urine completely cure themselves with exercises. I can remember patients who were so sure that they could not repair the prolapse that they opted for a surgical repair. I would try to delay them to give them a chance at exercises. Many times, after a few weeks there is improvement, and after a few months there is a complete cure. These women are dry again. And they are very happy. And they do not have surgical risks.

There are things called "Pessaries" that can go into the vagina to hold up the other structures. Pessaries are great because they are simple, mostly free of side effects and risks, and assist the Kegel exercises to repair the prolapse. Pessaries can cure the problem with enough time and exercise. Although, many older women keep them forever. And they are happy because it gives nice support and does not hurt, and has no surgical risks.

The surgeries do work, that is for sure. They are not completely reliable, in that there is an unfortunate failure rate, and an even higher recurrence rate. There are hundreds of surgeries described to tighten the bladder  control, fix the fallen uterus and enterocele, and fix the fallen rectum. Which surgery is done is mostly up to the surgeon you pick. The urologists will frequently pick a mesh implant repair. I am not a huge fan of the mesh due to some of the mesh problems that have occurred. Although it is ok when it is done properly, and the success rate is high. I have my favorite types of surgery because I have had good results.

Most of these prolapse surgeries are done through the vagina, because that is where the problem is. There are abdominal approaches. They do not have a higher success rate than the vaginal procedures, and add a lot of surgery to the technique. So, with some exceptions, I prefer the vaginal route to repair. That makes me an old fashioned Gynecologist. Because the newer Gyne's usually prefer meshes, implants, and sometimes abdominal and even robotic repairs. Those procedures are all technically demanding, higher risk operations.

So, to get back to the original point, Kegel exercises really do work. There is solid scientific evidence to this claim that it works. Kegel exercises can prevent and or repair a fallen pelvic floor. You just have to keep doing it enough. It can save a huge amount of problems later.  I encourage all of my patients to do it. I can teach them.

Sometimes a little bit of estrogen in the vagina can help strengthen these tissues as well, and complement the Kegel efforts.

Comments are appreciated.

Thank you sincerely,

John W Marcus MD FACOG
Ridgewood, NJ, 07450

201-447-0077

Article updated on 5/28 at 1 AM to tighten up the prose, and to change pronouns to nouns. 

Securing Your Test Results.

How do you get your test results from your Gynecologist? This is an interesting dilemma for the doctor and the patient. Until recently there was absolutely no good solution. 

Did your doctor leave your results on your answering machine? What if your doctor, or the nurse in the office,  said, on the answering machine, that your herpes testing was negative? Obviously your children, your nosy neighbor who was in your Kitchen for tea, and your spouse could hear that message. Their first obvious thought would be, "why does this person need herpes testing?". Or maybe, your doctor said, on the answering machine, "call me for an important result."  And then when you got the message on the answering machine, the doctor was overseas for a week leaving you in dire stress due to the unknown results. Or, maybe your doctor sent you a letter with the results. But, the letter got lost. Or, maybe your spouse opened the letter to find that your herpes testing was negative, or your pregnancy test was positive. Or your cancer test was suspicious and needed further testing. Since the doctor has no way of knowing if you got the letter, the doctor will just file the chart away. This might leave you with undiagnosed cancer. Don't get me wrong, that would be poor office procedure, but it does happen. 

As a physician, these problems are nearly insurmountable, especially if the doctor is caring enough to not leave you in dire stress. So we wind up making tons of phone calls. And we find that fewer and fewer people actually answer the phone anymore. This leads to the scary "call me" messages on the answering machine. 

All of these problems are untenable, and have no good solution at all. We just muddle through with a bunch of phone calls, using discretion when necessary, trying to honor patients requests for brutal honesty on the answering machine, and keep a giant pile of results pending delivery. Usually, results are delayed until the patient happens to call back when the doctor is available. Or, ultimately, we send certified letters so that we know the patient got the results. (for the non USA folks reading this, the definition of a certified letter is one in which the letter carrier gets a signature from the recipient on a sheet that certifies delivery. So then the doctor can breath easy because there is written documentation that the results have been delivered. 

How do we solve this problem? There is a new technical solution that seems to solve all of these problems at once. And this solution allows the doctor to get the message out in a very secure and private manner. And one more thing: This solution allows the doctor to be completely open and frank with the patient in a manner that absolutely no one else can hear. 

This solution is a web service called "Secure Reach". You can Google it. 

This solution is not cheap, but it is so much better than all of the other alternatives that it literally changes the efficiency of the practice. And allows people to get their results in a real hurry. 

What I will do with results is, I speak into a secure, password protected, voice mail box. The patient is the only one that can access the mail box, unless they have chosen to share their password with someone. Such sharing should be frowned upon in the modern world. Passwords should be kept completely private. Even from spouses. 

Anyway, no one can hear these results but the intended recipient, if the recipient chooses to keep it private. The recipient can find a quiet place and hear the message privately, on the phone.  Since it is securely private, I can pretty much say anything that is necessary to say. 

This solution satisfies HIPAA compliance. HIPAA is a gigantic health care privacy bill. When it first came out it was so over-interpreted that physicians could not call people by their first name anywhere in the office. This particular over-interpretation has since been rescinded. 

And it makes my life easier. For instance, I just got home from the hospital after delivering a baby. It is 11 pm. There is no chance that I am going to call people at home. But, I can leave messages for them on the Secure Reach Messaging System. They will then get a secure message tomorrow. No one can hear  it but them, and no one can read their mail. 

This system is a great solution to the problems outlined above. 

Thanks for reading, 

Sincerely, 

Doctor John Marcus 

89 North Maple Ave

Ridgewood, NJ, 07450 

My Medical Groups 

I basically worked all weekend in the hospital. I have been too busy to blog. But I am back now.

Last week I went to a Medical Meeting of my group of Ob/Gyns. I used to be solo, but no more. Solo medical practice is dumb and inefficient.  This time, our meeting was in Red Bank, New Jersey. My Group is called Lifeline Medical Associates. We are based in Parsippany, NJ. We are composed of about 90 Ob/Gyns. Our website is www.lma-llc.com. Our web site is really very good. It requires Flash, though, so it won't work very well on an iphone. Lifeline is one of the biggest Ob/Gyn groups in the country. We are also a founding member of what is called the Women's Healthcare Alliance. Our Alliance is an over arching group of big Ob/Gyn groups. The Alliance is not very formal yet, but it seems to be rapidly growing in capabilities. 

When we get groups this big, something magical happens. All of a sudden, we get gigantic economies of scale. For instance, as a progressive Ob/Gyn, I wish to be on the cutting edge of Electronic Medical Records (EMR).  One problem of being a solo doctor, is that picking an EMR is hard. I have to pick an EMR out of what seems to be thousands of different types, then I have to install it, make a million decisions about what to do with this bit of data or that, and then actually go through the extensive, risky, and somewhat brutal process of changing my medical practice to fit the new paradigm of digital medicine. But, in a large group, only a few motivated and technically proficient Ob/Gyns have to make all of the beginning decisions. Then, they can debug the brutal "going live" stage, and give all the rest of us a ton of help and pointers about "best practices". 

And there are a million other gigantic economies of scale. Such as Human Resources, Protocol Development, Contract Negotiation, Business Practices, Billing Practices, etc. 

Because I am in Lifeline Medical Associates, I no longer have to work until midnight running the "business" of my business. I can, instead, focus on the "medical care" of my business. This frees up some time for me to, for instance, write this blog. In my experience, running the "business" of the business, takes up about 30 hours a week for any generic type of business, to do the job properly. This means, in no particular order, doing all of the "human resources" type of work, creating and mailing all of the bills, producing information for the accountant, going over the IRS forms, signing and sending them, checking the bills for fraud and then paying them, picking a phone company, fixing the phone system, hiring a cleaning service, fixing the plumbing, calling the landlord to get the building maintained, and all of the rest of the things that a business must do before it even starts creating the product that the business exists to create. For a solo doctor to try to do all of these things himself is a ridiculous wast of time. And that time wastage will certainly take time away from their family, and likely take time away from patient care.  

The business of the business is handled for me by Lifeline. This is so efficient it should be scary. It really ought to be scary for the medical doctors who try to do all of this on their own. They are simply not going to be efficient. They are wasting their efforts doing things that ought to be done by people who do the "business" of the business for a living. They do it all day long and are good at it. 

There are still many solo doctors and small groups around. The ones that are good at it are still doing well. But for most, it is at least a struggle. 

So, for about 4 years now, I am in Lifeline. And Lifeline is a founding member of this Women's Healthcare Alliance. This alliance is Big, on a Big Scale. It consists of many groups of large Ob/Gyn groups. It covers about a thousand Ob/Gyns in several states, hundreds of thousands of patients, and controls many billions of dollars of medical services. We, as Ob/Gyns, are now on a national stage. We can use this size to do a lot of good for the women of the world. I am really glad to be a part of this. If there are national, or international, sized decisions to be made that affect women's health care, we aim to be part of it, sitting at the table. And this will directly benefit my patients and my community. 

The future of medical care is a giant unknown. We don't know what medical advances will bring. We don't know what political changes will affect our future. But there are a few certainties. One, medical care in the US is technically proficient. Two, medical care is gigantically too expensive. Three, we don't have better outcomes than other advanced countries, despite spending a lot more money on health care. Four, many medical doctors are struggling to pay their bills. Five, most insurance companies are making so much money that their biggest expenditure is buying other insurance companies. Six, many doctors have not had a pay raise in decades, despite providing great care to their patients. 

The business of providing medical care in the US is an industry that is very inefficient and seems to many people to be entirely broken, and even dangerous in some peoples opinion.  Lifeline, and the Women's Healthcare Alliance, and even my college, the "American College of Obstetrics and Gynecology", are doing what we can to fix it. Our Mission is to provide the best medical care possible, to the most women that we can, proficiently, safely, and efficiently. We aim to do this while using evidence based medicine, and keeping ourselves on scientifically based protocols. We aim to do all that we can do while staying at the advancing edge of medicine. We are very far along on the process of introducing EMR, when many practices have not even begun yet. We are well into our second generation of EMR, and evaluating the next steps now. It is not possible for a solo or a small group to do this much work on this problem. 

I do have stories to tell about EMR, though. On my first day, going live, I booked half the usual number of patients. I should have booked one tenth. I had five patients in the office before I finished the first one. I was kind of worried, to say the least. But I held my commitment, worked as best I could, and finished the day. Somehow. It has not been perfect. I am not completely EMR yet, even after a few years. I still have some paper charts. I don't think they will, or should, ever go completely away. 

Thanks for reading. Comments are appreciated. 

Sincerely, 

John Marcus Ob/Gyn 

Ridgewood, NJ 07450 

201-447-0077 

How to Make Smarter Children:

Today I have something to say that may astonish some of you that haven't had a baby in the last 8 years or. The story surrounds essential nutrition and how to make your kids much smarter and calmer, and get better vision to boot. There is a simple dietary change you can make that will give your child an IQ boost of up to 10 points. There are a couple of other things that you can do that can similarly increase your child's IQ. Lets do the two easy ones first. First, get a pet. There is data that having a pet, any pet, will mean that your child has an IQ boost of about 10 points. It doesn't seem to matter what kind of pet. A fish, a goat, a pig, a cat, a dog, a bird, whatever. It seems that the responsibility engendered by having someone depend utterly upon you for survival leads to smarter kids. In fairness, it has to be said that this may be a case of correlation and not causation. In other words, it may be that smarter kids are the ones that wind up with pets, and not the other way around. I'm not sure. But since pets are great to have, it seems like a good bet to me. Personally I love pets. The unconditional love that a dog has just seems to suck the stress out of the day. And watching a fish swim around and eat the food that you dropped in to the tank is mesmerizing. And a purring cat, that seems like heaven to me. And then watching it catch a mouse is even better. 

The next thing you can do is take advantage of the Mozart studies. It seems that fetuses that are exposed to Mozart have a 10 IQ point boost. Again, there may be a correlation/causation reversal here, in that the smarter kids are really the ones that wind up getting exposed to complex music. But I don't think so. I think that the human brain is stimulated in complex ways by the complex music. And I don't think it is limited to Mozart. I think that the Beatles, Billy Joel, or the Beastie Boys can do it. Personally, I think Wagner is pretty cool too. The Ride of the Valkyries turned up loud is something to behold. And Beethoven. My kids knew what Bah Bah Bah Boom was just about the same time they new about UB40. Bah Bah Bah Boom is Beethoven's fifth, by the way. It is easy to get music to the fetus. Just turn it up kind of loud and enjoy it. Dance if you want. But high impact dancing may not be good for the placenta, so take it easy on the impact. Just moderate low impact dancing and some moderately loud music. It can be really fun. 

Finally, how to have a smarter kid: What you probably don't know is that human brain cells are made out of a molecule that can be called DHA. The human retina, as well. The retina is really just a neuron, anyway.  DHA is an ESSENTIAL FATTY ACID. DHA cannot be made by human cells inside of human bodies. That, essentially, is what makes it an essential fatty acid. It means that it must be consumed in the diet. The chemical name for DHA is DocosaHexaenoic Acid. DHA is necessary for the fetal brain to develop. My theory is, if you don't nourish the fetal brain enough, it will not develop to it's maximum potential. The experts who have decided how much is enough, have decided that you will need 300 milligrams in your diet to help the baby grow good brains. The average American Women, circa 1990, ate about 50 milligrams a day. There is a similar deficiency in other countries that don't rely on seafood in their main diet. Women in other cultures that get a lot of seafood, have much more DHA in their diet. Nordic countries, coastal China, Japan, all of those women get a lot more DHA. Mezoamerican Aztecs, relied on maize, or corn. Who has been more successful? 

Why do I say that seafood matters? There are only two known sources for DHA in nature. And that is one, fish, and two, algae. And the fish probably get it from the algae. Since DHA is an oil  (fatty, remember), the fattier the fish, the more the DHA. Salmon is a yummy very fatty pink fish meat. It has 600 milligrams per palm sized piece. Whitefish, like Cod, Tilapia, Bass, Trout, Flounder, etc, has about 100 milligrams per palm sized piece. Salmon is number one for DHA. To stack the deck even more, Salmon has almost no mercury. This makes Salmon number the number one fish for pregnant women. Tuna is sort of a whitefish, with the requisite amount of DHA, but it has some mercury in it. So a pregnant women should limit her Tuna to once a month or less. Shellfish is yummy, has some, but not enough. A pregnant women can eat shellfish, but it will not in itself be enough DHA. 

Some people will sell you an omega three supplement made out of flaxseed, or some other terrestrial source. You should be aware that this terrestrial source has no DHA, even though it is a legitimate omega three fatty acid. But, it most clearly is not DHA. And it will not help to make babies brains or eyes. The only vegetarian source of DHA is algae. There are some algae sourced DHA supplements on the market. The biggest brand is Expecta. This is an algae sourced DHA. It is  on the market, for pregnant women, with no mercury, marketed by Mead Johnson.  Mead Johnson is a big producer of infant formula as well. Expecta has about 200 mg of DHA per capsule, so itself it is not quite enough, but it goes a long way towards a proper dietary consumption. 

In the last few years, most of the big providers of prenatal vitamins have been adding DHA to the mix.  Some of the PreNatal Vitamins have 300 milligrams. Some have 200. So, you must read your label to decide how much fish to eat, or if you need an extra supplement, such as Expecta, or need to add  some Salmon to your diet. 

An important DHA story comes out of the FDA. It seems that about 30 years ago, the American FDA advised pregnant women to stop eating certain kinds of fish because those fish had mercury in them. Those recommendations were very controversial at the time because even back then the story of Essential Fatty Acids was known. The experts thought that pregnant women would give up all fish when they heard that some fish were bad. Those experts thought that pregnant women were better off eating all fish, than eating no fish. In the end those experts were right. American women basically stopped eating all fish in their diet, potentially depriving their babies of DHA. I think that American women just assumed that since some fish were bad, then all fish were. 

Not a day goes by in my office when a pregnant women will announce to me that fish is bad for pregnant women. I try to explain to them the DHA story. In the end, many of them wind up taking the vegetarian sourced DHA. That is fine with me, as it has the same function as fish oil. And the algae oil has no mercury. 

I have a lot of studies on my office that establish that DHA supplementation increases IQ, decreases jitteryness in babies, and improves vision. All of these are important ways to improve the life of a baby. 

So there you have it. Three ways to improve a human babies IQ. And the DHA will decrease jitteryness, and improve vision as well.  

Sincerely, 

John Marcus MD

Board Certified Ob/Gyn

Ridgewood, New Jersey, 07450 

201-447-0077 

Comments below are welcome. Thank you. 

Today, as  I promised, Circumcisions 

Circumcisions have been done for thousands of years. Many different cultures from around the world do it. There must be some really strong reason for it to have started so long ago, for it to have lasted so long, and for it to become so widespread.

When I say old, I mean really old. How many people know that the star constellation Ursa Major (that is the Big Bear, in, you guessed it, Latin) is called the Big Bear in cultures as far separated as Africa and Native American Indians? According to Scientific American, human beings started their existence in Africa about 200,000 years ago. The original human tribe included about 40 women, according to DNA studies of mitochondria, which only passes from mothers to children. It started in Africa. We are literally all cousins. One of the youngest human gene pools is Native Americans, which passed from Asia to North America over the Bering Strait about 12,000 years ago and populated the Americas. Yet, Africans and Native Americans both call this constellation the Big Bear. Since it looks like a bunch of stars, and nothing like a bear to me, I presume that the original humans must have named it the Big Bear, and it has been called that ever since.

Similarly, Circumcisions have been around for a very long time. And the origins of the custom are lost into the mists of historical time. It is practiced in a lot of places. Nobody knows the original reason, but it must have been a very good one to justify the risks and the pain. It must have been a very good reason to justify the persistence of the culture, and the very widespread "popularity" of the culture.

Whatever the ancient reasons are, we still do it. The reasons we do it now are pretty clear. It is done because out fathers are circumcised, and their fathers as well, going back to the beginning. Religion demands it for it's own reasons. And social custom demands it because "all of the other boys are done". A few years ago it was determined to a scientific likelihood that circumcision was not necessary. But now, more and more interestingly,   science has determined that HIV is much less likely to transmit if the boys are circumcised. So now, in Africa, where HIV is a heterosexual disease, a lot of the boys are getting circumcised again. Like I've said many times, science seems to cycle. Science is not immune to fads. And the foundation which underlies any particular science can change, rendering moot all of the knowledge built on that particular foundation.

Theologically, there is a story in the old testament. King Abraham at some point made a covenant with God. A modern lawyer would call a covenant a contract. King Abraham's one and only covenant with God was this: Circumcise your sons, and your children will populate the Earth. This is Genesis 17:1-13. Biblical genealogy puts King Abraham at about 4000 years ago. Since then the Jews have populated some Earth, the Christians followed about 2012 years ago, and the Muslims about 800 years ago. The Muslims believe that Abraham himself built the mosque at the very center of Mecca. All three religions are called "Abrahamic" since they are descendants of Abraham. And they all circumcise their boys. So, circumcision is very very old indeed. At least as old as the very first book of the Bible and the Torah.

Circumcision is also very popular in China and Asia, although it is not done for religious reasons, it is one of the most common operations done there.

So, when the San Francisco "intactivists" tried to ban circumcision within city borders, the result was predictable . The measure was thrown off the ballot in 2011, by the Courts. The reason for removing it from the ballot was that it was in violation of California State Law, in which the state alone could regulate medical procedures. But, if the courts didn't strike the ballot, the weight of human history would not be in favor of a ban. Circumcision would continue no matter who tried to stop it.

What is a circumcision?

A human penis is created with a sheath, or tube, of loose skin that covers the penis from it's base to above the head. Of course there is a hole for urine. Circumcision involves cutting the sheath so that the head is exposed. How much to cut is not covered in any textbook that I have ever read. It is simply taught from teacher to student as a procedure. And it has been this same teaching that has been done since the beginning of history. The part of the sheath that is cut off is simply called the foreskin. My preference is to simply cut off enough to get the head exposed. I will leave some sheath in place. I will usually have a discussion with the parents describing my technique and preferences. It seems to me that some boys are over circumcised and this leaves a penis with no extra skin at all. I tell my patients that more can always come off, but you cannot put it back on later. I am not quite minimizing the circ, but I am not skinning the penis either.

Nevertheless there are some surgeons out there that have the feeling that they can diagnose "excess foreskin", even in newborns. And they tell the mothers that the circumcision was "botched" and the penis should look like the fathers, despite the fact that it is much smaller. If I can, I will tell the mothers that they should leave the penis alone and let it grow. It will fill in normally and then look like daddy's. Although it is unlikely that a mother is going to get a look at her grown son's penis to do a comparison. I think that these surgeons are mistaken, to say the least. They have a right to their opinion, and so do I. I think they should leave these boys alone.

So my preference is to do just enough to get the head exposed. This means the edge of the incision should be just below the rim of the head. By the time the boy is a grown up, the sheath will look normal. But there will be enough sheath left to make erections and intercourse comfortable for both partners.

When I do it, I use a cookie cutter type device that is called a Gomco. Our hospital uses a new one every time. With this device, making the circ round is a no brainer. There are other devices. The Mogen is a popular device. It pinches with a vertical instrument side to side. It is hard to overcirc with a Mogen, but the result cannot be round. And in rare cases, it has been known to partially amputate the head.

Anesthesia for the circ is another question entirely. Anesthesia meds have some risk. Not using them means no risk from the meds, and no painful shots into the penis. We use other means, including a quick placement of the Gomco. Once that is on, there is no pain from the scalpel at all.

In case you haven't figured it out yet, a circumcision is the job of the Ob/Gyn, at least where I work. Jews would sometimes prefer that a specially trained religious person called a Mohel do it, on the eighth day of life, with a ceremony done at home called a Bris.

When I do it, I try to honor any cultural traditions that exist as best I can. We can make a mini ceremony out of it, including the ritual wine if the parents and grandparents want. I find it personally valuable to honor whatever traditions that people may have.

Before I even begin, I try to see why the parents want it. If there is any hesitation, I will try to ask if the father is done. If not, it is possible that maybe it shouldn't be done at all. But at our hospital, the vast majority of the boys are circumcised.

Thanks sincerely,

Dr John Marcus Ob/Gyn.
Ridgewood NJ 07450

201-447-0077

Early Detection of Breast Cancer 

I am going to talk about breast cancer today. Breast cancer is a subject that everyone needs to know about. Why? One of every eight women that you know will develop breast cancer. Even some men will. The good news is that the vast majority of these people will be cured of their disease. The key to the cure is early detection. With early detection, breast cancer can be cured, in most cases. 

Breast cancer is greatly feared by women. It seems to me that they fear it even more than they should.  I have seen studies that analyze the perception of risk that people have.   That perception of risk is all wrong. When women are asked what they perceive their risk of breast cancer to be, they will say 50 percent. When asked what their perception of heart disease is, they will say something like 10 percent. The reality is inverted. The real risk of women dying from heart disease is 50 percent. That is the same risk as men. The common wisdom that women have some kind of protection from heart disease is all wrong. Women have the same heart risk as men. That risk is 50 percent. A full half of all living women and men will die of heart disease.

On the other hand, women in general have a 12 percent chance of getting breast cancer, not 50 percent as they perceive. Since most of those women will be cured, only about three percent of women will die of their breast cancer. Thus the real risk is much lower than the perceived risk.

But many women spend much more effort on worrying about breast cancer than heart disease. If the worry effort were proportional to risk, women would have to spend about 15 fold more time worrying about heart disease than breast cancer. How can heart disease be prevented? You can hear about this every day on the news. It is a very basic list of suggested behaviors. Don't smoke, or if you do smoke, don't smoke too much. Lose weight. Exercise. Keep your LDL cholesterol down and your HDL cholesterol up. Keep your blood pressure down. Don't eat too much processed foods. Eat more vegetables and fruits, and less red meat and refined carbohydrates. Keep your stress level down. Get enough sleep. Manage depression and anxiety better. Get regular checkups. Each one of these interventions will lower your cardiac risk a certain amount.

But women do need to consider the risk of breast cancer and do some things to help protect themselves. What can women do?

First of all, women should be doing self breast examination. The studies show that it works. Almost all women complain that they don't know how to do it, and they think they will do it wrong. When they say that, I will point out to them that the studies which validated self exams were done on women very similar to themselves. All of the women in the studies started out not knowing how to do the exam. They were then briefly instructed on how to do it. Then they did it. And some of them found lumps. Self exams are cheap, easy, repeatable, and the responsible thing to do. There is no excuse for not doing it. Even the feeling of inadequacy is not any kind of excuse. Lumps found early, are much more curable, should they turn out to be cancer.

Second of all, women should be getting checkups. A physician who has palpated breast cancer in the past will have the ability to find lumps that the women may have overlooked, or missed. Gyne's, Family Doctors, Nurse Practitioners, Internists, all are capable of doing a competent breast exam.

Generally, what does breast cancer feel like? To me, the best description is that it feels bad. It really feels like it doesn't belong there. Breast cancers can be really firm, or hard. Benign lumps are soft. Breast cancers can be really bumpy, with bumps of all different sizes. Smooth lumps are usually not breast cancer. Breast cancers are asymmetrical. Benign lumps, also known as fibroadenomas, are commonly smoothly round. Breast cancers are fixed in place, maybe to the skin, maybe to the bone, maybe to other lumps. They are fixed in place with projections of growth. Benign lumps are usually mobile, not fixed to anything. Finally, breast cancers are usually big and get bigger over time. Big is usually relative, but believe me, when a women finds a scary lump, even a pea feels gigantic. Benign lumps usually attain a certain size, and then they don't grow anymore. If a women tells me that a lump has been there for years without change, it is very unlikely to be breast cancer.

Thirdly, women need to be getting their mammograms. When a women gets a mammogram, the radiologist is looking mainly for one type of finding. That finding is called clustered microcalcifications. When that mammogram finding is reported, it will be reported as a positive mammogram finding. Not positive as in certainty, but positive as in the findings suspicious for cancer are really there, and it is not a negative mammogram. The new terminology will call it BIRADS 4. BIRADS 1 is completely negative. BIRADS 2 is negative with some benign findings. BIRADS 3 is suspicious, but not positive for cancer. BIRADS 4 is likely cancer, and there are clustered microcalcifications. BIRADS 2 is the most common report I get.

A radiologist will commonly request a sonogram if there is a BIRADS 2 or 3. A sonogram will not tell us as much as a mammogram. But it will be helpful if the sonogram reports a simple empty cyst. Cysts are nearly always benign, only contain a water like fluid, and only a few will need to be drained.  If the fluid that comes out is clear, then the fluid can be thrown away as it is not cancer.

Women need a baseline mammo at 35, then yearly after 40. There was a committee at the NIH in 2009 that declared that no mammos before age 50 were useful, and that self breast exams were not worth the stress and anxiety they caused. What ensued was a firestorm of indignation. My patients, especially the ones between 40 and 50, were outraged. The qualifications of the members of the committee were highly questioned. All of the relevant professional groups had to put out press releases decrying their wrong conclusions. Even President Obama had to have a press conference stating that no one in the government was going to change any protocols. During this whole process the giant new health care bill called Obamacare was undergoing debate, and this whole debacle strengthened the opposition to the bill.  Everyone assumed that Obamacare would follow the most restrictive rules possible, in order to save money. As of now, that debate isn't done yet. I believe that the bill does empower the same committee at the U.S. Preventive Services Task Force to make binding recommendations.

See http://www.uspreventiveservicestaskforce.org/about.htm for the USPSTF.
See http://www.nytimes.com/2009/11/17/health/17cancer.html for a news story at the time.

Since then, ACOG, my professional society, has reconfirmed that yearly mammo's are required after 40 years of age. This will save lives, for sure.

So now we get to the crux of the matter: what do we do if there is a lump or a finding? The basic rule is simple, it is that all persistent new lumps need to be biopsied. Why? because the only way to be absolutely sure that any lump is not cancer is to get a piece of it into the lab. Anything short of this is taking a chance on someone's life. There are some things that one needs to be aware of when using this rule. First, cysts are not lumps, they are water, and draining them is optional. Second, a lump that goes away is not cancer, as cancer cannot go away on it's own. So, if you re-examine a lump after a menstrual cycle and it is gone or much smaller, then there is no worry. Just follow that lump over time.  Third, a diagnostic mammo and sono are required, as they can give us very important info. If it is BIRADS 4, then she needs to go to the surgical oncologist now. Fourth, even BIRADS 3 is not usually cancer.

The bottom line is that too many women will get breast cancer. Of every 100 women that you know, 12 of them will get breast cancer. 3 of them will succumb to the disease. It will always be painful to them and to those around them. Every single one of them who gets breast cancer will wish with all her heart that she did something to diagnose it sooner. Because of this, failure to diagnose breast cancer is the number one malpractice loss for gynecologists in the United States. No Gyn or doctor on Earth wants to fail to diagnose it. That may be why your Gyne pushes so hard to get you to do all of those things above.

This was another very wordy blog but the material is so important that everyone should read this twice. And take my advise.

Thank you, Sincerely,

Dr John Marcus Ob/Gyn
Ridgewood NJ 07450
201-447-0077

Tomorrows post: Circumcisions? Why? Why are we cutting the little boys? 

HPV Incidence and Pap Smears 

Hi everybody. Thanks for coming back to read my blog again.

Today someone in my office had read my blog and suggested that I write about HPV. HPV is very common and is responsible for a lot of pap smear issues. It has been in the news a lot lately because of the Gardasil vaccine and the newer vaccination protocols. There has even been some effort to vaccinate the young boys. Gardasil is approved for young girls from 9 to 27 years of age, and similar ages for the boys. Gardasil has new competition now, the Cervarix vaccine. The HPV vaccines are nearly 100 percent effective at preventing infection with the two pre-cancerous HPV viruses, type 16 and 18. Their effectiveness against the other precancerous viruses is much lower, if at all. We don't yet have data that these vaccines actually prevent cancer. That data will take at least a few more years to come out.

First of all, everyone needs to know that HPV is unbelievably common and prevalent. About 90 to 95 percent of humans carry HPV in our cells somewhere in our body. People catch HPV commonly when they are young. Little children get HPV, also known as warts or condyloma, on their hands, their feet, their elbows, and all over the place. It is extremely easy for HPV to go from one person to another. HPV can be caught in any manner that includes skin contact. HPV is easy to transmit with sex. But HPV can be transmitted non-sexually just as easily. HPV is very common in the vagina, and on the penis and scrotum. HPV, at least some variants, seem to like it in there and grow quite a bit. It is in there that it stirs up pre-cancerous activity of the cervix, vagina, vulva, and anus. HPV, in a human, becomes dormant after the immune system starts fighting it. There is controversy about whether some people eradicate it completely from their systems, but most Gyn's believe that once you get, you don't completely get rid of it. It just stays dormant. When women get HPV on their pap smear report, many women assume that it is clear evidence of a Sexually Transmitted Disease. Many times, this conclusion is false. HPV is easy to get without sex. Little kids get it all the time. It is common that some if not many cases are non sexual. Try not to let women's lives be wrecked over this possibly incorrect interpretation.

HPV affects all women because women need to get their pap smears, and a modern pap smear should include HPV testing, at least for women over 30 years of age. Younger women are at less risk for cancer, so we don't test them for HPV on a routine basis.  Why do we test for HPV?  This is because the prolonged presence of a high risk HPV requires an examination for precancerous cells. In my practice about 30 percent of the time, when  there is prolonged HPV, there will be precancerous cells as well. 

HPV has about 115 different variants. Of course, the variants are more similar than they are different. Of the differences, though, some are more likely to be in the vagina, especially when we look for the higher risk variants. Of the 115 variants, about 13 of them are commonly found in precancerous conditions of the vagina and cervix. Two of those, type 16 and 18, seem to be the highest risk type, and are very common. Only recently have Gynecologists started separately testing for type 16 and 18. When we find type 16 or 18, we should move to testing for pre-cancer sooner rather than later. I find these types all the time in my practice.

About 1 in 4 women will eventually get an abnormal pap smear. I can almost guarantee that you personally know someone who has had an abnormal pap smear. You may not know it, because women don't like to talk about it. But, in my experience, if you share your abnormal pap smear experience with women, then the ones who have had it will come out with it and talk about it. It can be very supportive, talking with your friends about this. But be careful and only speak with your closest friends. Other people can get mean about it.

To do the workup for precancerous cells, we will need to look in the vagina with a microscope. This procedure is called a colposcopy (remember the procedures are named in the Greek right? From a prior blog article. Greek for vagina is colpos). Generally, in my office I do several colposcopies a day. A colposcopy requires a special microscope, some vinegar to wash out the vagina fluids, a green light, and special training and experience that almost all Gynecologists have. The vinegar makes the precancerous cells turn white under the green light. They also swell up a bit. I presume that the precancerous cells absorb more vinegar, get thicker and more opaque, and are therefore easier to see. Without the vinegar, the abnormal cells are almost impossible to see, even with the microscope. I don't think anyone knows for sure how the vinegar really works.

Sometimes when we do a colposcopy, we see absolutely nothing wrong. If that is true, then we may do a scraping inside the cervix and finish. But usually, we see some bits of whiteness here and there, or an abnormal looking blood vessel. If we see any abnormality we tell the patient and then take a small biopsy under local spray on anesthesia. Then, after the biopsies, we'll have a discussion with the patient about what we've seen. But for the final diagnosis we willl have to wait for the official diagnosis from the pathologist.

Commonly there will be mild dysplasia, or pre-cancer. This is also called CIN-1, SIL-1, Class-1, or some other names. Mild dysplasia, depending on where it is, will need to be either followed or removed. More serious dysplasias, will definitely need to be removed.

Removing pre-cancerous cells is easy but not guaranteed. Unfortunately, we have no technology to remove the HPV. Removing the precancerous cells can be done with the laser, they can be frozen off in some places, they can be burned off with electricity or heat, they can be surgically removed, or chemotherapy can be used in some cases (that is my least favorite method, and in my opinion requires a visit to a gyn oncologist). Most of the removal methods leave behind about a 20 percent risk of persistent pre-cancerous cells. Therefore careful followup is necessary.

For that followup we will do more paps and likely more colpos.

In my practice, preventing cervical cancer is easy. I cannot remember having a patient proceed from abnormal pap smear to cervical cancer. All of the known pre-cancerous lesions have been sufficiently removed to prevent cancer.

But there are still women who get cervical cancer. Generally it is mostly women who don't get pap smears. They are at risk of cervical cancer. I can also remember one women who had three negative pap smears over 8 months, and then a biopsy showed cervical cancer. The cervical cancer must have been below the surface, where the pap smear couldn't detect it. Either that, or it advanced so fast that there was no chance to prevent it. But generally, cervical cancer is preventable in the pre-cancerous stage. The pre-cancerous stage usually takes years to progress, giving us a very long time to stop it.

All of the areas near the pap smear source are at risk. I have diagnosed pre-cancer from the mons to the cervix, to the anus.

Talking about pap smears and HPV and pre-cancer can be long winded. But, I can assure you, it is important to the women who have had to go through with these tests and things.

Thanks again for reading. More good blogs are coming up.

Next time, breast lumps and the basic rules about how to deal with them. Are they cancer?

Sincerely,

Dr John Marcus MD
89 North Maple Ave
Ridgewood NJ 07450

Second paragraph edited on 5/15.

Prenatal Genetic Testing  and the Dangers of Amniocentesis

Today I would like to talk about Prenatal Genetic Testing. This is an important part of Prenatal Care. 

When a woman is pregnant, or wants to be soon, I will provide what is called "Prenatal Care". This type of care is provided by an Obstetrician. This job is what makes an Obstetrician an Obstetrician. Ob's are usually gynecologists as well, but there are many Obstetric sub-specialists in Maternal Fetal Medicine who are not gynecologists.   They only provide care to pregnant women. MFM's provide an important part of prental care, but they usually don't provide the whole spectrum of prenatal care from pre-conception to post-partum. As far as myself, an obstetrician, I provide pre-natal care, as well as take care of high risk pregnancies. Personally, I don't hesitate to call in the MFM's when their consultation is appropriate. 

Prenatal care is important for many reasons. Prenatal care has been shown to reduce obstetric morbidity and mortality about 99 percent. That is a huge reduction in risk to the new mom. Another way of looking at it, is there is a 99 fold reduction in risk. Women who are pregnant without any prenatal care are putting themselves and their babies in a very risky situation. 

One important part of prenatal care is evaluating the genetics of the fetus. One of the most common genetic birth abnormalities is Down Syndrome. For a 20 year old, the risk of having a Downs baby is about 1 in 1000. For a 30 year old, about 1 in 500. For a 35 year old, the risk is about 1 in 300. For a 40 year old, about one is 50. It is higher yet for older women. 

The historical medical test to screen for Downs Syndrom is called Amniocentesis. Amniocentesis consists of putting a sharp hollow needle near to the baby, through the mothers abdomen, into the babies amniotic sac, and withdrawing some of the amniotic fluid. We usually take 20 cc's. This is a very small part of the total.  Amniotic fluid is mainly the fluid that is created in the babies kidneys, and the baby urinates it out into the sac. Amniotic fluid is very similar to urine, but it doesn't have urine smell, and it is almost never yellow. Amniocentesis is very easy to do if an Obstetrician is well trained. We always use the sonogram to guide the needle placement, to keep the needle away from the babies vital parts, and to avoid the umbilical cord. I have done this procedure more times than I can count. After the amnio, we get a preliminary FISH chromosomal analysis in about 2-3 days. 

The problem with amniocentesis is that it has some significant dangers. About 1 percent of the patients that have this done will have a persistent leak of amniotic fluid from the vagina. This is frightening, but it usually heals up in a matter of hours. Unfortunately, some babies will miscarry after the amnio. The studies that measure the risk are all over the map, but the reported risk varies from 1 percent, or 1 in a hundred, to 1 in 1500. If the miscarriage happens to you, then the statistics mean nothing. It is just painful.  

Because the Amnio is risky, Ob's usually restricted it to women who had some kind of elevated risk. Most commonly, the elevated risk is what we call Advanced Maternal Age, or 35 years old at delivery. That would be 34 and 1/4 years of age at conception. Other risk factors would be a family history of chromosomal problems, including any past miscarriages with chromosomal abnormalities. 

Women really hate having to think about having an amnio. They resist it quit a bit. In my practice, if I detect that a woman is simply afraid of the needle, then I will try to counsel her that the needle pain is small and temporary, and insignificant compared to the importance of the knowledge gained. 

But the good news is amnios are no longer needed for screening. We now have a newer nonivasive technology call a nuchal test. In this test, we do a sonogram at 12 weeks and look for a couple of important markers of fetal well being. Those markers are the nasal bone and the nuchal fold thickness. We then test for some biochemical markers of fetal well being. This nuchal testing technology has no direct risk to the baby. The nuchal test will not give us a yes or no answer about Downs Syndrome, but it comes close. At 12 weeks we get a test result that shows odds against Downs. Many times the odds go below 1 in 10,000. 

Then we do the sequential test at 16 weeks. This is only blood work. After that the odds against Downs Syndrome can go to as low as 1 in 250,000. When a pregnant women gets a report like this, she will have to think long and hard if she still wants to risk the Amnio. This is because the amnio might cause thousands of miscarriages of healthy babies before it was able to detect a downs baby. I believe that an amnio remains a right for pregnant women, so she should have it if she wants it, even in low risk scenarios. But it is very rare for a woman to choose it if the risks of Downs are this low. 

On the other hand, if the nuchal and/or sequential test shows an elevated risk for Downs, then we should offer the amnio to the woman. Some women will do it, some won't. A common reason for not doing it is that the woman and her family have religious objections. Those families will never terminate any baby. Even one with downs syndrome. These women should be counselled that the amnio is unnecessary. Sure, we might gain some information, but we would be risking the normal and healthy babies to get at that knowledge. For those  women, it is important that they make choices that are consistent with their spiritual values and needs. It is my job as an obstetrician to help her make choices within her spiritual needs. If the woman would never terminate a Downs baby, then they should not choose to risk all the healthy ones by doing amnios. 

Thanks everyone for reading my blog. 

There is tons of things to write about. 

I have a lot of ideas in mind. 

Sincerely, 

Dr. John Marcus MD 

Obstetrician and Gynecologist 

Ridgewood, NJ, 07450 

201-447-0077  

Infertility Evaluations and Treatments

Thank you all for reading my blog. Writing this is really rewarding for me. I feel like I am doing something that really needs to be done. And I don't think anybody else writes a blog like this. I believe that it needs to be done. Thank you all for reading. Please don't hesitate to say a few words in the comments. Criticism or praise is welcome. And linking would be great. I hope to get higher on the google ranks if people like my blog.

I am a little bit late posting my blog today. I have been at The Valley Hospital in Ridgewood New Jersey with a number of full term patients having babies. Everybody is doing well. Today was a bit busy. I've delivered 2 boys and a girl today and it's now time to take a bit of a break. All of these babies are beautiful miracles. In fact, all babies are beautiful miracles. I am so lucky to be a part of all of these lives. I think that I have the best job in the world. The hours are long, the work is busy, but I like my job and that makes this all very easy. I like what I do and I never regret the long hours. I think my patients can see that I like my job. My patients can see that I am having fun and they can truly appreciate it. I wind up with thousands of baby pictures on my wall, and it's great. Please come by and see them if you are close by.

But, I promised to write about a significant problem that some couples have. There are plenty of women in the world who would love to be in the delivery room today, in labor, who are not. I see these patients in my office every day. Frequently I will see these couples in my office for a checkup. Many times, after some delicate back and forth discussions trying to find out what the couples goals are, I find out that there has been no contraception for some time. In other words, they want to be pregnant and are not. Most of the time, these women are becoming more and more stressed as the months go on. It seems to them that all of their friends are having babies and they are not. Each time the menstrual period starts, they become more and more stressed. Many times there is tears, every month there is more.

About 20 percent of couples that want to have a baby cannot get pregnant.

The old textbooks used to say that there was not a problem with fertility unless the couple has tried for Two Years and there is still no pregnancy. I can tell you all right now that after two years of wanting to be pregnant, most women would be out of their minds with anxiety. Many of my patients have deferred pregnancy into the mid or late thirties, or even later. This means that the "Biological Clock" is ticking very loudly. They simply cannot stand waiting any more. They know that if they wait,  they may completely lose their chance to have a baby. That is a damn shame.

I think the new standard of care should be SixMonths. If there is no contraception for six months, then they deserve a consultation about what to do.

When a patient presents to me with this problem, my job is to help them figure out what is wrong. This is not hard at all. Sometimes, the problem is really easy to diagnose. And many times, the problem is really easy to overcome. I have done it many times.

Also, there are times when a couple needs help but the diagnosis presents itself with the patient. Very little workup is required. For instance, there are gay couples. Women that are married, or consider themselves married, to another woman, that want to have a baby, are infertile. It is not rocket science to know that there is a lack of sperm. Helping them is really easy, and unbelievably rewarding. I have helped these women out. I have helped these couples form entire families. It is so easy to do. Any properly trained gynecologist can do these things. Many times a sperm bank is the answer. Some women have other solutions in mind.

But the usual infertile couple is a man and a women who have been having "unprotected intercourse" for 6 to 24 months. If they are not pregnant, then then are in my office for that problem.

After doing a complete checkup and making sure that nothing obvious is wrong, I will sit down with the patient and discuss several things. First, I will explain what the common "factors" of infertility are. These are, in anatomical/biological order:

-Male Factor
-Timing Factor
-Cervical Mucous Factor
-Uterine Factor
-Obstructed Fallopian Tubes, or Tubal Factor
-Weak or absent ovulation, or Ovulatory Factor, or Luteal Factor
-Peritoneal irritations, or Peritoneal Factor, most likely endometriosis
-Defective Embryo's, or "old ovaries and eggs".
-Unexplained Infertility 

This discussion can be tailored to the specific couple. It usually takes only a few minutes. Many times I will write these things down on a small legal pad that I keep handy.

But this discussion of "factors" is not what usually catches their undivided attention. It is the next step that really catches their attention. This is really important.

I start with making of plan of action for the couple to figure out what is wrong. I will almost always write this plan on my small legal pad. I try to make this plan very specific.

Here is my usual workup, or plan, for the usual patient:

-Basal body temperature charting. Easiest to chart on www.fertilityfriend.com, but paper charting is OK.
-day 2 to 5 basic Gyn hormone levels, including thyroids, prolactin, LH, FSH, AntiMullerianHormone.
-Ovulation predictor test kits, or OPK's,  from days 10 until the 3 day surge of LH is over, about day 19.
-Post coital test on day 13 or so, or the day prior to ovulation
-Luteal day 7 progesterone blood test to evaluate the Corpus Leuteum, and evaluate the ovulation.
-Semen Analysis
-Hysterosalpingogram, or HSG, in the early second or third good cycle.

Usually, after these tests are done, after a month or so, we have an idea of what is wrong.

About 50 percent of the time there is a mild male factor. About 40 percent of the time, the women is not ovulating very well. Many times, the cervical mucous is "hostile" to the sperm, and will not let sperm swim in to the uterus. About 10 percent of the time, there is endometriosis, and this is "hostile" to the embryo before it implants into the uterine wall. If the woman is near menopause, then there is likely either a weak ovulation, or defective embryos.

I can easily test for most of these things in my office.

And then overcoming these problems is mostly straightforward. Most of the technology is easy to do in the office.

But, for some factors, such as a serious tubal occlusion, a very very low sperm count, anovulation resistant to oral medications, or a bad case of unexplained infertility, the patient will need to be referred to an IVF clinic. This is a sad development. IVF is very expensive, and it is highly interventional. The good news is, is that IVF is highly effective. The latest IVF success rates are about 50 plus percent. 50 percent of the IVF cyles will lead to a confirmed pregnancy. This is very welcome news indeed to a couple who has been trying to get pregnant for a very long time.

There are two kinds of reactions that women might have to this kind of infertility technology. The most common is intense relief that we are finally doing something that may help. But some women are very over-stressed by all of this scientific analysis. The stress is just too overwhelming. Sometimes they just give up.

I think that supportive care givers can help quite a bit.

I've done this many times .

I find that it is really rewarding to help women and couples through these problems. The reward is in their smiles when the baby finally comes. Like I said before, every baby is a miracle and a gift from God.

Thanks for reading. Please comment and let me know if you have any constructive criticism.

This blog is really rewarding for me and I am having a great time doing it. I don't think any other Gyne is doing exactly this kind of a blog.

Thank you, Sincerely,

Dr John W Marcus MD FACOG
89 North Maple Ave
Ridgewood, NJ, 07450
201-447-0077

website is www.doctorjohnmarcus.com
blog is doctorjohnmarcus.blogspot.com

The Therapeutic Alliance 


In my day to day practice I like to think about ways to make me a better doctor. Being a better doctor, to me, means being successful at relieving pain, preventing problems, saving lives, and helping people to maximize their human potential, whatever that might be. That might be helping them to be happier in their lives or recognizing when something big must be done to change. It even extends to, for instance, helping people realize why their politics have changed when they have a baby. Politics usually do change a bit. I will post another blog about that someday.

One of the ways that I think that I and other doctors can improve their skills is by developing what I call a Therapeutic Alliance with patients.

A Therapeutic Alliance is a concept of how a doctor and a patient can relate to each other in their day to day activities. It is not explicit. A Therapeutic Alliance is an implicit unspoken agreement between two people, the patient and the doctor, that there will be cooperative work done between them to achieve their goals. What are their goals? Their goals are maximizing health, reduction or removal of pathology, maximizing their human potential, and prevention of morbidity and mortality. A Therapeutic Alliance works toward advancing the interests of the patient. An important component of a Therapeutic Alliance is unfettered communication between the two people about what the medical issues are. What medical issues? History of any problems, the evaluations needed, what do these evaluations cost in pain, time, money, and risk, the medical methods to be used, the risks and side effects of those methods, and the hoped for outcomes. Also, of course, is the prevention of disease.

The biggest obstacle is unfettering the communication. Once the communication is free and easy, almost anything therapeutic is easy to achieve, if it can be achieved at all.

Notice that a Therapeutic Alliance does not require unfettered trust. In fact, I think unfettered trust is dangerous because it will impede the communication of important hesitant feelings. If my patient asks about trust, or even tells me that they trust me implicitly, I will tell them "do not trust me". Why? If the trust is so deep, I may not know that the patient has misgivings about what needs to happen. The patient has to agree to whatever plan is made. They have to agree in order to make it right. If the patient is not agreeable, then however technically correct the medical plan might be, it may not work. I don't want blind trust from my patients. That is a dumb thing to ask a patient to have. Only a snobbish physician demands implicit trust from a patient.

But the therapeutic alliance does require a certain kind of trust. It is the trust that the physician and the alliance itself will work diligently and professionally to achieve the patients goals, as discussed above. That kind of trust needs to be there. We as physicians need to serve the patients interest. The patients interests must come first. The alliance must proceed in a manner that the patient herself would proceed if she had the knowledge base and experience that the physician has. And that also means that the physician will stay within their zone of competency, and the patient must know that.

So, the end result is that there are two (or more?) people in an alliance to achieve goals that serve the patients best interest and no one else's.

A very interesting thing about a therapeutic alliance is that if it ruptures and is then repaired, it can be even stronger than it ever was. Even stronger than one that never ruptured. But a broken therapeutic alliance that remains broken is dangerous. This is because the patient will never agree to even sensible plans, and that means bad outcomes all around.

The concept of therapeutic alliance has been a subject of quite a bit of scientific study. It is easy to read about these things on the web. The last time I read the Wikipedia entry about it it had a paragraph about the ruptured Therapeutic Alliance. That Wikipedia entry also shows that this concept has been over analyzed and made confusing.

A Therapeutic Alliance is a theoretical thing that represents an ideal of how the Art and Science of medicine should work. In reality, there are obstacles. The biggest obstacle is hindered communication. If a patient doesn't understand that I am trying to open the communication, to be a better doctor, then it won't work. Worse yet, if I don't get the kind of trust that I outlined above, then it won't work. Again, I don't want or need blind trust. Just a trust that I will do my best as a physician, as a member of our Alliance, to work diligently. Another common obstacle is lack of time. There is just not enough time to do the things that need to be done. And also, sometimes a Therapeutic Alliance is just unnecessary and waste of time. For instance, women who just want a routine checkup and to get back to their business don't want or need to delve into this kind of thing.

When I was in med school there was very little time devoted to these concepts, and only in the psychiatry rotations. But I paid attention to these concepts and I saw how they could be applied to all of medicine. And I use it in my practice every day.

Generating the therapeutic alliance means unfettering the communications, even on delicate matters, and then doing a good job as a physican with basic things like getting a history, doing a good exam, ordering tests appropriately, making a fair plan, and communicationg all the other things like risks, benefit, and likely outcomes. It seems to me that it is just basic and good medical care.

It is my belief that a good Therapeutic Alliance is a wonderful thing to have.



My next post will be about the basic infertility workup.

Frequently women will be brought to tears every month and they need some help.

Are these blog posts hard to read? How is my writing? please post comments below. Thank you.

Dr John Marcus MD
Obstetrics and Gynecology
Ridgewood NJ, 07450

201-447-0077

Hysterectomy Decision Making is Hard

When an unfortunate day comes that a women decides that she must have a hysterectomy for one reason or another there are a series of decisions that must be made. Unfortunately, sometimes the doctor makes the decisions for her. Sometimes the doctor offers these as options, with an explanation of why of one thing or another might be done. These decisions are usually difficult. These decisions are based on lifestyle and odds of future problems. Women can be overwhelmed.

First decsion: What kind of hysterectomy? TAH? (explained in prior post). LAH?. Vaginal hysterectomy? Robot? Many times women are not given a choice. Sometimes women are given a fake choice, like "the robot is best, that is what needs to be done". There is a whole bunch of analytical thinking that needs to be done to choose the route.

Second decision: Take out the cervix? (explained in prior post). This decision is affected by the first decision. For instance it is difficult and traumatic to take out the fundus (see prior post) and leave the cervix in if the uterus is to come out via the vagina. Sure, you can cut a hole in the posterior vaginal wall, but that might lead to some significant surgical risks, even involving the colon and rectum. That's usually not worth it.

Third decision: Take out the ovaries? I will discuss that after the cervix.

Why would a women want to remove the cervix? The answer is first of all, cervical cancer will be impossible. Because of this, she may not need as many pap smears in the future. This can (optionally) save money on paps, which keep getting more and more expensive through the years. Please note, though, that I have saved women from vaginal cancer by doing pap smears in women who don't have a cervix. Doing the pap should always be a choice for women, should they choose to want to do it. Bean counters should not restrict it.

It is important, though, that even if a women chooses to skip pap smears, she will still need to get annual Gyne exams. This is to check a bunch of things that really matter. In no particular order, this will include: Bladder position, support, tumors (easily palpated via the vagina), rectal position and support, vaginal mucosa or skin, vaginal infections, the vaginal cuff support, position, or tumors. The skin of the Labia for tumors, melanomas (more common there than elsewhere per square inch, and I have found them there), infections, whether the cuff is getting weak and letting intestines fall into the vagina, the levator muscle position, strength, conditioning, and again, tumors, The quality of the ligaments and muscles that support all of these things. The breast exam for lumps, thickening, swollen lymph nodes, suspicious skin and or nipple changes, a general state of health, illness, or deconditioning. Sexuality issues are also important. Much help can be provided there if necessary. Also, to maintain a relationship with a trusted physician who can be a lifesaving resource when needed.

That last paragraph was an aside about general Gyn checkups. But back to the cervix. Another reason women might want to keep it is because there is some data that it might have a sexual purpose. The cervix definitely moves during sex and orgasm. The cervix is also very close to the G-spot. The science on the matter, though, shows no difference in measures of sexual function whether the cervix is in or not. Sexuality has been measured in studies, and there appears to be no difference. In my practice, I would talk about it with women prior to removing it, and discuss their options. The bottom line, taking it out removes what may be a normal organ in an effort to prevent cancer and save on pap smears, at some small undefined risk to sexual function. Keeping it preserves what may be a normal organ, and may preserve sexuality,  but raises the risk of cervical cancer back up to baseline. This decision should be evaluated in light of the woman's pap smear history. Any abnormal pap's or HPV in the past would argue for removal. If a woman does not get regular pap smears in the past, it would argue for removal, as she is likely to skip paps in the future, and risk becoming an unfortunate statistic. Keeping the cervix also preserves the normal arrangement of the supporting ligaments of the pelvic structures. This is only a benefit if the supporting ligaments are in good shape. Preserving stretched out poorly supporting ligaments is not a benefit but a recipe for a fallen bladder, rectum, and cervix. Finally, in an effort to preserve the cervix, there may have to be a change in the method of removal of the fundus. Like I said before, it is difficult to remove the fundus and keep the cervix if the plan is to remove the uterus via the vagina. Maximum preservation of the cervix (and G-spot) requires some kind of abdominal approach to the hysterectomy.

Should a women take out her ovaries for a hysterectomy that doesn't involve any ovarian pathology? This decision is even more complicated than the cervical one, and has day to day consequences for a woman. Removing the ovaries prevents nearly all cases of ovarian cancer. Keeping them preserves their important hormonal function. Ovarian cancer strikes about one in 60 women. But all women have important hormones, so losing the hormones affects everyone.

The official position of the American College of Ob/Gyn is to recommend removal of the ovaries after 50 years of age, leave them before 40 years of age, and make individualized recommendations in between. The in between years are very common.

Note that in some women, the ovarian cancer risk is so high that they should be removed as soon as she is done having her children. This would be women who carry the BRCA gene. I have now started testing for this gene in my office, and I have found women who carry the gene. I use Myriad genetics as my genetic testing provider.

If we remove the ovaries in a women under 57 years of age or so, there will be hormonal consequences. She will likely lose almost all of her estrogen and her testosterone. A woman would be lucky indeed if she didn't feel the loss of those hormones. There will usually be hot flashes and night sweats. Commonly there will be a loss of libido and orgasm. Almost always there will be a dry vagina. There may be a tremendous weaking of the skin of the vagina called Urogenital Atrophy. This makes for more urinary infections, leakages, pains, and small bladder syndrome. That is as icky as it sounds. It will likely make sex very dry and uncomfortable, oddly even when using lubrication. The pelvic ligaments may get weak. Moodyness is very common, although some people attribute that to the loss of sleep from the night sweats and flashes. Decreased memory is a common complaint. Long term, there is bone loss, usually at about 3 percent per year, becoming dangerously osteoporotic at about 20 years out. Altogether, I have seen lists that include about 150 symptoms of menopause. All of these are worse when the ovaries are removed. The cost of preventing ovarian cancer is quite high on a woman's life.

The good news is that these ovarian hormones that are lost are replaceable with their natural equivalents. These hormones can be taken orally or topically. Theoretically at least, they shouldn't increase her risk more than the natural hormones that they are replacing. Replacing these hormones is called Hormone Replacement Therapy, or HRT. HRT has it's own set of risks, but it certainly should not be restricted from a woman who is suffering as described in the prior paragraph. It really does normalize the life of women who are suffering.

There was a giant study done a few years ago called the Women's Health Initiative (WHI), which detailed the risks of HRT. When the study came out, many many women quit their HRT. The WHI found that HRT increased the risk of breast cancer by about 7 cases in 10,000 women. Concurrently, the cases of colon cancer dropped some similar amount. The WHI also proved that their class of women had no cardiac benefit from taking HRT. This was not the common wisdom of the day, and changed a lot of thinking. Since then ACOG has decided that women who don't need HRT should stop taking it. It is extremely important to note that the WHI excluded women who had menopausal symptoms. And mainly the women were an older group than perimenopausal women. Because of this, the WHI has no implications for perimenopausal women with symptoms, including surgically induced menopause. For perimenopausal women, we need to use older studies of symptomatic menopause. Many of these studies showed an unequivocal benefit to taking HRT.

It is really easy to see that these decisions are nontrivial. All four of these decisions above are about as important as decisions get. The  four decisions are

-How to take out the uterus
-Whether to take out the cervix.
-Whether to take out the ovaries
-Whether to take HRT afterwords

For the route of the hysterectomy, straight vaginal is easiest and least painful. It can be done in 20 minutes or less sometimes. Vaginal also gives access to vaginal repairs that might be neccessary. Laparoscopic is less painful than open but gives access to intraabdominal conditions. Laparoscopic also leaves unsightly scars on the abdomen. These scars are abhorred by fit women, they are life altering for models, movie stars, and young women. Laparoscopic takes a bit longer and has more surgical risks. Robotic takes longer yet, and leaves sometimes even bigger scars, and also has more surgical risks. Open leaves one scar just above the pubic bone, hidden by hair or bikinis. Open has more pain, but this passes in a few days. Open sometimes gives better access to pelvic problems. All of the abdominal approaches preserves the G-spot, optionally preserves the cervix, and allow better access to the ovaries and intra-abdominal problems.

I am open for comments.

Thanks for reading.

Next post on what I call the Therapeutic Alliance.

John Marcus
Obstetrics and Gynecology
Ridgewood New Jersey
201-447-0077