Waiting....

If I know it would take this long I would have done something different. How many times have we said that as we've waited for someone?

I started this blog as a required project for work, but the project is over and now I must apologize in advance as I think it is going to get a lot more editorial.
Every few month we get a printout of patient surveys. I must admit I rarely look at them anymore. I can usually identify those who made the most venomous comments, which fortunately are few. The old stand-by complaint, though, is wait time.

Now, I'm an OB. You'd think that pregnant women, of all people, would understand that babies come at random times. You'd think they should also understand, that if in the middle of the night, fear suddenly grips you about your unborn child, and you become somewhat irrational, that you will probably need a few additional minutes at your appointment, that was added into an already full schedule, to reassure you. Regardless of the other patients in the waiting room.
I'm not trying to say that all women are inpatient, in fact, there are probably just a scant few. But those few can sure complain a lot. I have also had 4 children myself and have spent many hours in the waiting room of my doctors office. I understand.

But today, I've felt the need to complain about how much time I spend waiting for my patients. I don't think you all realize how much of my time I waste waiting for you. I've currenlty been in the hospital, on my day off, a Saturday none-the -less, for 3 hours, waiting for someone to delivery. Fourth baby,thought it would go fast....the thought, "If I had known.." has crossed my mind many times. My children and husband are at home waiting to see what we can do today. I'm on call next weekend so this is the last day in 14 that I can do anything with them, and yet I'm here, waiting... I wait for patients to go to the bathroom (they didn't have time while they were in the waiting room I guess). I wait for them to call their husbands to help them make decision, I wait while they change their babies diaper, I wait for them to get off the phone, close their book, finish their magazine. I'm not trying to say that things should change, I just sometime wish I would get a survey on each patient. Rate on a scale of one to five, Was she nice? Did she seem concerned? Was she intellegent? Was she clean? Did she make you wait?

Should I get a flu shot in pregnancy?

Okay, a quick blog this time. I get asked frequently if I encourage a flu shot in pregnancy-of course I do!. There are two main strains of flu in the vaccination-the common strain and the H1N1.
Last year we were hit by the H1N1 and in hindsite it is apparent how bad it really was for pregnant women. This is a bad flu anyway, but it hits pregnant women harder than others. There were many deaths from this flu in otherwise healthy young women. These were terrible deaths, in the ICU, on ventilators, doing emergency c-sections to try and save the baby. Not something that you want to go through. Even here in Cache Valley we had several mothers who were incredibly sick, some even transferred to Salt Lake for further care.

The other strain is the more common strain. I head a lot of people say, "I only get the flu in the years that I get the flu shot.". This has been studies and is just not the case. I think a lot of people are confused at what the flu is. It is not jut the stomach virus that gives you vomiting and diarrhea. The flu is a virus that causes respiratory illness and body aches. It can make every hair on your body hurt. Most people-no matter how strong you are-lie around in bed wishing they were dead. It costs the US millions of dollars in lost wages from missed work. It usually lasts about 10 days and is really not something that you want. Can you image having this flu and then going into labor? I've seen it- it's not pretty. These women can hardly remember having a baby.

I think that I've seen quite a decrease of women with both of these flu-a testament in my mind that the vaccines work. There is really no down side to the vaccine except a sore arm for a couple of day. It does cross the placenta some and may be the only way to protect a newborn from the virus as well.

So the answer is yes! Get the vaccine if you are pregnant

Let's not talk about the hemorrhoids!

I asked my medical assistants what topic they think I should address and I was very surprised that they said, "Hemorrhoids". They said that questions about hemorrhoids was one of the most common phone calls that they get. I guess it is easier to talk about them over the phone than in the office!

So, while hemorrhoids are usually under the hospices of the general surgeon, here I go to review them briefly.

What is a hemorrhoid? Hemorrhoids are just varicose veins around the anus and rectum. Some are more external and some are internal. Just like other varicose veins, there are usually from a blockage and backup of blood in those veins. Most commonly in my office, the blockage comes from a pregnancy. The pressure on those veins back up the blood and the veins swell until they are easy to see and become irritated. Once the blockage is removed, the veins usually decompress pretty quickly. Like a balloon though, the first time the veins are expanded it takes some force, but once they have been stretched they can pop right back up again with minimal pressure.

Symptoms: Varicose veins, in and of themselves, are not usually a problem. You may just feel them when you wipe. Usually the external ones are soft and fleshy. When they get swollen, irritated, or if a clot forms in them they suddenly become a much bigger, "pain in the butt". They are often the cause of painless bleeding with bowel movements. (Painful, tearing bowel movements that cause bleeding is usually a fissure).

Treatment: The treatment for the swelling and irritation is usually a hemorrhoid cream that includes a steroid. Topical ointments and pads, such as tucks, are soothing but don't offer any anti-inflammatory action. Prep H., anusol etc, have some hydrocortisone (a steroid) in them which will work much more effectively in reducing the irritation. These need to be used regularly, at least 2-3 times a day and maybe even 4 times a day until things get better. There are some prescription strength creams that are effective as well.

In additional to topical medications, the pressure has to be off. This means, no heavy lifting or straining. Stools should be the texture of a ripe banana. You may have to take fiber drinks-metamucil, citracel etc. to get your stools softer. (hint. start slowly with the fiber drinks and work your way up to the dose that gets you results. Going to fast will make you very gassy and bloated). Stools softeners like colace will work for the short term but if you are prone to constipation you may need the fiber for the long term.

After a pregnancy with normal bowel function, decreased lifting, topical creams and time, the hemorrhoids should go away until your next pregnancy.

If you get a clot in one of the veins you will know it. The pain is pretty intense and instant and will probably bring you to the ER. There, they will just incise the veins and remove the clot. Relief is almost instant with this treatment.

Surgical treatment of hemorrhoids is the very last resort and some say the surgery can be worse then the hemorrhoids. It is definitely worth the slimy orange drinks and the creams to avoid needing surgery.

Prevention: Preventing hemorrhoids is difficult, particularly in a pregnancy. Not allowing for on going constipation is the best prevention. Choosing your parents wisely will help too as hemorrhoids can have a large genetic predisposition.

Warning: Hemorrhoids that seem way out of proportion for your situation, that get worse and worse, or that bleed a lot, need to be seen. Severe hemorrhoids can be a sign of other problems such as colon cancer. Obviously rare in younger women who are having children, but not unheard of. Never be too embarrassed just to have them checked if they are not improving as expected.

Well, hopefully that answered some of your questions that maybe your were afraid to ask! Now back to the gynecology!

Do I really need a pap smear?

So with all the changes in healthcare guidelines you may be wondering if you really need a pap smear. I'm going to go through a few of the new guidelines with you, but remember, it's always safer just to get the exam.

My first big disclaimer is that there is more to a physical exam than just a pap smear! There are many other issues that we like to address at your physical such as diet and exercise ( I know, you don't want to hear it), good heart health (still the leading problem in women), emotional wellbeing, menopause, irregular periods, breast and skin exam etc. etc. Depending on your age and healthy you may not need a physical every year but you need to talk to your doctor about that.

Now, for cervical cancer. The only thing that a pap smear checks for is cervical cancer. Sure, we may get a little yeast on the smear, and sometimes some endometrial cancer cells, but the purpose of the pap is to screen for cervical cancer. We know that cervical cancer is from the HPV virus (Human papilloma virus). This is sexually transmitted but it can be skin to skin contact and not penetration. It is a very, very common virus. There are many strains of this virus. A handful cause cervical cancer and a handful cause genital warts. Unfortumately, you can not tell if you have the virus that causes cancer until you start getting precancerous cells on your pap smear. Occassionally we will check if you have the virus but this is not covered by insurance except in certain conditions. Sooooo, you have to get your pap smear if there is any chance you may have been exposed to the virus in your lifetime.

Okay, now I know that there are many of you that say it is impossible for you to have a STD as you and your partner have been monogamous. I really wish that this was always the case and that all partners were faithful. Not wanting to cast any doubt on your true love, I'd still recommend getting a pap smear per the following recommendations. I've seen too many surprised women and blushing men.

So here are the current recommendations from the American College of Ob/Gyn (ACOG);

Young women under 21 should not get a pap smear. Young women have great immune systems and even if they get the virus their bodies can usually fight it off.

Paps should be done every 2 years from 21-29 years

Women 30 and older, if they have had three consecutive negative paps, and no prior history of precancerous cells (CIN) and no medical conditions that compromise their immunity, and get their paps every 3 years.

Women who have had a hysterectomy and no history of abnormal paps can forgo any further pap smears.

Women over 65 with no prior abnormal paps, can stop having paps.

Women with prior abnormal paps needs to continue to be screened for at least 20 years after treatment.

Women who have had the immunization should still follow the above guidelines.

There. I hope that helps. Again, I want to stress that appointments for physical should go well beyond just a pap smear. A yearly pelvic exam may still be needed to screen for other cancers such as ovarian, vulvar and colon cancers. Addressing other issues in your life should be equally as important and hopefully, as your physician we can make these appointments worthwhile!

What if I don't want to get pregnant?

So, I've talked about getting pregnant but I want to talk a little about what is out there for birth control options. This is by no means comprehensive but just a little overview.

First, there are different types which include barrier methods and hormonal methods. I'll first summarize the differences and then talk about each one.

Barrier methods are just that, a barrier-keeping the sperm and egg apart. This includes condoms, diaphragm, copper IUD, and sponges. Barrier methods are not usually as good as hormonal methods. The analogy would be liking trying to keep a spilled drink from dripping on your favorite purse by trying to contain the liquid vs by removing the purse. Hormonal therapy just removes the purse. Barrier methods are trying to control the spilled drink.

If you use condoms and diaphragms regularly and follow the directions they are fairly effective. You know there are pros and cons for each. The biggest point of barrier methods it that they do not control anything hormonal. They will not change your moods, treat PMS, or alter your periods.

Hormonal methods will prevent pregnancy by stopping ovulation. These include the pill/ring, the depot provera shot and the implanon. These do affect your hormones and may alter your periods, PMS and moods ( for good or bad).

The mirena is somewhere inbetween. It acts as a barrier but has some hormones that will at least affect your period. In some women it may stop ovulation and may change moods, cause acne etc., but the main effect is on the uterus.

Lastly, there are permanent methods which are all ways of blocking the tubes-tubal ligation, ariana and essure.

Barrier methods:
condoms-used at the moment, about 89-93% effective, less mess for the woman, decreased sensation for the man. Low cost.
diaphragm-put in before and taken out about 8 hours later. Best with spermacide. Buy one and reuse it.
copper IUD-placed in the office, lasts up to 10 years, can make periods heavier and crampier. 1/1000 chance of getting pregnant.

Hormonal methods:
Pills- there are many, many different pills. They will give you regular cycles and lighter periods. They can help acne and occassionally PMS. They are protective against ovarian and endometrial cancer. You can also use them to time your periods, skip periods etc. On the bad side, they can alter you moods for the worse, cause irregular spotting and make you nauseous. Each pill works differently on different women and so trying several of them may help you find the perfect one. The nuvaring is just a different way of getting the same hormones-you just don't have to remember to take a pill. I rarely see weight gain and you can get pregnant soon after coming off. If fact, in some infertility cases we use a month of pills to help increase fertility.

Depot Provera-a once every three month shot given in the office. Should make your periods disappear but may cause spotting for 3-6 months. Can increase appetite and weight gain can be a problem. Will thin your bones if used for a long time but most bone density will increase when you stop taking it. Can take some time to get pregnant after coming off. May cause some depression.

Implanon- a rod placed in the upper arm in the office. Lasts for three years. Should get rid of periods but may have spotting. Should reverse quickly but may take some time to concieve. Manufacture reports no weight gain.

Mirena- IUD placed in the the uterus. Has progesterone but it usually just affects the uterus. This causes the lining to be thinner and so your periods are light to non-existant. It shouldn't affect your moods, acne etc but it does in some women. Lasts up to 5 years. Very quickly reversible. As effective as a vasectomy for birth control. Can cause some acne and mood changes in some women. Will have spotting for 2-6 months.

Remember, hormonal problems have to be treated with hormones.

Permanent sterilization
Tubal ligation-done in the OR or post partum- effective immediately, can cause periods to be a little heavier and crampier. Requires entering into the abdomen (a little more risk to the surgery) .
Ariana/ essure- done in the OR (some MD's will do it in the office), placed by going through the cervix and plugging the tubes. No incisions required. Are not immediately effective and you are supposed to get an HSG (tubal study done in radiology) 3 months later to be sure it is effective. Not currently recommended to to other surgery with it-like an ablation- but some practitioners do.
Vasectomy-safest for the women :). Done in the office. Not immediately effective. Test for effectiveness should be done in 2- 3months.

Hope that gives you a little better understanding of what is available.

sleepy docs

I was reading an article in the American Journal of Ob/Gyn and thought you might like this quote-especially if you're doctor missed your delivery.

"The average practicing obstetrician gynecologist works hours significantly in excess of those allowed for younger resident physicians. In addition, obstetrics remains the only medical specialty in which the attending physician is rountinely expected to both manage a critical and potentially life-threatening process for 2 patients during labor and at the same time seeing office patients or performing elective surgery. Although some might see this as part of the general devaluation of women and children's health care, patient expectations are at least as much to blame. Given the realities of clinical practice, it is simply impossible for every woman to be delivered by the obstetrician of her choice, without accepting the occurrence of sleep deprivation-induced congnitive impairment of that health care provider." Aug 2009 pg 136.

There are times when I will have the on-call doctor deliver one of my patients because I'm just too tired to think straight. I hope you all understand that it is really in your best interest. We really do want the best care for you. I love to deliver my own patients, and would deliver all of them if it were safe. There are some areas, like in Arizona, where they have laborist; physicians who just stay in the hospital and deliver everyone's patient that may come in. In these places you will have about a 1 in 15 chance that your doctor will deliver you. I hope it doesn't come to that everywhere but with new health care policy etc. it may even happen here. (No plans for it in the near future!) Just a little insight I thought you might like.

whats with the Vit D?

Vit D. deficiency is something that is fairly new. It has been surprising how many women, even in sunny areas, that are low in vit. D. Vit D. is used for calcium absorption and calcium is used for bone growth and muscle function. Being low in vit D and calcium can affect your bone density as well as your muscle function. There may be other benefits of vit D as well that are still being studied. These benefits may include decreased colon cancer risk, better prognosis with breast cancer, and decreased risk for pre-eclampsia in pregnancy.

It is thought that since we are staying out of the sun and drinking less milk-both sources of vit D-may be the cause of so many people having low levels.

So what do you do? First, get your vit D level checked-a simple blood test. If it is low then you may need supplementation. The amount you need will depend on how low your levels are. If severely low you may be put on 50,000IU's for 8 weeks. If borderline, you may just be given an over-the-counter vitamin. Pregnant women should probably be taking around 2,000IU. It is important for pregnant women to have adequate vit D for the health of your baby's bones.

There is no known "toxic level" of vit D. but megadoses are not recommended. In fact, some supplemention with vit D and calcium may cause kidney stones.

Again, I've been surprised at the number of tan, active women who have had low vit D levels. I've also been surprised that many of these women feel better when on their supplements. They feel stronger and will some increased energy.

If nothing else, enjoy a little sun (with SPF of course) and drink your milk!