Get the Pelvic ‘Floor-One-One’

**By Kathleen Kobashi, MD, FACS, FPMRS**

While pelvic floor health disorders can seem alienating, it is important to know that you’re not alone and there are a variety of ways to treat bothersome symptoms.

The pelvic floor is a group of muscles in the pelvic region, that can be described as a “hammock” of ligaments that sling between the pubic bone in the front and the tailbone in the back. For women, these muscles and ligaments work to support and control the uterus, vagina, bowel and bladder; whereas for men, they support just the bowel and bladder.

As a multidisciplinary team, the members of the Pelvic Floor Center at Virginia Mason treat virtually every pelvic floor health issue that can be experienced by both men and women. In this article we’ll dive into common health problems associated with the pelvic floor and why maintaining pelvic floor health is so important. Pelvic floor disorders can become huge quality-of-life issues that can interfere with our daily activities. It is vital for us to be aware that there are successful, minimally invasive treatment options available.

Common health issues associated with the pelvic floor

When it comes to pelvic floor health issues, there are several key terms to remember, like incontinence and prolapse. Incontinence is the lack of control of bladder or bowel function resulting in leakage, while prolapse is the displacement or dropping of pelvic organs through a weak pelvic floor, much like a hernia. There are other pelvic floor disorders that may result in the opposite problem of difficulty emptying the bladder or bowel.

Mother and daughter drinking coffeeThe two most common forms of urinary/bladder incontinence are stress and urgency leakage. Stress incontinence is the involuntary release of urine from coughing, sneezing or other similar actions and is commonly (but not exclusively) experienced by women who have had vaginal delivery of babies. Aging, genetics and gravity can also play a role. Conversely, urgency incontinence is exactly as it sounds – when nature calls, you don’t always have a say in when you answer, and it is urgent. This form of incontinence can be caused by the consumption of dietary irritants, such as coffee or wine, that aggravate the bladder, as well as hormonal changes that make the bladder more irritable. In men, urgency can also be related to prostate enlargement.

Fecal/bowel incontinence (aka accidental bowel leakage) is an involuntary loss of bowel control that can result in stool abruptly leaking from the rectum. Disorders associated with bowel function can range from constipation to complete loss of control of the bowel, and everything in between.

Prolapse occurs when pelvic organs – such as the bladder, uterus, bowels, vagina or rectum – drop down into or outside of the anus or vaginal canal. Prolapse can be due to a number of issues, including pregnancy, childbirth, obesity, chronic respiratory issues, constipation and cancer in the pelvic region.

Signs to look out for and when to see your doctor

If you’re concerned you might be dealing with a pelvic floor problem, here are a few signs and symptoms:

  • Urinary/bladder incontinence – symptoms can include leakage of urine with coughing, sneezing or exercise, and can also be associated with a sudden, intense and often uncontrollable urge to urinate. Other lower urinary tract symptoms may include frequent urination, slow or dribbling streams of urine or the inability to completely empty your bladder.
  • Fecal/bowl issues – symptoms can include chronic bloating, constipation, diarrhea or involuntary loss of fecal matter.
  • Pelvic organ prolapse – symptoms can include a feeling of fullness in the pelvic floor or vagina, a feeling that something is “falling” out of the anus or vagina, discomfort with sexual intercourse, urinary or fecal incontinence, a sense of trapping of stool or the inability to completely empty your bowels.

It’s important to note that any combination of the symptoms above can occur.

The importance of pelvic floor health

Given the critical bowel, bladder and sexual functions these muscles support, keeping your pelvic floor healthy and strong is crucial. There are a variety of exercises that can be done to improve overall pelvic floor health and functionality, with some of the more common ones being Kegels. Working your pelvic floor regularly is especially important for women in order to minimize the risk of developing prolapse, incontinence or other pelvic health issues that stem from pregnancy or aging.

If you’re experiencing any one or combination of the symptoms discussed above for an extended period of time, it may be time to call and arrange a visit with your doctor. From there, they can work with you to decide your best course of treatment, whether that’s pelvic floor therapy or proceeding with some tests that can help identify the root cause of your problem and facilitate treatment planning.

Kathleen.KobashiKathleen Kobashi, MD, FACS, FPMRS is board-certified in urology with a subspecialty certification in female pelvic medicine and reconstructive surgery. She is the section head of Urology and director of the  Pelvic Floor Center at Virginia Mason. Dr. Kobashi is a urologist/urogynecologist who specializes in the treatment of pelvic floor disorders, including urinary and bowel incontinence, pelvic organ prolapse, and urinary tract fistulas, with expertise in pelvic floor reconstruction through open and robotic surgery.

Q&A with a Family Doctor: Tips for a Happy, Healthy, Safe Birth

There are lots of articles out there about birthing styles, the best ways to give birth and how to prepare for birth. However, despite what they might tell you, it turns out there is not one “right” way to give birth.

We sat down with Dr. Juliana Wynne, a family doctor at Virginia Mason Edmonds Family Medicine, to talk about some of the choices when it comes to giving birth, common questions her patients ask her and any advice when it comes to handling the unexpected … when you’re expecting.

What are some ways patients can prepare for birth?
The best way patients can prepare for birth is by educating themselves. I recommend that patients bring up any questions they have about it with their provider. Patients can take birth classes – these can be accessed virtually, including at Virginia Mason. Expecting parents can talk to friends and family about their experiences. I recommend finding reliable resources about birth, such as the book “The Mommy Docs’ Ultimate Guide to Pregnancy and Birth” by Yvonne Bohn, MD; Allison Hill, MD; Alane Park, MD and Melissa Jo Peltier. In general, I think it’s important to feel informed going into labor.

What are some common questions your patients have? 
Patients often ask me about my role as an FM/OB (family medicine obstetrics) provider. I am a family doctor that provides prenatal, obstetric, postpartum and newborn/pediatric care. At my office, patients tend to see one prenatal provider. Our goal is to be the provider that is present for their labor and delivery in the hospital. I believe that the biggest benefit of seeing an FM/OB provider is the continuity of care, from the first prenatal visit, to the baby’s birth, to the newborn care in the office and the post-partum visit, to pediatric care as the child continues to grow older. I really get to know the patient and her baby, and often get to know the whole family. This leads to a whole-person and Ethnic toddler listening to her mothers pregnant tummywhole-family approach to care. 

Patients also ask about who will be in the room with them during the birth. Generally, the people in the room include their partner, me, their nurse, and a nurse for their baby. If needed, we have additional support staff available at all times, including additional nurses, the NICU (neonatal intensive care unit) team, and an obstetrician on call.

 What birthing styles are out there? 
Just like every mom and baby is unique and different, so is every birth. There is no one right way or style to give birth. As a provider who cares for women who are delivering babies, my goals are to do everything to ensure that mom and baby are safe, and that mom feels informed and in control.

How do you help moms choose the best birthing style for them? 
Again, there is no one right way to give birth and there are many options when making a plan. There are options for who you see for your care. You can see a midwife, an obstetrician, or a family medicine physician that does prenatal care, like myself and my colleagues at Virginia Mason Edmonds Family Medicine. There are options for where you give birth. You can give birth in a hospital, in a birth center, and some women choose to give birth at home. There are different people to lean on for support during labor, whether it be your partner, family, friends, doula, provider, nurse or a combination of all of these people. There are different ways to cope with pain during labor, which include utilizing a birthing ball, a hot bath, movement (walking, dancing), utilizing your breath, using nitrous oxide which is available in some birth locations, IV pain medicine or an epidural. When it comes to the actual delivery, there are also different positions to try.

A birth may not go as expected. How can patients prepare for this? 
It is helpful to keep an open mind going into your labor. Sometimes our plans change. For example, I hoped very much to have a natural vaginal delivery myself. However, after a long labor, I had a healthy baby via cesarean section. I felt that I did everything in my control to have a vaginal delivery, and yet was prepared for the possibility of needing a cesarean section (my little one was projected to be 9 pounds, and he was!). 

It’s important to share your goals with your provider so that we can best help you achieve them and advocate for you. Helping you to achieve your goals is our goal. 

Juliana WynneJuliana Wynne, DO is a family medicine doctor who provides prenatal, obstetric, women’s health, adult and pediatric care at Virginia Mason Edmonds Family Medicine. She is board certified by the American Board of Family Medicine.

Female Urinary Incontinence: Know the Non-Mesh Alternatives

**By Una Lee, MD**

It is important for all women to be educated on how their urinary tract works and options that exist when problems occur. A mid-urethral mesh sling is a common surgery that treats stress urinary incontinence. It has been one of the standard surgical treatments for stress incontinence since 1997.  The synthetic mesh sling works by acting as a “hammock” under the urethra, helping to keep it closed with activities like coughing or sneezing. However, women should be aware that there is an infrequent but known risk of minor, moderate or serious complications associated with mesh sling surgery. Many women ask if there are alternatives to mesh slings. Absolutely!

First, a quick review of incontinence basics. Urinary incontinence is the leakage of urine that can occur in women of all ages, and commonly occurs or worsens after childbirth. White Curls womanThere are difference types of urinary incontinence, including:

  • Stress incontinence – leakage with physical activity, like laughing or coughing
  • Urgency incontinence – leakage that occurs when you have a strong urge to urinate and are rushing to the bathroom
  • Mixed urinary incontinence – a common condition of having both stress and urgency incontinence
  • Post-void dribbling – leakage after you urinate
  • Incontinence without sensation – leakage that occurs with no awareness

The type of incontinence is important, because different treatments target different types.  Also, the amount of leakage – mild, moderate or severe – will also affect treatment options.

Starting with the least complicated, conservative management may be appropriate if urinary leakage is mild, infrequent, not very bothersome and can be controlled with pads. For many women, no treatment is a valid choice.

Weight loss is another non-surgical opportunity.  Studies have shown that modest amounts of weight loss (5 percent of total body weight) can significantly decrease urinary incontinence. For many women this is motivating and encouraging, while promoting their overall health.

Stopping smoking is another effective step.  Smoking and the chronic cough associated with tobacco use can make urinary leakage worse. Abdominal pressure from frequent coughing will in turn increase pressure on the pelvic floor and urethra, causing leakage.

Pelvic floor physical therapy with a qualified physical therapist who specializes in urinary incontinence is a totally natural option. You learn how to identify and strengthen your pelvic floor muscles correctly and how to use this skill to prevent leakage. This therapy is known to be effective and is a skill you can use for life.

Incontinence pessaries are medical grade discs that are placed in the vagina to support the urethra. The size and shape is custom fitted to you, and it is removable and comfortable. It is a good non-surgical option to try.

Urethral bulking is an injection into the inner lining of the urethra, which improves the sealing abilities of the inner part of the urethra. While not generally permanent, it’s an effective treatment for the right patient.

The Burch procedure preceded sling surgery as a standard stress incontinence treatment. Instead of creating a hammock supporting the urethra, sutures are placed for support and elevation. While not as effective as the sling procedure, the Burch procedure remains an option for some patients.

A variation on the sling procedure known as the autologous fascial sling has been around for years and has stood the test of time. A strip of fascia, or connective tissue, is harvested from your thigh or lower abdomen, then placed to support the urethra. While this surgery is effective, durable and safe, the downside is that it’s more invasive and requires longer healing time.

Enrolling in a clinical trial may be an option for some patients. Eligible participants volunteer and are fully informed of the study’s process and potential risks and benefits. Participants are advised to talk to their health care provider before participating in a clinical trial.  One study is currently investigating using muscle-derived, regenerative cells to treat stress urinary incontinence. For more information on participating in clinical trials, click here.

Vaginal laser treatments, using a carbon monoxide (Co2) laser, are used as a therapy for vaginal dryness and atrophy. Currently, there is not enough evidence to support the claims that they treat stress urinary incontinence. Additionally, laser treatments are costly and typically not covered by insurance.

Medications for urinary incontinence generally help with urgency incontinence and overactive bladder symptoms, but not stress urinary incontinence. So they can help with that “gotta go” feeling and resulting leakage, but not with leakage that happens during Zumba class. These medications are designed to help with bladder control. Most are prescription, so ask your doctor if bladder medications are appropriate for you. One treatment, the oxybutynin transdermal patch, is available over the counter. Side effects can occur with these medicines, with about 20 to 40 percent of women remaining on the medication in one year’s time.

Treatment with vaginal estrogen helps treat thinning tissues in the vaginal area. By improving the quality of the tissues, symptoms of urinary urgency can improve. Some women report their incontinence improves as well.

Botox injections in the bladder can dramatically help women who have leakage of urine that is associated with urgency, but are not effective for stress urinary incontinence.

Bladder pacemakers, also known as InterStim therapy, regulate bladder signals by stimulating the sacral nerves located near the tailbone. This electrical stimulation helps the brain and bladder communicate for better urinary control. The implants help reduce urinary urgency and resulting leakage, urinary frequency and urinary retention (the inability to empty the bladder).

Urinary incontinence is a common, costly and important quality of life issue for women. Gaining a thorough understanding of the condition is the first step.  Given the sensitive nature of these bodily systems and their impact on women’s lives, knowing the range of treatment options is key to making the right choice for you.

Lee_UnaUna Lee, MD is a urogynecologist/urologist dedicated to women’s health. Dr. Lee and her partners in the Urology Department at Virginia Mason offer all FDA-approved treatments for urinary incontinence, with the knowledge and experience to support the best outcomes.      

Pelvic Organ Prolapse: How a Restorative Treatment Helped Mother and Daughter

Kathy Silva describes the 12-acre farm where she grew up and where her mother, Rosemary Cockrill, still lives. Life in scenic Port Angeles, Wash. could be low key if you let it. But Rosemary, 86, kicks it up a notch, making time to go to concerts, see a play or a movie, or take a class at the senior center.

“She’s never going to get old,” says Kathy, who lives about 20 miles from her mom, in the town of Joyce, and works for the local school district.


Kathy Silva (right) and her mother, Rosemary Cockrill

But Rosemary’s life wasn’t always so active. For years, she suffered the symptoms of pelvic organ prolapse, when weakened pelvic floor muscles and ligaments allow organs such as the bladder, uterus or rectum to drop, sometimes protruding out of the vagina. Pelvic organ prolapse develops over time, often long after childbirth has stretched connective tissues. When the bladder is the affected organ, a feeling of heaviness or pressure, compounded by the frequent need to urinate and the fear of accidents, can keep women from getting out and doing the things they enjoy.

“My mom asked me to please look at Virginia Mason’s website to find a urologist who could help,” says Kathy. “I chose Dr. Una Lee, who specializes in pelvic organ prolapse, and all the information we needed about her was right there.”

Dr. Lee confirmed Rosemary would benefit from surgical intervention. A minimally invasive approach using small abdominal incisions to repair the prolapse, and a supportive sling placed to support Rosemary’s bladder and urethra would relieve the constant pressure and incontinence. There was just one problem. “My mom doesn’t like anything to do with hospitals and she wasn’t excited about any of it,” remembers Kathy.

It was her mom’s evaluation at Virginia Mason that got Kathy thinking about her own discomfort. She wasn’t having any urinary problems, but she’d been feeling like she was sitting on something, and was constantly adjusting her position to get comfortable. A visit to Dr. Lee confirmed Kathy was also suffering from pelvic organ prolapse, which she learned can be hereditary. If her mom wasn’t ready yet, maybe Kathy could blaze the trail.

Dr. Lee completed Kathy’s prolapse repair in one operation through the vagina. The success of her daughter’s surgery eventually moved Rosemary toward a decision. She would have the surgery.

“Mom goes anywhere she wants now,” says Kathy. “My son got married in Vegas, and Mom insisted on going. She flew on the plane and enjoyed the whole trip without worrying about the bathroom. I know the surgery is what helped her make that trip.”

At the two-year mark after Kathy’s surgery, a check-in with Dr. Lee confirmed there was still a problem with prolapsed tissue near the rectum. Kathy’s previous repair to support her bladder remained in place, but she needed a second surgery in another area to fix what’s known as a rectocele, or posterior vaginal prolapse. Kathy credits both procedures for making her good as new, “and that’s not bad for 66,” she says. She has an enduring gratitude for Dr. Lee and the care teams who have encouraged and supported her over the years at Virginia Mason.

“No one tells you when you get older what’s not normal, and women may not be confident talking about it,” says Kathy. “Dr. Lee is easy to talk to, and she really wants to know her patients.”

Rosemary wholeheartedly agrees with her daughter, and then some. “Dr. Lee and this surgery have given me my life back,” she says.

This story also appears in the Virginia Mason Health System 2017 Annual Report.  


“Fake” UTIs: Alternative Facts or Reality?

**By Una Lee, MD**

Fake news has invaded our newsfeeds. There are even courses on how to tell fake news from legitimate news. But a fake urinary tract infection (UTI)? Is that even a thing? In fact, this fake is for real. A fake UTI is when a women (or man) experiences symptoms that seem exactly like a bladder infection, but are not caused by bacteria.  The fake version mimics a real UTI, but is not due to an underlying infection. It is more common for both real and fake UTIs to happen in women, but they can happen to men as well.

So what’s behind these fake UTIs? Sometime urinary symptoms like urgency, frequency, burning, urinary pain or discomfort are due to other causes, such as inflammation or irritation of the urinary tract. Increased sensitivity of the nerves that inhabit the urethra and bladder can occur when bladder irritants such as caffeine or alcohol, sexual activity, dehydration and stress are in the picture, or it can simply happen out of the blue. These ramped up nerve signals can cause the strong feeling like you have to urinate, even when your bladder is not full, and after you just went to the bathroom a few minutes ago.  These signals can also cause discomfort around that area of the body and can range from mild to horrible.

StormWhat can you do when this happens?  You can be evaluated for a real UTI, where a urinalysis and urine culture will determine if there’s been an overgrowth of harmful bacteria in your urine.  If the urine culture is positive, then appropriate antibiotics can be taken for treatment of a real UTI. However, when the urine culture comes back negative (even when it may have visually appeared positive), the patient may still be experiencing symptoms that are very real. I have discussed this phenomena with my patients who suffer from these fake UTIs, for which the suffering is not only real, but a frustrating event in their lives. Add to that a delay that sometimes occurs getting the results of a urine culture, and if it’s negative, the need for a solution intensifies.

Now the question is: how do you treat a fake UTI? The key is supporting your body so it can heal from what is an inflammatory process happening in your urinary tract. Your immune system can rise to the occasion if helped to do so, by alleviating the process at the root of the problem. Steps to take include increasing water intake; getting adequate, good-quality sleep; eating nourishing foods; managing one’s stress and avoiding activities that are irritating to this sensitive area of the body.

But beyond basic health measures, some women take probiotics, some of which are formulated to promote urinary health, that provide live microorganisms thought to be “good bugs.” Lactobacillus, the active cultures in yogurt, are another example of good bugs that may sound familiar, known to promote healthy intestinal flora. (But keep in mind: probiotics are largely unregulated by the U.S. Food and Drug Administration, and most lack proven scientific results.) Some women find whole cranberry or cranberry supplements helpful, as there are natural elements in cranberry that have been used for thousands of years to support urinary tract health. On the other hand, some women find cranberry juice and cranberry products irritating and it can make them feel worse.

For more immediate symptom relief, an old standby in your medicine cabinet may help. Pyridium also known as “Azo” (active ingredient is phenazopyridine) is a urinary analgesic that is an over-the-counter medication that turns your urine bright orange and can help take the discomfort away temporarily and help you get through the day. Some recent studies showed that ibuprofen worked as well as antibiotics in the treatment of uncomplicated UTIs, though women who took ibuprofen felt symptoms longer and showed an increased risk of kidney infection. But in the case of fake UTIs, ibuprofen could be helpful for reducing inflammation and associated symptoms. Not to mention that in this age of increasing resistance to antibiotics, we need to be judicious in their use. Antibiotics kill the bad bacteria and the good bacteria, disrupting the natural flora of our bodies. Understanding the delicate balance and function of microorganisms is important for maintaining our body’s natural defenses.

So if a fake UTI suddenly becomes a bigger problem in your life than fake news, know there are ways to fight back. Nothing is more real than your good health!

Lee_UnaUna Lee, MD is a urologist specializing in urogynecology at Virginia Mason Medical Center in Seattle. Dr. Lee says she is constantly inspired by the strength and resilience of women in her care. She hopes to alleviate the stress of conditions like real and fake UTIs by bringing a deeper understanding of these sensitive body parts.

Understanding the Pelvic Floor: Five Things Women Should Know

**By Una Lee, MD**

What is the pelvic floor and why is it important? 

The pelvic floor is not a “floor” but more like a “bowl” of muscles and connective tissues that sits within the bony pelvis. This is a critical structure because it supports urination, bowel function, sexual function, pregnancy, delivery, and physical functioning. In my opinion, the term “pelvic floor” is kind of a G-rated way of referring to parts of the anatomy that people are uncomfortable saying aloud. But even if people would rather At doctorsay “pelvic floor” than other anatomic terms, that’s OK, because it’s referring to the same area and talking about it is a good thing. Women are often embarrassed to talk about these issues, and therefore many cope with bothersome symptoms for years. There is a common myth that pelvic floor problems are a normal part of aging and nothing can be done. In actuality, pelvic floor problems are very common and there are many effective treatment options.

 How do I identify my pelvic floor?

Many women are familiar with the Kegel exercise, which involves squeezing the muscles of the pelvic floor. To find these muscles, place one or two fingers in the vagina and squeeze around your fingers. Once you’re able to do this, you don’t need your fingers to do the exercise. The sensation should feel like you are lifting your pelvic floor up and in, as if you’re trying to pull something up into the vagina. Be sure to breathe normally and not hold your breath. Avoid tensing the surrounding muscles, such as your abdomen, thighs, or buttocks. Squeeze for a count of five, then rest for 10 seconds, and repeat. If you are not sure you are doing it correctly, ask your doctor for a referral to a pelvic floor physical therapist. Doing Kegels correctly is a skill that you will serve you for a lifetime, so it will be worth the investment.

What happens when the pelvic floor fails?

We take for granted that this incredibly complex structure works perfectly most of the time. But when the pelvic floor is not working well, you will notice leakage of urine or stool, rushing to the toilet and urinating frequently, or a sensation of your pelvic organs falling down or out of place. Symptoms can range from mild to severe. Sometimes symptoms get better on their own or stay the same over time, but they can also get worse and become more bothersome. If pelvic floor symptoms are affecting your quality of life and getting in the way of doing the activities you enjoy, it’s time to see your doctor or a specialist.

Did you know that November is Bladder Health Month? Please join us for one of our free education sessions presented by pelvic floor disorder experts on November 8 and 9, at Virginia Mason’s Federal Way and Seattle medical center locations.

Did you know that November is Bladder Health Month? Please join us for one of our free education sessions presented by pelvic floor disorder experts on November 8 and 9, at Virginia Mason’s Federal Way and Seattle medical center locations. Click a location to register, or call (206) 341-0360. These events are open to women of all ages, offering the latest information on conditions and treatments in a relaxed atmosphere.

What is a urogynecologist? 

A urogynecologist is a urologist or gynecologist who dedicates themselves to being a specialist in female pelvic floor problems — primarily urinary incontinence, pelvic prolapse, fecal incontinence, and also reconstructive surgery of the female genito-urinary system. Urogynecology is the intersection of urology and gynecology, and is a new board certification. Three board-certified urogynecologists currently practice at Virginia Mason including myself (Una Lee, MD), Kathleen Kobashi, MD and Alvaro Lucioni, MD.

What helps prevent pelvic floor problems?

Maintaining a healthy weight is one of the best ways to keep the pelvic floor healthy. Excess weight puts additional pressure on the pelvic floor, but even modest amounts of weight loss, just 5 to 10 percent, can improve symptoms significantly.

Avoiding things like chronic coughing due to smoking (quit!) and straining due to constipation will also decrease stress and pressure on the pelvic floor. Maintaining your overall health through good nutrition, hydration, sleep, sexual activity, and exercise also supports a healthy pelvic floor. Just having a better understanding of pelvic floor function is a step in the right direction. It’s an amazing part of the body that rarely gets discussed, so let’s start talking about it!

Lee_UnaUna Lee, MD is a urogynecologist in the Section of Urology at Virginia Mason who enjoys sparking discussion on these intimate topics, to help raise awareness and ultimately improve the health of women.


Genital Grooming: What to Know Before Going Bare Down There

**By Una Lee, MD**

razor (002)Pubic hair is a fact of life. The pattern of hair that grows on our genitals is a natural part of our body, and it serves a purpose. Pubic hair helps protect our genital organs and provide a layer of defense, first as a physical barrier, but also by promoting a microflora of normal skin and genital bacteria. As a uniquely human sign of sexual maturity, pubic hair effectively traps pheromones, scents the body produces that can be sexually stimulating to others.

So why do some people want to get rid of it? In modern life, genital grooming by some men and women has morphed into a form of self-expression. While some may leave their pubic hair “au natural,” others may trim or shave their pubic hair closely or into a desired shape, like a strip or inverted triangle. Being “bikini ready” is why some women shave or wax, including the well-known Brazilian wax in which all hair is removed.

Other reasons women state for their grooming habits down under came to light in a recent University of California San Francisco (UCSF) study, surveying more than 3,000 women across the U.S. Nearly 84 percent of the women in the study groomed to some degree, with young, educated Caucasian women more likely to groom than other groups. The reported reasons for the less-hairy choice ranged from achieving a desired look, to feeling “cleaner,” to accommodating sexual preferences.

But the pressure to maintain a certain look or feel may come at a cost. Another 2016 UCSF study looked at the link between genital grooming and increased risk for sexually transmitted diseases (STDs). Conditions that impact the skin, such as HPV, herpes and syphilis, were most strongly correlated with aggressive grooming. The study found that “extreme groomers,” or those who regularly remove all pubic hair, were more than four times as likely to have had an STD. People who had groomed at least once in their lifetime were nearly twice as likely to report they’d had an STD.

While only a correlation between genital grooming and STDs was confirmed by the study – not that grooming caused the diseases – 60 percent of groomers experienced complications, including skin cuts, ingrown hairs and bruising. And the possibility of incurring very small cuts from shaving and waxing, called “microtears,” is thought to make the skin more vulnerable to infectious microorganisms. Avoiding aggressive pubic hair removal right before sex may help reduce this risk.

Regardless of what motivates people to “manscape” or tend to one’s “lady garden,” the practice has been around since ancient times and will continue to be a grooming routine for many. Knowing the potential ways it can impact your health will help ensure this private issue doesn’t get too prickly.

Lee_UnaUna Lee, MD is a urologist/urogynecologist at Virginia Mason Hospital & Seattle Medical Center who is passionate about women’s health and all the things nobody talks about, but should. 

Innovative Radiation Therapy Attacks Early-Stage Breast Cancer in One Treatment

Virginia Mason was the first medical center in Washington state to offer intraoperative radiation therapy (IORT) to treat women with early-stage breast cancer. Since 2012, 350 patients have participated in the IORT clinical trial, receiving a one-time dose of internal radiation therapy directly to the tumor site during surgery.

Potential candidates for breast IORT are women aged 45 or older, with a new diagnosis of early-stage breast cancer who are planning to undergo lumpectomy. Watch the video to learn more and hear from IORT patients.

For more information or to discuss if you may be a candidate for IORT, please contact a Breast Cancer Nurse Coordinator at (206) 223-8862.

Making the Most of Your Visit: What Your Gynecologist Wishes You Would Do

**By Linda S. Mihalov, MD, FACOG**

patient-gown-waiting-webNo matter a woman’s age or how comfortable she is with her gynecologist, she may still be unsure about a few things – like which symptoms are worth mentioning, how often to make an appointment and how to prepare for an exam.

Based on my 30 years of providing gynecologic care to women of all ages, I thought it would be helpful to provide a few tips about how to make the most of your care visits.

Keep track of your menstrual cycle

Menstruation is a monthly recurrence in women’s lives from early adolescence until around the age of 51, when menopause occurs. Because of the routine nature of this biological process, it’s easy to become complacent about tracking your periods. Thankfully, there are numerous smartphone apps that help make tracking periods easy.

Keeping track of your period is important for numerous health-related reasons. A missed period is usually the first sign of pregnancy. Determining the due date of a pregnancy starts from the date of the last menstrual period. Most forms of birth control are not 100 percent effective, and an unplanned pregnancy is best recognized as soon as possible.

Conversely, women attempting to get pregnant can use period tracking to learn when they are most fertile, which may greatly increase the chances of conception.

In addition, a menstrual cycle change can indicate a gynecologic problem, such as polycystic ovarian syndrome, or even uterine cancer. It is also often the first obvious symptom of health issues that have no obvious connection to the reproductive organs. When a regular menstrual cycle becomes irregular, it may indicate a hormonal or thyroid issue, liver function problems, diabetes or a variety of other health conditions. Women also often miss periods – or experience menstrual changes – when adopting a new exercise routine, gaining or losing a lot of weight or experiencing stress.

One late, early or missed period is not necessarily reason for alarm. But if menstrual irregularity is accompanied by other symptoms, a woman should schedule an appointment with her gynecologic care provider.

Get the HPV vaccine

Human papillomavirus, or HPV, is a very common virus. According to the Centers for Disease Control and Prevention, nearly 80 million Americans – about one in four – are currently infected. About 14 million people, including teens, become infected with HPV each year. Most people who contract the virus will clear it from their systems without treatment, but some will go on to develop precancerous or even cancerous conditions from the infection.

The HPV vaccine is important because it protects against cancers caused by the infection. It can reduce the rate of cervical, vaginal and vulvar cancers in women; penile cancer in men; and anal cancer, cancer of the back of the throat (oropharynx), and genital warts in both women and men.

This vaccine has been thoroughly studied and is extremely safe. Also, scientific research has not shown that young people who receive the vaccine are more prone to be sexually active at an earlier age.

The HPV vaccine is recommended for preteen girls and boys at age 11 or 12 so they are protected before ever being exposed to the virus. HPV vaccine also produces a more robust immune response during the preteen years. If you or your teen have not gotten the vaccine yet, talk with your care provider about getting it as soon as possible.

The CDC now recommends that 11- to 12-year-old girls and boys receive two doses of HPV vaccine – rather than the previously recommended three doses – to protect against cancers caused by HPV. The second dose should be given six to 12 months after the first dose.

Teen girls and boys who did not start or finish the HPV vaccine series when they were younger, should get it now. People who received some doses in the past should only get doses that they missed. They do not need to start the series over again. Anyone older than 14 who is starting the HPV vaccine series needs the full three-dose regimen.

Young women can get the HPV vaccine through age 26, and young men can get vaccinated through age 21. Also, women who have been vaccinated should still have cervical cancer screenings (pap smears) according to the recommended schedule.

Understand how age affects fertility

Fertility in women starts to decrease at age 32 and that decline becomes more rapid after age 37. Women become less fertile as they age because they begin life with a fixed number of eggs in their ovaries. This number decreases as they grow older. Eggs also are not as easily fertilized in older women as they are in younger women. In addition, problems that can affect fertility – such as endometriosis and uterine fibroids – become more common with increasing age.

Older women are more likely to have preexisting health problems that may affect their or their baby’s health during pregnancy. For example, high blood pressure and diabetes are more common in older women. If you are older than 35, you also are more likely to develop high blood pressure and related disorders for the first time during pregnancy. Miscarriages are more common in older pregnant women. Losing a pregnancy can be very distressing at any age, but perhaps even more so if it has been challenging to conceive.

So, women who are considering parenthood should not put off pursuing pregnancy for too long or it may become quite challenging.

See your gynecologist for an annual visit

For women to maintain good reproductive and sexual health, the American College of Obstetricians and Gynecologists recommends that they visit a gynecologist for an exam about once a year. Generally, women should have their first pap test at age 21, but there may be reasons to see a gynecologic care provider earlier than that if there is a need for birth control or periods are troublesome, for instance. Although pap tests are no longer recommended every year, women should still see their provider annually for a gynecologic health assessment. This may or may not involve a pelvic exam.

Other reasons to visit a gynecologist include seeking treatment for irregular periods, sexually transmitted diseases, vaginal infections and menopause. Women who are sexually active or considering it can also visit a gynecologist to learn more about contraceptives.

During each visit, the gynecologist usually asks about a woman’s sexual history and menstrual cycle. The gynecologist may also examine the woman’s breasts and genitals. Understandably, a visit like this can cause discomfort among some women. However, periodic gynecological exams are very important to sexual and reproductive health and should not be skipped. The patient’s anxiety can be significantly decreased if she knows what to expect from the visit. Prepared with the knowledge of what actually occurs during an annual exam, women often find it can be a straightforward, rewarding experience.

There are several things women should do to prepare for a gynecological exam, including:

  • Try to schedule your appointment between menstrual periods
  • Do not have intercourse for at least 24 hours before the exam
  • Prior to the appointment, prepare a list of questions and concerns for your gynecologist
  • Since the gynecologist will ask about your menstrual cycle, it will be helpful to know the date that your last period started and how long your periods usually last

The pelvic exam includes evaluation of the vulva, vagina, cervix and the internal organs including the uterus, fallopian tubes and ovaries. Appearance and function of the bowel and bladder will also be assessed.

The gynecologic provider will determine whether a pap test is indicated, and order other tests as necessary, including tests for sexually transmitted infections, mammograms and screening blood work or bone density studies. Even a woman who has previously undergone a hysterectomy and, as a result, no longer needs a pap test can still benefit from visiting her gynecologist.

Primary care providers, including family practitioners and nurse practitioners, internists and pediatricians can also provide gynecological care.


Menopause can be a challenging time. Changes in your body can cause hot flashes, weight gain, difficulty sleeping and even memory loss. As you enter menopause, you may have many questions you want to discuss with your gynecologist. It is important that you trust your gynecologist so you can confide in them and ask them uncomfortable questions. The more open you are, the better they can guide you toward the right treatment.

Dr Linda MihalovLinda Mihalov, MD, FACOG, is certified by the American Board of Obstetrics and Gynecology. She has special interests in gynecology, gynecologic surgery – including vaginal and minimally invasive surgery – hormones, menopause and transgender care. Dr. Mihalov practices at Virginia Mason Hospital and Seattle Medical Center (1100 Ninth Ave, Seattle, WA 98101; 206-223-6191).

When Laughing Leads to Leaks: Dealing with Stress Urinary Incontinence

**By Una Lee, MD**

laughingWhat is stress urinary incontinence?

Have you ever laughed so hard you leaked urine? Do you leak urine when you run, dance, or work out? If you do and it happens consistently, you may have stress urinary incontinence (SUI). SUI is a type of incontinence caused by pressure from a physical activity, including laughing, sneezing, or coughing. The pressure generated by the activity overwhelms the strength of the urinary sphincter muscle, and suddenly you feel a leak. Stress urinary incontinence is common among women and treatable.

What causes SUI?

SUI results from weakened muscles, including those that that support the bladder (pelvic floor muscles) and those that regulate the release of urine (urinary sphincter). In women, poor function of these muscles may be caused by tissue or nerve damage during delivery of a baby. Sometimes, SUI symptoms from this damage may begin soon after delivery or occur years later. A weakness of the urethra unrelated to childbirth can also cause SUI.

Can SUI be treated?

If it happens enough that it bothers you or affects your ability to enjoy exercising or being active, then lifestyle or behavior changes are the first things to try. Limit your fluids, especially alcoholic and caffeinated beverages which irritate the bladder, and empty your bladder before going on that hike or taking that exercise class.

Kegel exercises, which help strengthen your pelvic floor muscles and urinary sphincter, can be guided by a doctor or physical therapist to be more effective. Just like any other exercise routine, consistency is the goal for seeing results.

For some women a vaginal pessary is an option. A vaginal pessary is a disk fitted by your doctor that helps support the urethra to prevent leakage during activity. Pessaries are often used for people who also have pelvic organ prolapse. There are now over-the-counter, disposable versions of urethral support available.

Material injected into tissues around the urethra, in a relatively noninvasive procedure, can improve the sphincter’s ability to close. However the procedure is not a permanent repair, and most people will require repeat injections. Other surgical options include adding support (your own tissue or a thin strip of mesh) under and around the urethra to recreate urethral support. So when an activity causes increased pressure, there is a “backboard” to help close the urethra and prevent leakage.

SUI Clinical Trial

Clinical trials are research studies that identify what is safe and if a particular treatment works to improve a specific health condition. Participation is voluntary, and participants are educated on the possible benefits and potential risks. If you suffer from a particular health condition, such as SUI, participating in a clinical trial may be an option for you.

Currently, Virginia Mason is participating in a global clinical trial (with sites across the U.S. and Europe) of a new investigational procedure for SUI patients. It is called the Autologous Muscle Derived Cells for Female Urinary Sphincter Repair clinical trial. The trial is evaluating the safety and efficacy of using cells derived from a woman’s own muscle tissue (autologous cells) to potentially strengthen the sphincter muscle that helps control urine flow.

The science behind the trial – the idea that injected cells may help restore tissues of the urinary passage – represents an emerging area of study known as regenerative medicine.  In regenerative medicine, specific types of cells are delivered to diseased tissues or organs for the purpose of restoring the tissue or organ function.

For more information about the Autologous Muscle Derived Cells Female Urinary Sphincter Repair study, visit or

Una Lee, MD
, is board certified in Urology and subspecialty certified in Female Pelvic Medicine and Reconstructive Surgery at Virginia Mason.