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

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).

Gynecologic Surgery: Minimally Invasive Approach Now an Option for More Procedures

**By Jil Johnson, DO**

female patient waiting in doctor exam roomAs an obstetrician and gynecologist, I have an appreciation for health care needs unique to my patients. I love that medical advances over the last five to 10 years have allowed me to help many women with an array of treatment choices, especially related to gynecologic surgery.

Many women consider gynecologic surgery for various conditions, such as abnormal bleeding, pelvic pain, ovarian cysts, fibroids or endometriosis. In the past, these surgeries were often done through large abdominal incisions requiring long hospitalizations and extended recovery time. In addition, they were sometimes accompanied by more scar tissue and increased risks of bleeding and infection.

Thankfully, as with much of modern medicine, an array of minimally invasive surgery techniques now exist to provide women with more choice, convenience and benefits, depending on individual needs. These approaches are usually associated with less pain, quicker recovery, and lower risks of infection and bleeding.

Using a minimally invasive surgical approach, many common procedures are now performed on an outpatient basis, including:

Endometrial ablation

This procedure ablates (destroys) the uterine lining or endometrium, which is shed each month during menstruation. It is typically used to treat abnormal uterine bleeding when medications have failed. It can also be used to treat small fibroids inside the uterus. The procedure does not require making an incision. Depending on the method chosen for the ablation, slender tools are inserted into the uterus through the vagina and cervix. Some methods of endometrial ablation use extreme cold, while others involve heated fluids, microwave energy, lasers or high-energy radiofrequencies to destroy the uterine lining. It can often be done using a local or spinal anesthetic.

Hysteroscopy

Hysteroscopy is a procedure for looking inside the cervix and uterus. The hysteroscope is a thin, lighted tube inserted through the vagina that can diagnose and treat uterine conditions. Other instruments can be inserted through the tube to perform minimally invasive surgery procedures. Hysteroscopy can also be used with other procedures, such as laparoscopy, in which an endoscope (a medical device with a light attached used to look inside the body) is inserted in the abdomen to view the outside of the uterus, ovaries or fallopian tubes.

Laparoscopic surgery for endometriosis or pelvic pain

Laparoscopy is the most common procedure used to diagnose and remove mild to moderate endometriosis, a disorder where tissue that normally lines the uterus grows outside the reproductive organ. Instead of making a large abdominal incision, the surgeon inserts a lighted viewing instrument, called a laparoscope, through a small incision. If the surgeon needs better access, they make one or two more small incisions for inserting other slender surgical tools.

Laparoscopic removal of ovarian cysts or ovaries

While a woman’s health history, symptoms, examination and ultrasound images can provide a lot of information, sometimes the only way to know for sure if a cyst is benign is to remove it surgically. In general, an ovary can almost always be saved if the cyst is benign and not too large. In young women, the ovary can almost always be preserved. If a woman is peri-menopausal or menopausal, it usually makes more sense to remove the entire ovary, especially if there is a concern that the cyst might be cancerous. Even large ovarian cysts or ovaries can be removed laparoscopically, avoiding the recovery associated with major surgery.

Considering gynecologic surgery?

Here are a few things women considering any type of gynecologic surgery should ask and think about:

  • Can the procedure be done through a minimally invasive approach? While some surgeries cannot be done this way because of existing scar tissue or an extremely large uterus or ovary, most women are usually candidates. A patient should speak with her doctor to discuss whether it might be possible.
  •  If a woman’s doctor feels her procedure cannot be done through minimally invasive surgery, she should consider a second opinion. Not all physicians are adequately trained to safely perform minimally invasive surgery, and some surgeons may not be comfortable with more complex procedures. If this is the case, a woman should consider seeking a second opinion from a surgeon with advanced training and experience before making a final choice regarding her options.

Some of the most important questions to consider when choosing a surgeon include:

  • How much experience does the surgeon have with this particular procedure?
  • Does he or she regularly perform the procedure?
  • Has the surgeon received advanced training for this procedure?
  • How often does the surgeon start a procedure with a minimally invasive approach, but then need to call for assistance or switch to a larger, open incision to complete the surgery?

Research shows that surgeons with higher surgical volumes and/or greater surgical experience usually have better outcomes. For example, although a woman may have a long, positive relationship with her local OB/GYN, who performs her yearly exams, she may decide this physician is not the best person to perform her gynecologic surgery.

Are you comfortable with your surgeon? Every woman should feel at ease with her surgeon. A woman should feel that all her questions and concerns were heard and addressed before the procedure. Any nonsurgical options should always be discussed first. Women should ask whether there are other procedures that may be good options for their particular condition. If surgery is the best option, a woman should ask about risks and what she should expect with recovery. She should also ask whether the surgery is likely going to adequately treat her symptoms and what happens if they persist afterward?

The decision to undergo surgery is not easy for most patients. Feeling comfortable with your surgeon and type of surgery is important. Do not be shy about being inquisitive. After all, it’s your health and your doctor should be happy to answer all your questions.


Dr Jil Johnson_head shotJil Johnson, DO, is board certified in Obstetrics and Gynecology. She practices at Virginia Mason Federal Way Medical Center and Virginia Mason Hospital and Seattle Medical Center. She specializes in gynecology, minimally invasive surgery and robotic-assisted surgery.

Helping Women in Rwanda

In the African country of Rwanda, radio advertisements sponsored by the Ministry of Health announce upcoming medical missions when U.S doctors will provide local treatment for women. The missions, organized by the International Organization for Women and Development, Inc. (IOWD) in Rockville, NY, send teams of surgeons three times per year to treat women suffering from injuries caused by childbirth and other gynecologic problems.

Doctors Linda Mihalov (left) and Blair Washington

Doctors Linda Mihalov (left) and Blair Washington

In February, VM gynecologist Linda Mihalov, MD, and urogynecologist Blair Washington, MD, joined the 10-day Rwanda mission to both perform and teach surgery. During the country’s 1994 genocide, thousands of educated professionals perished, leaving a shortage of experienced medical practitioners. Without access to training from volunteers, Rwanda’s budding medical community could never address the population’s growing need for medical treatment.

Most of the women who travel long distances to the participating hospitals are suffering from fistulas, an injury caused by prolonged obstructed labor. Without access to medical intervention, a baby who can’t pass out of the birth canal can remain there for days, cutting off the blood supply to tissue that separates the vagina, bladder and rectum. When the tissue dies one or more holes can form, through which a woman will leak urine, feces or both. The condition often makes the woman an outcast, abandoned by her husband and even her family. Most women have no way to pay for surgery and must wait for the visiting medical teams.

Dr. Washington provides guidance to the Rwandan medical student and resident team.

Dr. Washington provides guidance to the Rwandan medical student and resident team.

“It’s primitive conditions, so VM donated a lot of supplies to help us,” says Dr. Mihalov, who was new to the program this year. “We don’t have a lot of instruments, suction or electric cautery, among other things. I had to double as a scrub tech, because there wasn’t one.”

Dr. Mihalov mainly performed surgeries to remove fibroid tumors, repair vaginal prolapse and treat other gynecologic conditions, while Dr. Washington exclusively operated to close fistulas. More than 200 women came to the hospital to be evaluated, and 46 fistula repairs were completed by Dr. Washington and the team. Some women’s injuries are so extensive or complicated by botched operations that there’s nothing the surgeons can do. These patients take an emotional toll on the medical team members who want to help, but the patients appreciate even small attempts to ease their suffering.

“They are so grateful to be helped,” says Dr. Washington, who notes that women who can’t be cured surgically are offered specially designed waterproof undergarments. “They have none of the resources we do, which gives me a sense of purpose. It reminds me why I went into medicine.”

Rwanda’s Ministry of Health is closely monitoring the success of treatment provided by IOWD volunteer teams. Surgery outcomes are documented and patients receive follow-up care during subsequent missions. In the three years Dr. Washington has volunteered with IOWD, cure rates, or the percentage of women who regain continence, are consistently high. For many of the mission’s patients it means a second chance at life.

“I am renewed by the dedication and camaraderie I experience on these trips,” says Dr. Washington. “They always bring me back to center.”
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A version of this article was originally published on VM’s internal news site.