MUSC has just been ranked one of America's Best Hospitals for Gynecology by U.S. News & World Report!  It is published online at www.usnews.com and will be featured in the August issue which will be available on newsstands starting Tuesday, July 21.

Fibroid Facts for Females
Fibroids are the most common benign smooth muscle tumor of the uterus and the most common indication for hysterectomy in the United States.  Fibroids are found in over three-quarters of all hysterectomy specimens, even when the indication for surgery was not fibroids.  Fibroids are discovered in 40% of all women by age 35 and 70% by age 50, and are more common in black women.

Symptoms
The presence of fibroids within the uterus may produce no symptoms at all or may lead to excessive and irregular menstrual bleeding and/or pelvic and abdominal pain.  For some women, these symptoms can be debilitating.

You can’t make an asymptomatic woman with fibroids feel better by treating her; so, unless there is a rapid change in fibroid size, a woman with no symptoms needs no treatment.

Treatment
There are many treatment options for fibroids, and which is chosen depends upon a woman’s desire for pregnancy, her desire to keep her uterus, her symptom severity, and the location and size of the fibroids within her uterus.  The appropriate type of procedure: should be discussed with a woman by a gynecologist who is skilled in all these procedures. 

Medication options:  Medical therapy can, and should, always be the first approach to the management of fibroids symptoms. Oral contraceptive pills and progestin-type drugs will almost always control abnormal bleeding from fibroids, but will do nothing to reduce their size. A medication that will reduce fibroid size works only while the medication is taken, and fibroids will re-grow after the medication is stopped.  So, this latter medication is used to reduce fibroid size or stop uterine bleeding in preparation for surgical removal.   A new class of medications called selected progesterone receptor modulators are in development and should be a source for treatment in the future.

Uterine Fibroid Embolization (UFE):  This is a procedure that can permanently reduce fibroid size without surgery.  A woman’s appropriateness for this procedure will depend upon her symptoms, fibroid size and location, and her desire for future pregnancy, since this procedure is not recommended if future pregnancy is desired.  This procedure is done by a specially trained radiologist and involves injecting material which will cut off blood supply to the fibroid.  Over the course of a few months the fibroid will decrease to about one-half of its original size.  Women are usually kept in the hospital overnight in case they feel pain while the fibroid degenerates.  This procedure does not eliminate the fibroids, but most women will have a decrease in their symptoms.  A woman’s gynecologist or an Interventional Radiologist can determine her appropriateness for uterine fibroid embolization.

Magnetic Resonance Imaging Guided Focused Ultrasound:  This procedure can also reduce fibroid size, and therefore a woman’s symptoms, without surgery.  It is relatively new and is only available in approximately 30 center in the United States.  Its appropriateness is also determined by fibroid size and location and involves focusing high-frequency ultrasound waves into the fibroids to produce heat and to destroy them.  This procedure, like UFE, can only reduce fibroid size without removing them, and studies to-date indicate that the size-reduction is less than that achieved with UFE.

Myomectomy:  This less invasive type of surgery removes the fibroids themselves and can be performed, depending upon fibroid size and location, with minimally-invasive techniques such as hysteroscopy and laparoscopy, or, if necessary, an open abdominal procedure.  Myomectomies are the preferred procedure for those women wishing to preserve their ability to get pregnant.  After myomectomy, fibroids can recur, because each fibroid comes from a single individual uterine muscle cell. 

Hysterectomy:  This is the only procedure that completely removes all fibroids with no chance for recurrence, and with the permanent relief of symptoms.  The entire uterus is removed during this procedure.  Fortunately, those gynecologists skilled in vaginal and laparoscopic procedures can remove even very large uteri without making a large incision.  These minimally invasive vaginal and laparoscopic procedures markedly shorten hospital stay and post-operative recovery time and can even be done in the out-patient setting.  Many women can resume normal activity within a week of so after vaginal and laparoscopic hysterectomy.

Summary
Patient choice should play a significant role in deciding a treatment option for uterine fibroids.  Medication therapy will almost always relieve abnormal bleeding   Imaging studies such as ultrasound and magnetic resonance imaging (MRI) can be used to guide surgical and non-surgical treatment strategies.   Non-surgical options, like UFE, can greatly decrease symptoms.  Myomectomy is the treatment of choice for symptomatic fibroids in a woman wishing to retain her uterus for child-bearing.  Women should be well informed and question their healthcare provider if hysterectomy is the first and only option offered. 

MUSC has developed a Virtual Fibroid Center.  With the exception of MRI focused ultrasound, all other treatment options are available through MUSC Women’s Services.  Call 843-792-5300 for information or for an appointment with one of MUSC’s GYN physicians.

by:  Donald L. Fylstra, M.D.

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PMS is common – 80% of women report symptoms that occur during their cycle that “forecast” the start of their period and 40% of women seek medical assistance for their symptoms. These symptoms include: depression, angry outbursts, irritability, anxiety, social withdrawal, breast tenderness, bloating, headaches, and swelling.  Sound familiar?

When these symptoms happen most months but go away within the first few days of bleeding, you probably fit the diagnosis of mild to moderate premenstrual syndrome. However a small percentage of women do experience symptoms that impact their daily lives.  These women experience fatigue or sometimes, insomnia, extreme changes in appetite, severe anxiety, difficulty concentrating, and/or a marked decreased interest in normal home and work activities. This may be a more serious condition called Pre-menstrual Dysphoric Disorder or PMDD.

What causes this?
As with many complicated disorders, researchers don’t really know what causes premenstrual syndromes.  The current consensus among researchers is that PMS and PMDD are probably caused by normal hormone functions in a woman and are not hormonal imbalances. There may be some link between the sex hormones (estrogen and progesterone) and neurotransmitters like serotonin, but the research continues.

How do I know if I have PMS or PMDD?
There is no specific blood test to diagnose PMS or PMDD. Your provider will do a routine exam to check for any abnormalities that may be causing your symptoms, such as a thyroid disorder or depression.

The best thing that you can do to help your provider is to keep a diary of your symptoms. There are several tools available (i.e. Calendar of Premenstrual Experiences ) to help you keep a daily record and to help you and your provider develop a treatment plan.

Is there anything that will help my symptoms?
There are several changes that you can make on your own to try and improve your PMS symptoms, including dietary changes and vitamin supplements. Dietary changes include: decreasing or avoiding caffeine intake, eating a balanced diet, adequate water intake, and decreased high-salt foods. There are some vitamin and mineral supplements that have been researched and are thought to help as well.

Alternative therapies that help many women include relaxation techniques, guided imagery, yoga, aerobic exercise, and massage/reflexology. These activities all help in stress reduction which may improve PMS symptoms. Your provider may also recommend a psychiatric professional in certain cases, which has proven very helpful in teaching coping skills to deal with the cyclic changes that are happening.

There are also several prescription drug options that you and your provider may consider.

You are not ALONE!
It is okay to ask for help with your PMS symptoms. There is no magic pill to fix PMS, but you and your provider can work together to stop PMS from interfering with your life.

By:  Allison Nissen, CNM

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Human papillomavirus (HPV) is the most common newly acquired sexually transmitted infection (STI) in the United States.  Furthermore, the incidence of HPV infection has increased during the past two decades, with approximately 6.2 million newly diagnosed cases annually.  HPV infection has a very high prevalence rate in sexually active adolescent girls and young women. One study showed that 36% of women 25 years of age or younger are HPV-positive. Although HPV can cause genital warts, cervix dysplasia (a precursor to cervical cancer) and cervical cancer, most HPV infections do not cause symptoms.

Transmission typically occurs at the time of sexual intercourse.  Increased risk for contracting HPV has been associated with multiple sex partners, younger age of sexual debut and failure to use condoms.  One study reported that 20% of women became infected with only one lifetime sex partner, suggesting that both partners must be sexually naïve to prevent infection.  The risk of infection increases substantially when initiating a new sexual relationship. The transmission of HPV infection can be blocked by latex condoms if the infected area is physically covered.  However, HPV lesions often occur on external genital sites not covered by a condom, and so the latter does not prevent all infections.

The currently available HPV vaccine is effective in preventing infection with HPV types 16 and 18, the types that cause abnormal Pap smears and are related to cervical dysplasia and 70% of cervical cancer.  The vaccine also prevents infection due to types 6 and 11, the types responsible for 90% of genital warts.  Since other HPV types are not covered by the vaccine you should continue to have regular Pap smears. 

Girls and women aged 9 to 26 years old are candidates for the vaccine.  The vaccine is administered in three separate doses with an initial dose followed by additional doses at 2 months and again at 6 months.

Women with a history of an abnormal Pap smear are still candidates for the vaccine.  Most abnormal Pap smears are due to infection with a single type of HPV.  Since the vaccine covers 4 different types of HPV (types 6, 11, 16, and 18) it will offer protection against the types of HPV not causing the prior abnormal Pap smear.

by:  David Soper, M.D.

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Are you interested in receiving a vaccine that protects against Human Papillomavirus (HPV)?  If so, you may be eligible to participate in a research study being conducted through the MUSC OB/GYN department.

STUDY HIGHLIGHTS

• This is a 42-month research study consisting of 11 visits to the doctor’s office.

The purpose of this study is to:

• Test the safety and effectiveness of the investigational drug 9-valent HPV as compared to GARDASIL®.

• This study includes a pelvic exam, pap smear, physical exam, and vaccination at no cost to you.

Contact Betty Oswald @ (843) 792-0347 for more information.

Compensation is available for qualified individuals.

When should I bring my daughter to the gynecologist?
The American College of Obstetrics and Gynecology recommends having an “initial reproductive health visit” with a gynecologist between the ages of 13 and 15. 

What happens at this visit?
This initial visit is designed to be a preventative care visit.  It serves as an opportunity for young women to establish a relationship with a gynecologist.  It allows the doctor to screen young women for high-risk behaviors and to educate them about age and experience appropriate topics.  This visit is a good time to discuss and initiate HPV vaccination if you haven’t done so already.

Will there be a pelvic exam?
No.  The gynecologist is explicitly discouraged from doing a routine screening pelvic exam at this visit.  A pelvic exam would only be indicated if the medical history revealed certain physical complaints or a high-risk sexual history.

When should a woman have a pelvic exam?
A woman should have her first pap smear (cervical cancer screening) at the age of 21 or 3 years after the onset of sexual activity, whichever comes first.  We recommend yearly STD screening for all sexually active women under the age of 25.

by:  Ashlyn Savage, M.D.

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The decision to begin hormone replacement therapy is a key one for many women. Women are bombarded daily with information about the “right” hormones to use. Recently bioidentical hormones have received a significant amount of attention in the media. However there is a lot of confusion and misinformation about bioidentical hormones in the medical community and in the general population.

In simple terms, bioidentical hormones refer to hormones that are identical to the chemical structure of the hormones produced by a women’s body. There are two types of bioidentical hormones available: synthetic and compounded.

Synthetic
Synthetic bioidentical hormones are manufactured by drug companies to very rigorous standards. They have undergone clinical trials and are known to be safe and effective hormone replacements. The most common of these FDA-approved bioidentical hormones are Estrace, Climara, Vivelle, and Prometrium. There are a variety of ways to take these hormones including a skin patch, vaginal creams, vaginal rings, and pills.

Compounded
Compounded bioidentical hormones are only available from a special pharmacy that mixes a hormone recipe. There is a wide variety in the quality and consistency of compounded hormones. While some of the hormones included in a compounded hormone treatment are identical to the synthetic hormones, others are precursors that are converted by the body into a useable form. There is very little information about how the compounded hormones interact with the body and with other drugs. Even though these hormone preparations are considered “natural,” they are still drugs. There can be significant interactions and dangers to taking these preparations without the supervision of a physician.

The Right Dose?
I have women who come to me and ask for a “hormone” test to make sure that they are taking the “right” amount of hormones. Saliva tests and blood tests can measure the amount of estrogen and progesterone in a woman’s body, but they are not useful to make decisions about hormone treatments. Every woman’s body is different and each woman needs a different level of hormones during menopause. There is no number that tells you if you if your hormones are “too low,” “too high,” or “just right.” The best way to judge if you are taking the right hormone dose is to examine your symptoms. If you are not having hot flashes or mood swings and you are feeling more like yourself, then you are taking the right dose of hormones. That dose will be different for every woman.

There is no easy solution to improve the symptoms of menopause. The best treatment comes from an ongoing discussion with your doctor about which treatment works for you. If you want more information about bioidentical hormones or menopause, the North American Menopause Society has an informational website at www.menopause.org.

by:  Margaret Villers, M.D.

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“Why do I need a Pap?  I got a Pap the last time I was here.”

As providers, we often hear this from our patients and are unable to find documentation to support this statement.  There are no results in the chart and no documentation that a Pap smear was obtained.

What we find instead is that the patient had a pelvic exam that may have included a gen-probe, a wet-mount, or even simply a bi-manual exam.  No collection of cervical cells was obtained for a Pap smear. 

Often, patients believe that any time they are in the stirrups they had a “Pap smear”.  This can lead to lack of follow up by the patient because they feel “they already had that test” and don’t need to come back to do it again. 

Below you will find some answers to some very common questions to give you an understanding of what is necessary to maintain your reproductive health. 

Why do I need a Pap smear?  What is that for anyway?

During a Pap smear, your provider takes a random sampling of the cells from the surface of your cervix (mouth of your womb) and sends them to be analyzed by the pathologist.  The pathologist is trained to look at these cells and determine if they are changing and possibly becoming “pre-cancerous”.

What makes a Pap smear different from other pelvic exams?

Other things can be evaluated during a pelvic exam such as STDs, vaginal infections, pelvic infections, and structural abnormalities.  None of these exams, however, are looking for pre-cancerous cells like the Pap smear.

So, when do I need to get a Pap smear?

This depends on a few things.  According to the American Cancer Society (ACS), if you are 18 years or older, you need to have a pap every year.  However, if you are under 18 years of age but have begun to have sex, you need to have a Pap smear within three years of starting sexual activity.

My friend said her doctor told her she doesn’t need to have a Pap every year so why do I?

The ACS has determined it is appropriate to screen a woman less frequently depending upon her previous Pap smear results and other risk factors. Your doctor will tell you when it is safe to start having the Pap smear less frequently.

I can’t afford to get a Pap smear.  Besides, I don’t want anyone touching me down there but my partner.

It would cost more not to get the test and end up with cervical cancer.  No woman enjoys having a Pap smear and pelvic exam.  However, statistics show us that 60-80% of American women with newly diagnosed invasive cervical cancer had not had a Pap smear in the past 5 years or greater.  That seems like high odds to play against just to avoid having to be “touched down there”.

Early detection of pre-cancerous cervical cells through Pap smears greatly improves your chances of successful treatment and gives your healthcare provider a fighting chance in preventing you from ever getting cervical cancer. 

We, as healthcare providers, urge you to take advantage of this small inconvenience to prevent a devastating diagnosis of cancer.

Thankfully, women have this test available to help prevent a horrible disease. 

by:  Julie Colna, R.N.

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Urinary tract infections are one the most common reasons for doctor visits.  The urinary tract consists of the urethra, bladder, and kidneys.  UTI’s are more common in women, because the urethra is short and close to the vagina and rectum.  During her lifetime, a woman has a 6/10 risk of developing at least one urinary tract infection.  Given that UTI’s are so common, it is important to know the signs and symptoms, associated risk factors, and prevention and treatment measures.   
 
The most common symptoms of a bladder infection include pain during urination and increased frequency.  Less often, you may experience increased urge to urinate but make less urine, bad smelling urine, abdominal pain, and bloody urine.  If neglected, bladder infections can spread to the kidneys, which is a more serious infection.  Signs of kidney infection include back pain, fever, chills, and nausea.  These infections need immediate attention, especially if you are pregnant. 

Urinary tract infections should be treated with antibiotics.  Over the counter medications, such as pyridium, are for pain relief only and do not treat the infection.  If you are experiencing symptoms of a urinary tract infection, call your physician’s office.  Because 90% of bladder infections are caused by E. coli, your physician may call in an antibiotic prescription without a visit.  However, to determine the bacteria causing the infection and it’s susceptibility to antibiotics, a urine specimen must be sent to a lab.  Bacteria can become resistant to antibiotics, so it is important to call your physician if the symptoms are not resolving.

Treatment is half the battle, but understanding your risks for infection is key to avoiding UTI’s.  Factors associated with bladder infections are frequent sexual activity, diaphragm and spermicide use, incomplete bladder emptying, and poor hygiene.  Some medical conditions associated with bladder infections include pregnancy, diabetes, sickle cell trait, and kidney stones.  Postmenopausal women may experience more frequent UTI’s due to low estrogen levels.

In order to prevent a urinary tract infection, consider the following tips:

- Drink at least eight 8oz glasses of water a day
- Drink cranberry juice when you suspect a UTI to increase the acidity of your urine
- Go to the bathroom frequently and don’t hold your urine for long periods
- Urinate before and after sex
- Wipe from front to back

by:  Gweneth Lazenby, M.D.

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December 1st is World AIDS Day.  AIDS or Acquired Immunodeficiency Syndrome is caused by Human Immunodeficiency Virus (HIV). HIV affects 1.1 million Americans, one quarter of whom are women. The majority of women acquire HIV through having sex with infected male partners.  Other routes of HIV transmission include: IV drug use, childbirth, breastfeeding, and blood transfusion.  Because most women are infected with HIV during their reproductive years, it is important to consider the effects of HIV on pregnancy and childbirth.

All women should take prenatal vitamins and be up to date on vaccinations before becoming pregnant. Prior to pregnancy, HIV positive women should have good viral control in order to prevent transmission to their baby.  If you are taking antiretrovirals it is imperative to discuss this with your doctor prior to becoming pregnant, because some medications should be avoided. If your partner is HIV negative, there are methods to avoid exposing him to HIV in order to become pregnant.  Your doctor can direct you to the best options for becoming pregnant and protecting your partner and baby from HIV infection.
 
Before antiretroviral medications were available, pregnant women had a 25% risk of transmitting HIV to their baby.  The majority of babies become infected during pregnancy, half at the time of delivery.  The rest are infected through breastfeeding.  Currently, women taking anti-retroviral medications have a 1-5% risk of having an HIV positive baby.  During pregnancy, the goal is to suppress the virus in the bloodstream to a very low level in order to reduce the rate of transmission to less than 1%.  HIV positive women should not breastfeed.   
 
The Center for Disease Control recommends routine HIV screening in all pregnant women.  Some women are known to have HIV before they become pregnant, but many are diagnosed at their first prenatal visit. Antiretroviral therapy is recommended during every pregnancy in order to prevent transmission to the baby.  Most women can start antiretrovirals by 14 weeks of pregnancy.  For the best prevention of transmission, the latest start of anti-retrovirals is 28 weeks of pregnancy.  All pregnant mothers with HIV should be seen by an Infectious Disease specialist to determine the safest, most effective anti-retrovirals during pregnancy.  HIV positive women require more visits and lab tests during pregnancy in order to ensure a good medication response.

HIV positive women should take antiretrovirals until delivery.  HIV positive women with low viral loads can attempt a vaginal delivery.  Women with higher viral loads should consider a c-section to prevent HIV transmission to their baby.  Typically, the c-section should be done before the start of labor, at approximately 38 weeks of pregnancy.  HIV positive women with prior c-sections are encouraged to consider a repeat c-section.  All HIV positive women should receive IV zidovudine (AZT) at least 3 hours before delivery.  AZT is an anti-retroviral and can decrease the rate of HIV transmission during labor. After delivery, women should resume taking their medications for HIV.  
  
After delivery, it is extremely important to continue with the planned anti-retroviral therapy.  All patients should discuss their postpartum HIV medication regimen with their doctor.  Stopping these medications without your doctor’s input can cause HIV to become resistant and difficult to treat.  All babies born to HIV positive mothers will be advised to take anti-retroviral therapy for approximately six weeks.  Babies need frequent blood tests up to 6 months of age to ensure they are HIV negative. 

Lastly, all women should have a plan for reliable birth control after delivery and experience the freedom to determine when their next child is born.  HIV positive women can use all the available methods of contraception: pills, injections, patches, vaginal rings, and IUDs.  Women who are interested in permanent sterilization should talk to their doctor in advance to ensure legal documentation is completed before delivery.  Condoms are the only method that can prevent HIV transmission during sex; therefore, HIV positive women should use condoms to protect partners from infection.

by:  Gweneth Lazenby, M.D.

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