Annual Exam (Well Woman Exam)
Review of medical, surgical, obstetric and family history; review of systems; review of social history; pelvic exam; pap smear; cervical cultures; urinalysis; vital signs/weight; breast exam; general physical exam; referrals for a mammogram; blood work; radiologic studies as indicated; appropriate counseling and follow-up.
Bartholins Gland Abscess/Cyst Drainage and Treatment
The Bartholin’s glands are a pair of glands at the opening to the vagina. They provide a small amount of lubrication to the introital opening. The glands can get clogged, and as a result, can form cysts or painful abscesses if infected. Cysts can become bothersome when they are large, and can cause pain during intercourse. If the cyst becomes infected, these abscesses often rapidly enlarge and cause severe pain. They typically are treated with antibiotics, warm soaks, and drainage. On occasion, a short catheter is left in place in the gland so that it may continue to drain while the site heals. Cultures can be done to identify specific bacteria in the cyst material. Drainage in the office provides immediate relief with decompression of the cyst/abscess.
Breast and Ovarian Cancer Gene Mutation (BRCA) Testing
Hereditary breast and ovarian cancer syndrome is an inherited condition that causes an increased risk of breast and ovarian cancer. If you have a BRCA gene mutation you could have up to an 87% risk of breast cancer and 44% risk of ovarian cancer in your lifetime. Certain gene mutations are more common among people of Ashkenazi Jewish descent. BRCA mutations also increase the risk of other cancers in both men and women, including up to a 7% risk of male breast cancer. You could have this inherited risk if you or a family member were diagnosed with breast cancer before the age of 50, you or a family member had ovarian cancer at any age, you have a male family member with breast cancer. These are just a few of the known risk factors. Women positive for the gene mutation can monitor their breasts and ovaries more often with MRI and ultrasound, take prophylactic medications or consider risk reduction surgery, such as removal of ovaries and tubes. Genetic counseling is typically recommended in this instance. The BRCA test is done in the office. It is a saliva collection test whose only requirement is that the patient not eat, drink or chew gum for one hour prior to collection. Learn your family history, and make an appointment for counseling with us if you or your family members meet any of the above criteria.
The clinical breast exam (CBE), including mammogram if appropriate is an important part of breast cancer screening. Depending on risk factors, it may also be part of your annual well woman exam.
Breast Self Exam
If you notice any of the following abnormalities during a BSE, we encourage you to come in to see us right away.
- Lump, hard knot or thickening
- Swelling, warmth, redness or darkening
- Change in the size or shape of the breast
- Dimpling or puckering of the skin
- Itchy, scaly sore or rash on the nipple
- Pulling in of your nipple or other parts of the breast
- Nipple discharge that starts suddenly
- New pain in one spot that doesn’t go away
Source: Susan G. Komen for the Cure (website)
Colposcopy is a microscopic examination of the cervix used to diagnose potential abnormalities of the cervix and vagina. An abnormal Pap smear is the most common reason for needing a colposcopic evaluation. During the procedure a stain or chemical agent may be placed on the cervix or vagina to improve visualization. If an abnormal area is seen, a biopsy may be taken. The whole procedure typically takes about 15 minutes. Biopsy results may take 1-2 weeks to return to the office after evaluation in the laboratory. Colposcopy is sometimes associated with mild cramping and minimal bleeding.
Implanon is a type of implantable birth control for women. It is a flexible plastic rod the size of a matchstick that is put under the skin of your arm. It contains a hormone called etonogestrel. It is effective for three years. It does not contain estrogen. It prevents pregnancy in several ways, the most important being that is stops ovulation, so that your ovary does not make an egg. Failure rate is less than 1%. The rod is inserted with a local anesthetic under the skin on the underside of your arm, in the office. It is important to ensure that you are not pregnant at the time of the insertion and this may require a pregnancy test. Fertility returns quickly after removal. The most common side effect is irregular menstrual bleeding.
Cultures and Tests for Vaginal Infections
When a patient presents with symptoms to include itching, burning, odor and discharge, they are evaluated for vaginal infections. These tests can include swabs of the discharge for inspection under a microscope, cultures that are sent to the lab for growth and identification, or specialized tests for yeast, bacteria and trichomonas. Treatment is based on these results, physical findings and history.
Cultures for Sexually Transmitted Diseases
There are specialized cultures that can be done when a sexually transmitted disease is suspected, such as Herpes, Gonorrhea and Chlamydia. These are obtained during a pelvic exam. Symptoms include burning, discharge, pain with urination, blisters and pelvic discomfort. Treatment is based on the physical findings, history and cultures.
Lupron is a hormonal agent that significantly reduces estrogen levels. The medication is a hormonal messenger that decreases the ovarian production of estrogen dramatically. Lupron is prescribed for women with endometriosis, severe menstrual bleeding or fibroids. Side effects that have been associated with the use of Lupron frequently include hot flashes and night sweats. Treatment with Lupron is limited to six months overall and is given as either a monthly shot or as a 3 month dose. It is important to note that it is not a contraceptive, so a non-hormonal method of contraception should be used during treatment if indicated. Lupron needs to be pre-certified through your insurance company. We will help you with that process.
Injectable progestins like Depo-Provera inhibit ovulation and change the cervical mucus to help prevent sperm from reaching the egg. It provides protection for 12 weeks, and must be given by a health professional in the office. It has a failure rate of approximately 1%. There are some concerns regarding long-term use of this medication and the loss of bone, and development of osteoporosis. Please speak to your health professional about which method of birth control is best for you.
Diaphragm Fitting and Education
Diaphragm is a flexible rubber disk with a rigid rim that is designed to cover the cervix during and after intercourse so that sperm cannot reach the uterus. Spermicidal jelly or cream must be placed inside the diaphragm for it to be effective. It must be fitted by a health professional, and refitted if you lose or gain more than 15 pounds. A diaphragm used with spermicide has a failure rate between 6-18%.
Fecal Occult Blood Testing
Colorectal cancer is the second leading cause of cancer-related deaths in the U.S., largely due to the low rates of early screening in patients. As many as 60% of deaths from colorectal cancer could be prevented if everyone age 50 and older were screened regularly. The office uses an immunoassay stool test that does not require any dietary restrictions prior to testing. One immunoassay test is as accurate as three of the older guaic-based tests. The recommended testing for colorectal cancer includes a colonoscopy beginning at age 50 with a repeat in 10 years if normal. Yearly fecal occult blood testing is recommended as well by the American College of Gastroenterology.
Genital human papillomavirus (HPV) is the most common sexually transmitted virus in the United States. There are many strains of the virus. About 20 million people in the U.S. are infected. Most HPV infections don’t cause problems and go away on their own. But HPV is important because it can cause cervical cancer in women. The HPV Vaccine, Gardasil, protects against 4 strains of the HPV virus. The strains covered by the vaccine account for 90% of the strains that cause warts, and 70% of the strains that cause pre-cancer and cancer. The vaccine consists of three injections given over six months. It is recommended to be given between the ages of 9 and 26, preferably prior to exposure to the virus with sexual activity. If given prior to sexual activity, the vaccine can prevent almost 100% of disease caused by these 4 types of HPV targeted by the vaccine. Protection provided by the HPV vaccine is expected to be long-lasting but vaccinated women still need cervical cancer screening because the vaccine does not protect against all HPV types that cause cervical cancer. The HPV vaccine may be given at the same time as other vaccines.
All hysterectomies include removal of the uterus, but the type of procedure used often depends on the condition being treated. In a partial or supracervical hysterectomy, the upper portion of the uterus is removed and the cervix is left intact. A complete or total hysterectomy involves the removal of both the uterus and the cervix. A hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, cervix, fallopian tubes and ovaries. A radical hysterectomy is an extensive surgical procedure, typically done when cancer is involved. The uterus, cervix, ovaries, fallopian tubes, upper vagina, some surrounding tissue and lymph nodes may be removed. In the past a total abdominal hysterectomy, removal of the uterus through a large abdominal incision, was the only type of hysterectomy offered to women. There are now improved surgical devices and innovative techniques that allow for less invasive procedures that can remove the uterus but can sometimes allow you to keep your cervix, ovaries and fallopian tubes. Hospital stays and recovery times have also been reduced.
Total Abdominal Hysterectomy (TAH)
This open or traditional approach to hysterectomy involves the removal of the uterus and cervix (with or without the ovaries and tubes) through a large abdominal incision. TAH may be recommended if you have very large fibroids, significant scarring, endometriosis or cancer.
Total Vaginal Hysterectomy (TVH)
This is a procedure that removes the uterus and cervix through an incision deep inside the vagina. A vaginal hysterectomy may result in less post-operative discomfort than you would feel after a total abdominal hysterectomy. Ovaries and tubes can be removed during this approach as well.
Laproscopically Assisted Vaginal Hysterectomy (LAVH)
This technique uses a laparoscope inserted through an incision in the navel. The laparoscope allows the surgeon to inspect the abdomen and pelvis, and do a portion of the surgery with laparoscopic instruments as needed. The uterus and cervix are removed through an incision in the vagina. Hospital stay, cost and recovery are similar to that of a TVH.
Laproscopically Assisted Supracervical Hysterectomy (LASH)
This type of hysterectomy uses the laparoscope to carefully separate the uterus from the cervix and remove it through the small incisions in the abdomen. The cervix is left in place. This type of hysterectomy causes less stress to the body than the traditional “open” hysterectomy, resulting in less pain, minimal scarring and a shorter recovery time. Some research suggests that retaining the cervix may help to reduce the risk of pelvic floor prolapse, urinary incontinence and other complications sometimes associated with total hysterectomies.
Hysteroscopy and Uterine Evaluation
A hysteroscope is a small lighted telescope used for visual examination of the cervix and uterus to help diagnose and treat abnormalities including abnormal bleeding. The procedure may be done in the office. A local anesthetic is used. The hysteroscope is passed through the cervix and uterus after cleansing the cervix, measuring the length of the uterus, and dilating the cervix if necessary. Typically carbon dioxide gas is used to distend the cavity so that the internal anatomy can be seen using a camera. The image can be seen on a monitor. A biopsy is typically done after the cavity is visualized. Following the procedure there may be some slight bleeding and cramping. You will be instructed as to which medications to take prior to the procedure. The majority of patients are able to drive themselves home. Discharge instructions and precautions will be given prior to leaving the office
IUD Placement and Removal
IUDs are small plastic, flexible devices that are inserted into the uterus through the cervix. It is felt that the IUD alters the tubal and uterine fluids, inhibiting the transport of sperm through the cervix and uterus. The failure rate is less than 1%. This procedure is done in the office, utilizing a local anesthetic injection when indicated. It is recommended that the patient take a non-steroidal anti-inflammatory or Tylenol prior to the insertion, to minimize transient cramping. There are two IUDs available in the United States, Mirena and Paragard Copper T. The IUD needs to be pre-certified through your insurance. They are best placed within 5 days of the start of your menses to ensure that you are not pregnant at the time of insertion. IUDs are typically easy to remove in the office for either pregnancy planning or replacement. The Mirena is viable for 5 years, and the Paragard for 10. Please discuss which IUD is best for you with your healthcare provider.
Once you are evaluated for heavy bleeding concerns, you may be offered a uterine ablation as a management option to treat your symptoms. An endometrial ablation reduces or stops heavy bleeding by scarring most, if not all of the lining of the uterus. The lining of the uterus, the endometrium, builds up and sheds each month, giving you your menstrual cycle. Benefits of endometrial ablation include decreased bleeding, less cramping, and less anemia. For more information please contact the office or visit the website: www.PelvicHealthSolutions.com
Essure is a proven permanent birth control procedure that works with your body to create a natural barrier against pregnancy. This gentle, non-surgical procedure can be performed in minutes. Essure blocks the egg and sperm from meeting, so conception never occurs. Essure is 99.74% effective with no pregnancies in five years of clinical trials. The physician places soft, flexible inserts into the fallopian tubes. No incision is needed because these inserts are delivered through the vagina and cervix. Over the next three months, a natural barrier forms around the inserts. At the end of the three months, a special radiology exam is done to verify that the tubes are, in fact, completely blocked. For more information, please call the office, or visit the company’s website at www.essure.com
A Pap test is used to detect abnormal changes in the cells of your cervix that could mean you have cervical cancer or are at increased risk of developing cervical cancer. Cervical cancer begins in the cells that form the lining of the cervix. It can be prevented if precancerous cells are caught by the Pap smear. A Pap test is a screening test, not a diagnostic one which means that if abnormal cells are found, additional exams, such as a colposcopy, may be recommended to further evaluate the cervix. In addition to cancer and precancerous cells, a Pap test can detect changes in cervical cells that may be caused by infection , irritation and hormonal changes. Your healthcare professional will discuss with you how often you need a Pap smear.
A pelvic exam is usually part of the Well Woman exam and often done at the same time as a Pap test (Pap smear) to find possible signs of a variety of disorders, such as ovarian cysts, sexually transmitted infections, uterine fibroids or early-stage cancer.
A pelvic exam may be done if you’re experiencing gynecologic symptoms, such as pelvic pain, unusual vaginal bleeding, skin changes, abnormal vaginal discharge or urinary problems. A pelvic exam can help diagnose possible causes of these symptoms and determine if other diagnostic testing or treatment is needed.
Pessary Fittings and Management
Relaxation or prolapse of pelvic organs such as the uterus and bladder can cause pelvic pressure, bleeding and urinary dysfunction. If someone is not a good candidate for surgery due to personal or medical reasons, a pessary may be used. It is a plastic or rubber device that comes in different shapes (ring, donut or cube) and sizes that may be inserted into the vagina in order to support or hold up the pelvic structures. Typically some type of cream is used to lubricate the pessary. It must be removed and cleaned periodically, typically by the health professional every three months if there are no problems or concerns. Complications are rare.
Skin Biopsies and Removal of Abnormal Lesions
If abnormal skin is noted, or a raised lesion is identified, it may be removed in the office. A biopsy is sometimes necessary in order to make a diagnosis. Skin tags, inclusion cysts, and warty lesions may be removed as indicated. The procedure is typically performed after sterilizing the area with an iodine solution, using local anesthetic and removing a small piece of tissue. Recommended care after the procedure includes keeping the area clean and dry, washing with soap and water. Healing typically occurs over 1 week.
Urinary Tract Infection Testing
Symptoms of a bladder infection or cystitis include pressure, burning with urination, frequent urination, bloody or foul-smelling urine, back pain and low-grade fever. Upon presentation to the office, we will ask you for a clean catch urine specimen. The urine will be tested in the office for bacteria, white cells, and blood. If necessary, the sample will be sent to the lab for culture, which will take 3-7 days. In the meantime, if indicated, you will be given medication to treat your infection and symptoms. The culture determines which bacteria is involved, and which antibiotic is best.
This is a diagnostic procedure that involves removal of tissue from the endometrium, the inner lining of the uterus. It is done to rule out endometrial cancer or hyperplasia when someone presents with abnormal bleeding. It is usually performed in the doctor’s office. A speculum is placed in order to visualize the cervix, the cervix is cleansed and stabilized with an instrument if necessary. A thin, pliable straw-like instrument called a pipelle is inserted into the uterus in order to sample the endometrium. We recommend that patients take a non-steroidal anti-inflammatory or Tylenol several hours prior to the biopsy for comfort. There may be transient cramping during the procedure that disappears quickly. Results are typically available from the lab in 1-2 weeks.
Sexually Transmitted Disease Counseling, Testing, and Treatment
Change Contraceptive Implant to Contraceptive Implant and Management
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