• Do You Accept My Insurance?

    We accept most major regional insurance carriers; this includes, but is not necessarily limited to:

    BLUE CROSS OF IDAHO – Traditional, HMO, PPO, Health Ventures True Blue(Medicare), Federal Employees Program

    REGENCE BLUE SHIELD OF IDAHO – Traditional, PPO

    MEDICAID OF IDAHO

    IDAHO PHYSICIANS NETWORK – Primary Health HMO, Primary Health HMO, CIGNA, United Healthcare, AETNA, Albertson’s Employee H&W Trust, Great West Healthcare, Auxiant, Smith Administrators, Mega Life & Health, AmeriBen IEC, DBSI Realty , StarMark

    FIRST HEALTH – Mail Handlers

    ST. LUKES EMPLOYEE BENEFITS – Riverside Benefits, Altius Health, Basix Health, Regence PPO, Select Medical, Power Engineers

    We also accept Medicare, GEHA, and Tricare/Triwest Patients. If you have any questions regarding coverage, please do not hesitate to contact our office – we can often make arrangements for you, even if your carrier is not listed above.

  • I like the idea of complete women's health care. What services can you provide?

    We can provide all of the traditional services you would expect at an OB/GYN office in addition to primary care. We will gladly work with you to assist in the pursuit of pregnancy and will excitedly manage normal as well as high-risk pregnancies. We can educate you about and treat any gynecological conditions from painful periods to abnormal pap smears to bioidentical hormone therapy to decreased sex drive to sexually transmitted infections. If surgery proves necessary, we will review all minimally invasive and definitive surgical alternatives to fit your needs.

    We provide primary care services to roughly 70% of our patients. We can ensure that you are up-to-date on all age-appropriate screening tests (cholesterol, mammograms, colonoscopy, bone density). Though there are some conditions that will be addressed more thoroughly by a specialist, most routine health conditions can be managed on-site. This includes (but is not limited to) colds/flu, sinusitis, skin conditions, hypertension, depression, anxiety, elevated cholesterol, weight loss, gastrointestinal disorders, and insomnia. For most women up to age 65, we can address virtually all of your health-care needs.

  • What primary care screening tests do you recommend for women?

    For baseline gynecologic care, annual breast and pelvic exams and annual pap smears depending upon age. We perform annual comprehensive skin survey (for melanoma, etc.) and blood pressure screens as well.

    At age 30, I recommend a baseline blood cholesterol test with follow-up testing every 1-5 years depending upon results. Mammography starts at age 40 every 1-2 years to age 50 and then annually thereafter. Colon cancer screening begins at age 50 with repetition depending upon screening method (annually for fecal occult blood testing, every 3-5 years for flexible sigmoidoscopy, and every 8-10 years for colonoscopy). There are many screening strategies for bone density/fracture risk assessment; I usually start at age 55 with repeat testing every 2-4 years.

    Many women in my practice ask about cardiac stress testing and chest X-rays. Currently, these tests are only recommended if a woman has particular symptoms or problems.

  • What services do you provide at your office?

    We provide a broad array of on-site services to maximize your comfort and convenience. Anatomic, growth, and dating obstetrical ultrasounds are performed in the office in addition to gynecological ultrasounds for pelvic pain and abnormal vaginal bleeding. Abnormal pap smears can be managed with colposcopy, LEEP conization, or cryotherapy in our office. We can also biopsy, remove, or freeze a variety of skin lesions involving inflamed skin tags, abnormal moles, warts, molluscum, and seborrheic keratoses.

    For women with bothersome or heavy periods, we can now provide an in-office procedure called Novasure (www.novasure.com) that can lighten or eliminate periods for 90% of women–ask us about it!

    All these services are in addition to standard in-office gynecologic procedures such as endometrial biopsy, IUD insertion, pap smears, STD screening, cervical cancer vaccine (Gardasil) administration, plus vaginal and vulvar biopsies.

  • When should my daughter start seeing a women's health care provider?

    Great question! The answer depends somewhat on whether your daughter is having any troubles with painful or irregular periods or considering sexual activity with a partner. In the absence of problems, I usually recommend a first visit between the ages of 14-16. To reassure your daughter, this visit usually does not involve a pelvic or speculum exam (pap smear recommendations have changed within the last 10 years). We strive to create a comfortable environment where your daughter’s questions are welcomed. Many of our younger patients continue to use us as a resource via phone even if they head out-of-state to college.

    It is not uncommon for younger women to feel more comfortable discussing sensitive issues with a female health care provider. Our nurse practitioner, Mary Stone-Arave, provides outstanding, comforting care for women of all ages.

    For information about the cervical cancer vaccine (Gardasil) for younger women, please see a question-and-answer piece elsewhere on this site or at www.gardasil.com


    There are a few circumstances that would mandate a gynecology visit for young teenagers:

    1. if she was having very painful or heavy periods (changing pads more than once an hour during heavy flow days);
    2. if she had not begun menstruating by age 16;
    3. if she were sexually active.

    Pap smear guidelines have recently changed–the American College of Obstetricians and Gynecologists recommends pap smear screening by age 21 or within 3 years of initiation of sexual intercourse.

    Despite these guidelines, I feel it is important that young women establish care with a gynecologist or women’s health care provider–sometime between the ages of 14-17. Even with great parenting and open communication, teenagers will not always be honest about sexual activity. Having a connection to a women’s health care office provides an additional resource for questions about anatomy, reassurance on body changes and periods, good health habits, and pregnancy prevention. Some of these issues are not immediately relevant to many of the young women I see in clinic; I always emphasize that patients can call me when questions arise or circumstances change. Young women will make better decisions if they have the opportunity to be informed about their health.

  • Can I exercise while I’m pregnant?

    Yes! Exercise has multiple benefits throughout pregnancy including controlling weight gain, flexibility, endurance during labor, and improving overall sense of well-being. Though you will often see recommendations not to exceed heart rate targets in pregnancy magazines, I don’t believe there is compelling evidence on this. It is important to hydrate well and to listen to your body. If you become light-headed or dizzy, increasingly short of breath, or experience pain, you should ease your activity level. You should also not attempt to significantly exceed your normal exercise regimen (i.e., if you weren’t training for marathons before, don’t start during your pregnancy!).

    You will likely need to modify your activity as your pregnancy progresses. Swimming, water aerobics, and yoga are great choices during the third trimester.

  • When do I get to find out the sex of my baby?

    You will get an ultrasound, usually in our office, around 18-20 weeks and to a 95 percent certainty, we should be able to determine gender. Though there are commercial ultrasound services that may be able to provide this information earlier in pregnancy, our priority is not simply to find out the sex of your baby, but also to see all of the baby’s structures including heart, lungs, and limbs. Many of these structures are not optimally seen until 18-20 weeks.

  • Is it safe to drink coffee in pregnancy?

    Great question! In Seattle, I used to have pregnant patients complain to me that they got dirty looks from baristas every time they tried to order a latte! Part of the knock on caffeine is due to older studies that were poorly designed. We know that smoking is more common in coffee drinkers than in non-drinkers, and smoking is associated with smaller babies. In studies that separated out the smokers and followed women’s caffeine intake throughout their pregnancies, there were no associations between caffeine and reduced birth weight or premature delivery.

    The other issue that’s received recent media attention is whether caffeine intake during early pregnancy leads to miscarriages. These studies are limited by another phenomenon that occurs in pregnancy–first trimester nausea. It has long been known that there is a modestly lower rate of miscarriage in women who experience nausea in early pregnancy. Coffee is a common aversion among women with morning sickness. One study from Sweden claims to show that among non-smoking women who drank more coffee, there was a higher miscarriage rate. However, the women who miscarried also had much less nausea, and less aversion to all foods, including coffee. It’s probably not the caffeine that “caused” the miscarriages; it’s the fact that women at higher risk for miscarriage (without nausea) tend to be able to keep their coffee consumption up.

    There will likely never be the perfect study–no one will ever force a large group of pregnant women, nauseated or not, to drink coffee. Avoiding any unnecessary drug exposures (including caffeine), especially in the first trimester is a reasonable principle, but I do not believe there is any compelling evidence to suggest that one to two cups of coffee a day are harmful in pregnancy.

  • I’m thinking about trying to get pregnant in the next few months. Do I need to do anything to get ready for pregnancy?

    The basic goals of pre-pregnancy planning are to maximize your pregnancy chances and minimize potential health hazards to the fetus once you’ve become pregnant. Excessive alcohol use (more than 1-2 drinks per day) and cigarette smoking can affect both sperm and eggs–minimizing use of these for both of you is important. If either you or your partner is on any prescription medications, you may want to check with your physician to see whether they affect fertility or could cause birth defects. Some health conditions (epilepsy, diabetes, high blood pressure) may require additional interventions before you become pregnant–again, check with your health care provider. Illicit substance use (ecstasy, methamphetamines, cocaine, marijuana) should be stopped.

    You will want to start on prenatal vitamins (with at least 0.4 mg of folic acid) at least 6-8 weeks in advance of pregnancy; this helps to reduce the risk of spina bifida/neural tube defects. This is also a good time to try to avoid any x-rays if possible. There is an organism called toxoplasmosis carried in cat feces. It can cause birth defects, so you’ll want your partner to change the litter box if you have one.

    Hot tub/sauna use can affect sperm count, so men should minimize their exposure. Artificial lubricants should not be used during intercourse, as they can reduce fertility rates. The two days prior to ovulation and 1-2 days after are your most fertile days during the menstrual cycle; you’ll want to increase intercourse frequency during that time.

    Obstetricians and many primary care providers can give you more specific information about preparing for pregnancy. They also can help explain how to increase your pregnancy chances with each menstrual cycle through checking your temperature (basal body temperature charting).

  • What is the right amount of weight to gain during my pregnancy?

    I’m not surprised that you’re confused. If you’ve read the pregnancy magazines, you’ve probably seen ten different answers! There is a wide range of normal –not only in terms of total weight gain, but also when this weight gain occurs. Some women gain evenly throughout; some gain predominantly in the first or third trimesters–any of these patterns is normal.

    Typical “recommended” weight gain for term pregnant women is 25 to 35 pounds. In heavier women, less weight gain is needed (10-15 pounds) while underweight women may gain 40 pounds or more. You should know that these recommendations were made by a panel of experts and have not been proven or subjected to rigorous study.

    I counsel pregnant women very loosely regarding weight gain. In women with a history of anorexia or bulimia, I spend more time emphasizing normal body changes during pregnancy and ensuring that minimum weight gain targets are reached. Otherwise, I rarely see a patient with inadequate weight gain. For women who are concerned about too much weight gain, I explain the wide range of normal and emphasize that pregnancy is never a time to diet. The best ways to slow weight gain in a healthy manner during pregnancy are to increase activity (walking, water aerobics, etc.), eat several small (instead of regular-sized) meals a day, and substitute lower calorie snacks for higher ones (fruit for potato chips; fat-free fudgesicles for ice cream). Breast feeding can also help with post-delivery weight loss.

  • Where do you deliver?

    Currently, I deliver babies exclusively at St. Luke’s Regional Medical Center in downtown Boise.

  • What about pregnancy classes?

    St. Luke’s Regional Medical Center offers a wide array of prenatal classes including breastfeeding, baby care basics, and labor and delivery. You can access these via the web at St. Luke’s Classes, Special Events, and Support Groups page.

    There are also many private classes in Lamaze, Bradley, and hypnobirthing, as well as doula services in the Treasure Valley.

  • I am interested in obstetrical/pregnancy care. When do I come in and how does it all work?

    Great question! First of all, if you are not yet pregnant, we recommend coming in to review healthy habits while pursuing, and once you become, pregnant. We can also review some simple techniques (such as basal body temperature charting) that can increase your chances of becoming pregnant with each cycle.

    We will usually schedule you for your first OB appointment between 6-9 weeks after the first day of your last menstrual period. At that visit, we will review your health history and identify any issues that will require special attention during your pregnancy. We will often obtain an early ultrasound to confirm your due date. At around 20-22 weeks, we will perform an anatomy ultrasound where we can see all of the organs of your growing infant and confirm gender if you wish. The frequency of your visits will gradually increase with weekly visits beginning at 36-37 weeks.

    I place a very high premium on answering all your questions and addressing any concerns that you have. You will see me for every pregnancy visit and it is extremely likely that I will be there for your delivery as I’ve delivered more than 98% of my patients over the last 5 years.

  • I had terrible nausea during the early part of my last pregnancy. Why does that happen and is there anything I can do to make it better?

    Nausea and vomiting complicate over 70 percent of pregnancies–a finding common enough to sometimes serve as the first marker of pregnancy. Though often called “morning sickness”, it can occur at any time during the day or night. We still have no good explanation for why this occurs, though pregnancies complicated by nausea and vomiting do seem to have a decreased miscarriage rate. For many women, particular foods or odors serve as triggers – and these can differ among pregnancies; for others, episodes occur without warning.

    Typical duration is from 7-12 weeks of gestation. Though it can be unpleasant and sometimes miserable, most women are able to keep enough food and liquids down to avoid medications or hospitalization. Rarely, the condition is so severe that it requires intravenous nutrition.

    What can be done? First, avoid any foods or odors that worsen the nausea. Greasy or spicy foods are common triggers. Second, use frequent small meals to keep some food on the stomach at all times. Having starchy foods like crackers or bread at the bedside to eat before arising in the morning can be helpful. I have had a few patients report that sniffing lemons or ginger, or eating salty potato chips helped with their symptoms.

    Although avoiding any medications during the first trimester (when fetal organs are being formed) would be ideal, sometimes nausea in pregnancy requires additional therapy-and this should always be directed by a health care provider. Medications proven effective in randomized studies with modest risk include Vitamin B6 (25 mg three times a day), and doxylamine, the active ingredient in Unasom. Though there is not as much supporting evidence, ginger (250 mg capsules four times a day) also appears to be effective. Directed acupressure has shown promise in small studies. There are also additional prescription medications that can be used.

    Let us know if you are experiencing nausea that is troublesome, as there are many treatment options.

  • My husband and I have been trying to get pregnant for six months without success. Should I be concerned?

    Traditionally, infertility has been defined as one year of unprotected intercourse without conception; this affects 10-15 percent of couples during their reproductive years. In normal couples without infertility issues, there is only a 30% chance of becoming pregnant with each ovulatory cycle. By one year, 85% of couples will attain pregnancy.

    When should a couple seek medical intervention? If a woman is in her mid-30s or younger, has regular menstrual cycles, and her partner is healthy – I would usually allow one year before testing extensively. Reasonable early evaluations would be a semen analysis (35% of infertility involves a male factor) and confirmation of ovulation (release of an egg) with each cycle. The latter can be done with over-the-counter urine tests, or by following a woman’s body temperature throughout the cycle (called basal body temperature [BBT] charting). Medications can be used to help a woman ovulate regularly, and depending upon the male factor – artificial insemination or other technologies can be used.

    We know that female fertility decreases over time; in general, the older a woman is beyond age 35, the earlier I would rule out causes for infertility. This would include a semen analysis and BBT charting as well as a pelvic ultrasound. In some cases, we might consider a test to confirm that the fallopian tubes are open (called a hysterosalpingogram or HSG), and possibly laparoscopy (camera in the abdomen) to visually assess the ovaries and fallopian tubes.

    Some primary care providers and nearly all OB/GYNs can provide more information about infertility and interventions that are appropriate for a couple’s particular circumstances. There are also infertility specialists (reproductive endocrinologists) that can help with more complicated situations or in vitro fertilization (IVF).

  • I often get painful headaches around my period. Is this normal? What can I do about them?

    Your complaint is a common one. About 10-20 percent of all women experience headaches of varying severity that occur around their menstrual periods. Menstrual migraines are defined as headaches that only occur any time from 2-3 days preceding to 2 days into a period. Menstrual-associated migraines can occur during the above times, but also at other times during the month. It is believed that menstrual headaches are associated with a relative decrease in circulating estrogen. This may cause blood vessels in the brain to be more susceptible to other biochemicals involved in producing migraines.

    What can be done to help? If you are troubled by headaches throughout the month, you may want to talk with your primary care provider or perhaps a neurologist about potential migraine triggers (certain foods, lack of sleep, stress) and medications to help prevent headaches and/or treat them when they occur. If your major problem is the menstrual headaches, there are several approaches. Though these measures may not prevent menstrual headaches, it is always helpful to get adequate sleep, exercise regularly – and avoid certain food triggers such as red wine, cured meats and hot dogs, and aged cheeses. Some small studies have reported success with cyclic (taken continuously from 2-3 days before a period to 3 days into a period) magnesium–360 mg daily or cyclic ibuprofen/Motrin–400-600 mg every 6 hours.

    Other prescription treatment options include traditional migraine medications such as Imitrex/sumatriptan–cyclic dosing of this showed an 80 percent reduction in headache symptoms in one study. Birth control pills can also be used to avoid the drop in circulating estrogen that occurs with a period if used continuously (i.e., the placebo pills are skipped each month and only hormone containing pills are used). I have had very few patients who have not been able to significantly reduce their menstrual headaches with one or a combination of the above methods, but it is critical to tailor therapy to an individual patient. Not all therapies work for everyone.

    One caveat–there does appear to be a very small increase in stroke risk in women who have migraines with aura (prodromal changes in vision such as “dancing lights” or partial visual loss that precede headaches). This risk can be increased with cigarette smoking, a family history of stroke or blood clots, high blood pressure, and slightly with estrogen-containing birth control pills. Though they are safe for most women, be sure to work with a health care provider when starting birth control pills for menstrual migraines.

  • I always have painful periods. What can I do to make them better? What is Endometriosis?

    You are not alone–around 10 percent of women have menstrual symptoms that are severe enough to miss school or work or otherwise incapacitate them. 75% of women report having mild-to-moderate emotional and physical symptoms with their periods at some time during their lives.

    Interventions with limited studies to support their use include restriction of dietary salt, refined sugars, caffeine, and cardiovascular exercise. Better evidence exists for daily vitamin B6 (50-100 mg a day) or calcium carbonate (1200 mg a day).

    Most women have tried using non-steroidal anti-inflammatory drugs (NSAIDS) such as Motrin or Advil. For greatest efficacy, you should start these medications around the clock one or two days before menses begin for 2-3 days into your period. If pain symptoms still persist, birth control pills usually significantly improve painful menses within 2-3 cycles. Occasionally symptoms can be severe enough that I’ll recommend continuous pill therapy–this involves using only active (hormone-containing) pills from a pack each day which results in the abolition of periods altogether for most women.

    Diuretics (water pills) can be helpful for women who are bothered mostly by bloating or fluid retention symptoms. A subset of women have severe moodiness and irritability from mid-cycle to onset of menses, also known as “premenstrual dysphoric disorder” (PMDD). Antidepressants like Prozac (also marketed as Serafem) are useful for these symptoms.

    When periods are painful enough to require birth control pills (especially continuously), there may be something more serious going on such as endometriosis. Let your health care provider know about aspects of your periods that trouble you.


    Endometriosis is defined by having cells and tissue normally confined to the uterus (the endometrium) elsewhere in the body, usually within the pelvis and abdomen. During a period, the endometrium is shed each month as menstrual flow. Unfortunately, when this tissue is elsewhere, it does not get shed – but can cause inflammation and scarring.

    How does this tissue get outside of the uterus?

    A few theories exist; one is “retrograde menstruation”–endometrium that backs up the fallopian tubes during a period. Another is a change from the normal cells that line the abdominal cavity to endometrial cells–a process called metaplasia. In any case, when looked at under the microscope, endometriosis appears just like normal endometrial tissue.

    What symptoms do women with endometriosis usually have?

    For many, it means very painful menstrual periods refractory to over-the-counter medications. Endometriosis responds to hormones much like normal endometrium, and this can cause cramping and pain. Sometimes this results in chronic inflammation leading to pelvic pain outside of periods and painful intercourse. Occasionally, endometriosis is not painful, but still causes scarring of the ovaries and fallopian tubes and infertility.

    Health providers often presumptively diagnose endometriosis on the basis of symptoms and physical exam. Laparoscopy (introducing a camera within the abdomen) with biopsy confirms the diagnosis. Since endometriosis responds to hormones, treatment is often directed there. Birth control pills, Depo-Provera, and Depo-Lupron (a medication that shuts off ovarian hormone production) are all commonly used. Endometriosis can also be ablated directly using the laparoscope and cautery or laser. Occasionally it is severe enough that hysterectomy is required.

    Who should talk to their health care provider about endometriosis?

    Women with:

    1. painful periods that are unresponsive to routine medications (like Pamprin, Midol, Advil, Motrin);
    2. Chronic pelvic pain;
    3. or painful sexual intercourse. Don’t accept these symptoms as normal! Even if endometriosis is not the cause, usually these symptoms can be improved with evaluation and treatment.

  • I have a hard time remembering to take my birth control pill. Are there any new contraceptives out these days?

    There are three hormonal contraceptives that allow less frequent dosing and don’t require pill taking. All are combinations of estrogen and progesterone, and thus they share some side effects with oral contraceptives; ones that often improve with time are irregular vaginal bleeding/spotting, nausea, breast tenderness, and headaches. Failure rates for each are 1-2 percent per year, similar to the pill. They also slightly increase the chance of developing blood clots in the legs and lungs, a risk that is multiplied when combined with cigarette smoking.

    The Nuvaring is a flexible contraceptive ring about the size of a silver dollar. It is inserted into the vagina during a menstrual period, left in place for three weeks, and then removed. Benefits include not needing an office visit and light periods. Though easier to place than the diaphragm, the Nuvaring does require a level of body comfort–not everyone is okay with insertion of a vaginal contraceptive. However, it has the lowest dose of estrogen of any combination contraceptive and very few women have side effects.

    Ortho Evra is a contraceptive patch that is applied to the skin (usually the upper buttock, abdomen, or upper back) on the first day of the menstrual period, and a new patch is applied every seven days for three weeks. The fourth week is a placebo patch, and is usually when bleeding occurs. Side effects include infrequent skin irritation, patch detachment (in 2-6%), and possible increased failure rate in women weighing over 200 pounds.

    Mirena is an intrauterine device (IUD) that can be inserted in a simple office procedure. It lasts for up to five years, and often dramatically decreases menstrual flow. It also has few side effects as the hormone (progesterone) is concentrated within the uterus–very little gets into your blood stream. It is a great method as long as you are aggressive in avoiding sexually transmitted diseases like chlamydia and gonorrhea (these infections can become much worse with an IUD in place).

    One of the newest birth control devices is a small matchstick-sized implant called Implanon. It is inserted just underneath the skin in your upper arm in a simple office procedure and lasts for up to three years. Let us know if you are interested in this–we would be happy to discuss it with you!

    Ultimately, your goal should be a contraceptive method that is reliable, has few side effects, is easy to use, and can be quickly reversed if you desire pregnancy in the near future.

  • Can you tell me more about emergency contraception?

    Emergency contraception (EC) is a way of reducing the chance of pregnancy following an episode of unprotected (non-contracepted) intercourse. This can also include condom breakage or spillage.

    There are several regimens that can be used. Recent studies suggest that EC can be used within 5 days (120 hours) of unprotected sex. Preven is an EC regimen containing estrogen and progesterone, 2 pills taken twice–12 hours apart. Plan B contains progesterone only–1 pill taken twice, 12 hours apart. Either of these is effective, though Plan B causes less nausea. After using any EC prescription, you’ll need to check a pregnancy test if your period is more than a week late or if you have symptoms of pregnancy (nausea, breast tenderness, frequent urination).

    At best, EC is only 70 percent effective–it does not replace standard contraception (pills, patches, rings, and Depo-provera are all over 95 percent effective in preventing pregnancy when used properly). Talk to your health care provider about whether you should have an EC prescription. More information is available here.

  • I am a 55 year old woman and recently decided to discontinue hormone replacement therapy, but have been troubled by hot flashes. Are there any alternatives?

    Most other problems associated with estrogen withdrawal (vaginal dryness, osteoporosis, high cholesterol) can be managed just as well with lifestyle changes or medications. Unfortunately, hot flashes lack a perfect therapeutic alternative.

    First, wean gradually off HRT over several weeks, as this may lessen the severity and duration of initial hot flashes. Avoiding caffeine, alcohol, and spicy foods, and keeping temperatures low in your home and work environments may decrease the number of hot flashes. Cardiovascular exercise helps as well. Vitamin E has not proven much better than placebo in small studies, but I sometimes recommend it to women wanting to avoid other medications (1000 IU/day for at least six weeks initially).

    Alternative medications that have proved better than placebo in preventing hot flashes include Effexor and Prozac (antidepressants), Neurontin (traditionally used as a pain medication–promising, but expensive), and Clonidine (a blood pressure med). Topical progesterone cream and another progestin (Megace) are also effective; these are not good choices for women who have discontinued estrogen because of a breast cancer diagnosis.

    I have had patients who have anecdotally reported improvement with black cohosh, wild yam cream, and a variety of herbal and nutritional supplements. To date, none of these has been evaluated in large randomized trials against placebo. Also, these supplements are not closely regulated by the FDA; they may vary considerably in their composition and concentration.

    Finally, if your hot flashes prove refractory to alternative therapies, you may want to reexamine the risks of estrogen with your health care provider. Quality of life is important, and this may outweigh other concerns, especially in the short term.

  • I'm a 32 year old mother of two. For the last year, I've had almost no sex drive. I'm very happy in my marriage, but my husband and I are both very frustrated. Please help!

    Though male sexuality is not terribly complex (for the majority of men, functional genitalia mean functional libido!) many factors play a role in female sexuality – including mood disorders (depression), stress, body image, emotional intimacy, hormones, presence of pain with sexual activity, history of sexual abuse, and certain types of medications. Women may be bothered by loss of libido with differing causes at different ages.

    Because of this complexity, one has to spend time taking a sexual history in order to figure out why the decrease in libido has occurred. Has this always been the case, or is it something new? Any recent changes in medications (birth control, high blood pressure pills, anti-depressants)? Is there any evidence of depression or increased stressors? I often hear about drops in sex drive following childbirth, usually from a combination of sleep deprivation, body image (“I don’t feel sexy!”), and multiple stressors–child/maintaining the household/working outside the home. In older women, hormonal changes may contribute. Estrogen maintains resiliency of the vaginal tissues and helps with lubrication, while testosterone (a male hormone produced by the ovaries in small amounts) stimulates libido. Surgical or natural menopause can thus affect not only sex drive, but sexual function as well.

    If high stress or depression is causing the problem, hormones and other related products are usually unsuccessful–stress reduction (if possible) or anti-depressants can help. If a woman is menopausal, trials of systemic or vaginal estrogen therapy and/or testosterone are reasonable. Though not approved by the FDA for use in women, a number of gynecologists are trying Viagra in select patients–I’ve seen mixed results with this so far. Sensua! (yes, the exclamation point is part of the product name…) is an FDA-approved cream applied to the clitoris. Though marketed as a sexual stimulant for women, it is actually only approved as a lubricant; this may or may not be helpful. Talk to your gynecologist or primary care physician for specific recommendations.

  • What exactly is a pap smear? Why do I have to suffer through one each year?

    I’ve had several patients who have told me that they dread their annual gynecological visit. “Oh, it’s not you, you understand…it’s the whole speculum exam thing!” I thought I should at least try to make a better case for the pap smear.

    Cervical cancer has been a significant killer of young women, and continues to be world-wide. Unfortunately, most women with cervical cancer have no symptoms; the cases of cervical cancer that still occur are usually in women who have not had a pap smear for several years. Over the last 25 years, cervical cancer deaths in the U.S. have dropped, largely believed due to annual screening.

    Nearly all cases of cervical cancer and dysplasia (pre-cancers) are caused by a virus–human papilloma virus, or HPV. Though this virus is sexually transmitted, we still have no good way of identifying carriers, and there is no vaccine or antiviral that can prevent transmission. 75 percent of women may be infected with HPV by age 30. For many women, the virus remains latent–no symptoms or abnormal pap smears. For others, the virus causes cervical cells to proliferate abnormally – and over months to years, dysplasia or outright cancer can develop. The best way to detect these abnormal cells (since women do not have recognizable symptoms) is to sample the cervical cells from time to time. We do this with a small spatula and brush during a speculum exam. “Pap” is short for Papanicolaou, the pathologist who developed the test and “smear” is how the cells are plated out on a slide for examination under the microscope.

    So who should get screened and how frequently? All women, regardless of race or sexual preference, should get an initial pap smear by the age of 21. Frequency of follow-up paps may vary between 1 and 3 years. Abnormal pap smears usually require more frequent follow-up and sometimes cervical biopsies.

    Cervical cancer can be prevented with annual pap smear screening, which is performed by most primary health care providers. It is a hassle, but a very worthwhile one.

  • I'm a 62 year old woman and a friend of mine recently had a heart attack. I smoke and worry about my risks for coronary artery disease. Is there anything I can do?

    There are many ways to reduce your risk of coronary artery disease. One of the most important is to quit cigarette smoking. This alone could reduce your heart attack risk by 30-40%. Talk to your health care provider about smoking cessation–there are several medications that can help you quit.

    Regular exercise can also promote heart health. One study from last fall showed a large risk reduction for women who exercised at least 30-40 minutes five times a week. You can work your way up to this gradually, even by parking further away from destinations and steadily increasing walking distances.

    Your provider can help you with other risk factor reduction. Cholesterol screening is important, and both “good” (HDL–high density lipoprotein) and “bad” (LDL–low density lipoprotein) cholesterol levels are important to know. Depending upon your risk factors, you may need medications to lower your bad cholesterol or raise your good cholesterol to certain targets. Blood pressure also needs to be controlled–you should get this checked regularly and if it runs above 140/90, it should be treated to reduce your cardiovascular risk. Exercise and weight loss can help, but medications may also be required. Some health care providers are also checking an inflammatory marker called C-Reactive Protein (CRP) to better assess heart attack risk; this may or may not be useful in your case.

    Many women ask me if they should get a “stress test” or echocardiogram to evaluate their heart. At present, there is no role for EKGs, stress testing, or echocardiography in women without symptoms. However, you should let your provider know if you have symptoms such as chest pain, increasing shortness of breath with exertion, palpitations, neck, arm, or shoulder pain with exertion, or increasing dizziness or light-headedness.

  • I'm a 48 year old woman who has smoked for 20 years. I've tried to quit several times without success. Is there anything I can do?

    You’ve taken an important first step–knowing that you want to quit smoking. There is nothing you can do that can reduce your risk of heart attack more than getting rid of the cigarettes.

    I counsel patients that there are three main steps to smoking cessation. First, pick a time to quit when your life stresses are low-to-moderate, not high. Second, you’ll need to change a lot of minor personal habits. Though nicotine dependence is the initial struggle, the psychological dependence continues to be a battle weeks and months out from your quit date. You’ll have to avoid restaurants and bars where you used to smoke, drink your morning coffee in a different place (if you are used to smoking with your daily cup of joe), and generally not do the things you associate with smoking. Third, most people require medications to successfully quit. Though nicotine supplements (patches, lozenges, nasal sprays) can help, these have not been shown to be very effective in keeping smokers off cigarettes in the long-term.

    here are now two effective medications that can increase your chances of success. One is called Zyban (also known as Wellbutrin). This can increase your chance of success from 5-10% to 40-50%. You start the medication for ten days prior to your quit date, then usually continue it for 3-4 months. Side effects include dry mouth, jitteriness, and insomnia–most improve with time. A more recently released medication is called Chantix–in limited head-to-head studies with Zyban, it appeared to be slightly more effective.

    Finally, don’t give up! Many ex-smokers had to try several times before they were ultimately successful. Ask your health care provider for more information.

  • I'm a 54 year old woman and my grandmother had ovarian cancer. Am I at risk? Should I be tested?

    Ovarian cancer is a fairly uncommon, but often deadly diagnosis; the lifetime risk for women in the U.S. is around 1 percent. Half the women diagnosed with ovarian cancer will die of their disease. Most (90%) of these cases are sporadic, meaning that they occur without a family history. As a general rule, if a woman has 2 or more first degree relatives with breast or ovarian cancer before age 50, genetic testing should be considered. In your situation with only one second degree relative affected, the increase in risk is likely minimal.


    Why is ovarian cancer mortality so high?

    Unfortunately, women with the disease tend to have few, if any symptoms until the cancer is far advanced. Symptoms that do occur are common in women without cancer–urinary frequency, constipation, pelvic pressure, and/or bloating. The best screening test in low-risk women continues to be an annual pelvic examination. I have had several women ask me about “the ovarian cancer blood test”. This is an ovarian tumor marker known as CA-125 which is not used in routine screening for several reasons: it is elevated only when a cancer is more advanced; many other conditions raise CA-125 including endometriosis, liver disease, and diverticulitis; and there is no proven mortality benefit. Currently, the only role for CA-125 and ultrasound in screening for ovarian cancer is in women with a strongly positive family history or confirmed genetic mutation.

    As for prevention, use of birth control pills and full-term pregnancies appear to significantly decrease the lifetime incidence of ovarian cancer, possibly by reducing the number of ovulation events over time. The risk can also be dramatically lowered by removing the ovaries surgically–an option to consider in higher-risk women after childbearing or at the time of hysterectomy for other reasons.

    Your annual physical should always include a pelvic examination. If you have any questions about your family history or the role of further testing for ovarian cancer, consult your health care provider.

  • I'm a 53 year old woman. My doctor told me to get screened for colon cancer. What about virtual colonoscopy?

    Your doctor is absolutely right. Colon cancer is the 3rd most common malignancy in both men and women. In women without a family history or predisposing condition, colon cancer screening should begin at the age of 50.

    Currently, there are several ways to screen for colon cancer. One is annual fecal blood testing–checking bowel movements for blood. Though this is inexpensive and can be done at home, it is probably not the best stand-alone test. Other options include colonoscopy (every ten years), barium enema (every 5 years), flexible sigmoidoscopy (a more limited colonoscopy–done every 5 years), or flexible sigmoidoscopy – plus annual fecal occult blood testing. The American Cancer Society recommends this last screening regimen. Though many people complain about colonoscopy/sigmoidoscopy because of the bowel prep (a liquid that helps empty the bowel), this is necessary to get an unobstructed view of the colon. Your primary care provider can help you decide on an appropriate screening plan.

    The “new test” is called virtual colonoscopy–a special CT scan of the abdomen. Though this may hold promise in the future, a bowel prep is still required – and if abnormalities are seen, a follow-up colonoscopy may still be necessary. It is not considered a primary screening strategy for colon cancer at this time.

  • I'm an 18 year old woman. Should I get a cervical cancer vaccine? Is it safe?

    The “cervical cancer vaccine” is called Gardasil. Genital warts, cervical cancers, and pre-cancers are caused by a sexually transmitted virus called human papilloma virus (also known as HPV). In women who received the vaccine, after 2 years, none had developed warts or abnormal pap smears/cervical pre-cancers. It is currently recommended for women between 9 and 26 years of age.

    There are many different strains of HPV (i.e., HPV-6, HPV-11, HPV-16, etc.). One important point about the vaccine is that it does not eliminate HPV strains that you have already been infected with; it only prevents you from becoming infected with most new strains. It is still important to get pap smears after receiving the vaccine!

    I generally do recommend this vaccine for young women as it can dramatically reduce the likelihood of warts and abnormal pap smears-both of these can cause a lot of stress, be expensive to treat, and can rarely lead to cancer. Whether to get it depends upon your life situation-if you are monogamous and will likely not be sexually active with another partner, it is unlikely you will be exposed to new HPV strains and therefore there is little reason to get the vaccine. However, if you have never been sexually active, or may be sexually active with other partners during your lifetime, it probably makes sense to get the vaccine.

    We do provide this vaccine (a 3-shot series over 6 months) at our office. You can find out more by calling us, or on the web at www.gardasil.com.

  • I'm a 48 year old woman and my mother was recently diagnosed with osteoporosis. Is there anything I can do to decrease my risk?

    Osteoporosis is a significant loss of bone density which increases the risk of spine or hip fracture. About 15 percent of post-menopausal caucasian women are affected. Most are without symptoms until fracture occurs, which can be catastrophic. One in five women with hip fracture dies within a year of fracture; more than half won’t regain their mobility and independence.

    Women accumulate bone mass until age 30 with a slow decline thereafter until menopause. After menopause, the rate of decline accelerates. Osteoporosis therefore depends not only on how fast you’re losing bone, but also how much bone mass you started with. This is why calcium intake and exercise in younger women are so important in preventing osteoporosis later in life.

    So what are risk factors for osteoporosis?

    Caucasian or Asian race, being post-menopausal, or having a first-degree relative with a hip or spine fracture are fixed risks. Modifiable risk factors include cigarette smoking, alcoholism, corticosteroid use, minimal exercise, inadequate calcium intake, and early menopause. What does this mean for women throughout their lifetimes? Women of all ages should avoid cigarettes, moderate their alcohol use, and regularly engage in weight-bearing exercise. Women ages 19-50 should get 1000 mg of calcium/day; after menopause, 1500 mg calcium plus 400-800 units of vitamin D per day. Calcium can be dietary (1 oz cheese, 8 ozs milk or yogurt or calcium-fortified orange juice, 1 cup broccoli all contain 300 mg of calcium) or supplemental. The cheapest calcium supplement is Tums (calcium carbonate). Each one contains 300 mg, should be taken with food, and no more than two should be taken with any meal–your body can only absorb a limited amount at any one time.

    Who should be screened for osteoporosis?

    The National Osteoporosis Foundation recommends screening in all women over the age of 65, and women under 65 who have risk factors or a fracture history. Testing includes ultrasound and DEXA scan–a non-invasive bone imaging study. Finally, who should be treated with medications? Women with osteoporosis identified on DEXA scan, or low bone density with other risk factors. Treatment medications include bisphosphonates (Fosamax, Actonel), selective estrogen receptor modulators (SERMs–Evista); and calcitonin. Estrogen is approved for prevention but not for treatment of osteoporosis.

    Hip and spine fractures can be devastating in later life. Though screening and treatment are important, adequate calcium intake and exercise play a large role in prevention, even in young women. As always, you should discuss your particular situation with your health care provider.

  • I'm a 56 year old woman and every time I cough or sneeze, I leak urine. It's gotten so bad that I need to wear pads nearly all the time. I'm so embarrassed...Is there anything I can do?

    Many women feel isolated and embarrassed because of urinary incontinence. The problem is a silent plague–it is extremely common but no one ever talks about it. There are two major types of urinary incontinence in women: stress and urge. Stress incontinence is characterized by the leakage of urine with increases in intraabdominal pressure (like coughing, sneezing, or exercising). Risk factors include older age, obesity, childbirth (especially forceps delivery), and chronic cough or constipation.

    The continence mechanism in women is complex–connective tissue supports which hold the bladder in place, a muscular sphincter around the urethra, and special types of nerve fibers all play a role. Trauma to parts of this system, often related to childbirth, can lead to incontinence. Sometimes this remains stable over time with loss of urine only during vigorous cough with a full bladder. Often it is a minor nuisance for women during their 30s and 40s with distressing evolution to chronic pad-wearing and clothing changes in their 50s and 60s.

    What can women do? First, if you are bothered by stress incontinence, do not accept the situation as “part of getting older”! For women who are minimally bothered with symptoms while exercising, use of a lubricated tampon inserted just before exertion can sometimes dramatically reduce leakage. In women with more severe or constant incontinence, the starting point is a history and physical examination with a gynecologist or urologist. Non-surgical therapies include physical therapy and/or biofeedback and/or medications. Surgeries include Burch colposuspension (an abdominal surgery) and Monarc or tension-free vaginal tape (TVT) placement. The latter two are both vaginal surgeries and allow a much more rapid recovery; most women are out of the hospital the same day or within 24 hours.

  • I'm a 48 year old woman with bladder problems. When I get the urge to urinate, I have to rush to the bathroom or I will leak urine. Sometimes it gets so bad I have to wear pads. What can I do?

    What you are describing is called urge incontinence–this occurs in about 10-20 percent of women. Common symptoms include frequent daytime urination (once an hour or more), getting up at night to urinate, and having triggers such as running water/garage door opening when you get home/key in the lock that cause an overwhelming urge to urinate. The screening question I ask in the office is: “When you feel the urge to urinate, do you need to get to the bathroom in a hurry, otherwise you’ll leak?”.

    We still don’t know why urge incontinence occurs. In contrast to stress incontinence (leakage of urine with a cough, sneeze, etc.), there is no loss of bladder or urethral support that can be surgically repaired. Urge incontinence is managed with medications or physical therapy. Common medications include tolterodine (Detrol) and oxybutinin (Ditropan)–both work to help the bladder relax. Physical therapy works on increasing vaginal and pelvic floor strength, delaying intervals between urination episodes, and reducing urge through relaxation techniques. Both methods have been shown to be equally effective in the short term.

    Urge incontinence can be bothersome and even debilitating for some women, but it can be treated successfully. Gynecologists, urologists, and some primary care providers can help.

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