How do they work?
Birth control pills provide hormones to your body. These hormones act on the area in your brain that signals your ovaries to release hormones. Since the hormones in the pill are already in your system, the signal for your ovaries to make hormones and release an egg is turned off. At the end of the pill pack, there are spacer pills, or placebo pills. These contain no active hormones. Therefore, your hormone levels drop and this signals the shedding of your lining. You see this as your menses.

There are 2 types of pills. One type is a combination of estrogen and progesterone. The other is progesterone only.

Combination pills work by preventing ovulation. The progesterone only pills work by increasing the thickness of the cervical mucous, preventing ovulation and preventing implantation from occurring.

What effect does this have on the uterus?
The uterine lining often shrinks and thins. This is why being on the birth control pill can lighten your periods and make them more regular.

Break-through Bleeding:
Break-through bleeding is very common first 6 months of pill use. Your body is adapting to the new cycle of hormones. Usually break-through bleeding occurs during the active pills. Usually it is enough to require the use of a tampon or pad.

Ninety per cent of women will have significantly less break-through bleeding after 6 months of pill use.

How can you prevent break-through bleeding?
Take your pill the same time every day. Even being a few hours late can affect the hormone levels and cause a drop. Try to build it into your morning routine, like taking it before you brush your teeth, so that you are more likely to remember it.

If you are traveling to a different time zone, try to take it the same time based on your normal time zone.

If you are doing this and still break-through bleeding occurs, you may want to switch the time of day that you are taking it. Sometimes, taking it before bed can be helpful (you are less stressed, typically you have an empty stomach). Keep in mind you can expect some spotting for 2 weeks anytime you change you regimen!

If this does not help, give us a call. Sometimes switching the brand of pill can be helpful by altering the type of estrogen and/or progesterone you are getting or increasing the amount. Also, sometimes taking an anti-inflammatory medication like ibuprofen (Advil) can decrease the amount of menstrual bleeding and cramps. Sometimes, this can help reduce spotting.

The pill may even reduce your menstrual flow to the point of where you skip periods.

Cancer Prevention:
Studies show that being on the pill decreases both your chances for ovarian cancer and endometrial cancer. Women who have been on the pill for 5 years show a decrease risk of endometrial cancer of 80%.

Benefits of taking the pill:
May reduce the amount and quantity of menstrual bleeding.
Can clear the skin.
Decreases the formation of ovarian cysts.

Possible Side Effects:
Nausea and/or vomiting - this can be decreased by taking the pill at bedtime or with food.
Weight gain or loss - not as common with today’s pills. Usually it is a shift in water weight that causes any weight changes, and this is shed by 3 months of pill use.
Change in sexual desire.
Headaches.

Rare side effects:
Blood clots (for women ages 15-34, the risk is 1/12,000. Women 35-44 it is 1/ 2,500), hear attack and stroke, benign liver tumors, high blood pressure, gall bladder disease

Who should NOT take the pill?
Pregnant women.
Smokers 35 or older - Smoking increases the risk of serious cardiovascular side effects. Heavy smokers (more than 15 per day) have higher risk.
History of heart attack, chest pain, stroke, or blood clots
Women with history of breast, uterine, cervical, vaginal or ovarian cancer
Women with unexplained vaginal bleeding
Jaundice or liver tumors

Other considerations that should be considered before taking birth control pills:
Breast nodules, fibrocystic disease of the breast, an abnormal mammogram
Diabetes
Elevated cholesterol or triglycerides
High blood pressure
Migraines, other headaches or epilepsy
Mental depression
Gallbladder, liver, heart, kidney disease
Women with any of these conditions should have a physical exam by us prior to using birth control pills.

When first taking the pill:
You need to use another form of birth control for the first pill pack.

What To Do If You Miss A Pill?
Keep in mind that by altering the time of day, you may experience break-through bleeding.
When you miss a pill, you should take you next pill at the regular time (even if this means you take 2 pills on the same day!).

If you miss 2 pills, take 2 pills on the day you remember and then 2 pills the following day. Then take 1 pill daily until the end of the packet. Use a back-up method of contraception for 7-14 days after the missed pill.

Call us if you miss your period.

If you miss more than 3 pills form the pack, call us so we can discuss it.

What about being on antibiotics?
Certain antibiotics and other medications can affect how the pill is absorbed. Be sure to check with us if someone prescribes you and antibiotic or other medication. You may have to use another form of contraception.

Excessive vomiting or diarrhea can alter the absorption of your pill. This can affect the amount of hormone that your body is receiving.

THE PILL DOES NOT PROTECT YOU AGAINST HIV OR OTHER SEXUALLY TRANSMITTED DISEASES. IT IS NECESSARY TO USE BARRIER METHODS (CONDOMS) TO PREVENT THESE DISEASE.

What Is Contraception?
Contraception, also known as birth control, is designed to prevent pregnancy.

What Are Some Methods of Contraception?
There are several general methods of birth control,including (but not limited to):

• Barrier methods. Barrier methods, such as condoms, the diaphragm and the cervical cap, are designed to prevent the sperm from reaching the egg for fertilization.
• Intrauterine Device. Intrauterine device, or IUD, is a small device that is inserted into the uterus by a health care provider. The IUD prevents a fertilized egg from implanting in the uterus. An IUD can stay in the uterus for up to 10 years until it is removed by a health care provider.
• Hormonal Birth Control. Hormonal birth control, such as birth control pills, injections, skin patches and vaginal rings, release hormones into a woman’s body that interfere with fertility by preventing ovulation, fertilization or implantation.
• Sterilization. Sterilization is a method that permanently prevents a woman from getting pregnant or a man from being able to get a woman pregnant. Sterilization involves surgical procedures that must be done by a health care provider and usually cannot be reversed.

How do I made a decision on which birth control is right for me?
The choice of birth control depends on factors such as a person’s overall health, age, frequency of sexual activity, number of sexual partners, desire to have children in the future, and family history of certain diseases. A woman should talk to The Rubino OB/GYN Group about her choice of birth control method.
It is important to remember that even though all these methods can prevent pregnancy, condoms are the only method that can protect against sexually transmitted diseases or HIV.

What is an eating disorder?
Severely limiting what you eat, vomiting on purpose, exercising too much, constantly thinking about being overweight and abusing diet pills and laxatives is unhealthy. People who use these methods to lose or control their weight often have an eating disorder.

Eating disorders can be divided into two main categories. The first is called anorexia nervosa, which involves limiting what you eat. The second category is called bulimia, which involves eating large amounts of food (binging) followed by an urgent need to vomit (purging).

The combination of overeating without purging and exercising too much to control weight also can be an eating disorder, although it doesn’t exactly fit the categories of anorexia nervosa or bulimia. Certain types of overeating also may require medical treatment.

More than 5 million people in the United States have an eating disorder. Most are women, but some men also develop eating disorders. Many young people are powerfully influenced by our culture’s belief that “thin is beautiful” and this can encourage the development of eating disorders. Others develop eating disorders because they feel their weight is the only thing in their lives they can control.

What are the signs and symptoms of an eating disorder?
Some signs of an eating disorder include:

• Refusal to maintain weight at a normal weight for height and age
• Intense fear of weight gain
• Unrealistic or distorted ideas about how one’s body looks
• Strange behavior around meals, including rituals
• Missing menstrual periods
• Withdrawing emotionally from people
• Anxiety around meal times
• Binging (eating large amounts of food very rapidly)
• Purging (getting rid of food by vomiting, excessive exercising or using laxatives or diuretics)

How are eating disorders treated?
People with eating disorders need emotional support and psychotherapy to overcome their condition. Often, nutritional counseling and medications also are used. Treatment always should include seeing a psychiatrist.
Psychotherapy is a series of private talks with a psychiatrist where a person discusses the feelings, thoughts and behavior that cause difficulty. The goal of psychotherapy is to help people understand and master their problems so they can function better. Psychotherapy can help people with eating disorders understand why they limit their food intake or why they binge and/or purge. This understanding can lead to healthier attitudes about food.

Most people with an eating disorder can be helped in an outpatient program. People with severe or life-threatening eating disorders may need to be treated in a hospital.

What is Essure?
The traditional tubal ligation ("tying the tubes") has advanced from the operating room to the office setting. In the past, having a tubal sterilization procedure required general anesthesia and a laparoscopy (a scope put through the abdomen). This approach required significant recovery time and risk. Today, we are able to perform tubal ligations in the office, WITHOUT INCISIONS. Essure sterilization is done through an ultra-thin hysteroscope. This small camera is inserted through the cervix under local anesthesia and the tubes are "tied" with tiny coils that permanently block them. Patients literally walk out in 15-30 minutes with essentially no recovery time. The Rubino OB/GYN Group has had excellent success with this procedure.

How long does the procedure take?
You must use another method of birth control for at least three months after the procedure before your doctor can advise you whether you can begin relying on Essure for contraception. You will need to visit your doctor 3 months after your Essure procedure to have an evaluation performed. This evaluation is called hystero-salpingogram(HSG) and the evaluation is performed to make sure that both of your Essure micro-inserts are in the correct location and that both of your tubes have been blocked. The HSG test involves injection of contrast (dye) into your uterus so that an X ray picture can be taken. It is important that you do not rely on Essure for contraception until your doctor has performed this test and has told you that you may rely on on Essure for contraception. If you rely on Essure for contraception before completing this evaluation, you may get pregnant, or have an ectopic pregnancy (pregnancy outside of your uterus). Ectopic pregnancies can be life-threatening. Because of this 3 month waiting period, you will need to talk to your doctor (before the procedure is performed) about another contraceptive method to use with Essure during this time. During this 3 month period, intrauterine devices (IUDs) or intrauterine systems (IUSs) cannot be used.

How long before I can resume regular activities?
In the Essure Pivotal Trial, women were typically able to leave the facility 45 minutes after the procedure and almost all working women resumed work in 24 hours or less after the day of the procedure. The majority of women returned to normal activities in 1 to 2 days, but many women reported that they were able to resume normal physical activities the same day as the procedure.

What happens to my eggs?
After an Essure procedure, your ovaries will continue to produce eggs until menopause. The unfertilized eggs will be absorbed by your body.

Does it result in menopause?
No. Essure does not cause menopause.

Why must I use another method of birth control for at least 3 months after the procedure?
The tissue response that leads to tubal occlusion takes approximately 3 months.

Is Essure right for me?
The Essure procedure is only appropriate if you are sure you do not want any more children, would like to have permanent birth control and believe you will not change your mind. If there is any chance you may want to have children in the future, you should choose another form of birth control. You should avoid making this choice during times of stress, such as a divorce or after a miscarriage, and NEVER under pressure from a partner or others.

You should not use Essure if you:

• Are uncertain about your desire to end fertility
• Are pregnant or suspect that your are pregnant
• Have delivered a baby, had a miscarriage, or had an abortion within 6 weeks before the Essure micro-incert placement procedure
• Have an active or recent pelvic infection
• Have an unusual uterine shape (for example, a uterus with only one tube or a divided uterus)
• Have a known allergy to dye (contrast media)
• Have a known hypersensitivity or allergy to nickel as confirmed by skin test
• Are unwilling to use another method of contraception for at least 3 months after the Essure micro-insert placement procedure
• Are unwilling to undergo an HSG approximately 3 months after your Essure placement procedure to make sure that your tubes are blocked and the devices are in the correct positions
• Have had a prior tubal ligation

What Is Genital Herpes?
Genital herpes is a viral infection that can be spread through close contact, most often during sexual activity. It affects one in five adults in the United States — about 45 million people. It is more common in women than in men. Genital herpes is a sexually transmitted disease (STD).

How does the Genital Herpes infection occur?
The herpes virus can pass through a break in your skin during vaginal, oral, or anal sex. It can enter the moist membranes of the penis, vagina, urinary opening, cervix, or anus. Once the virus gets into your body, it infects healthy cells. Your body’s natural defense system then begins to fight the virus. This causes sores, blisters, and swelling.

What are symptoms of Genital Herpes?
Many people infected with herpes have no symptoms. When symptoms do occur, they vary with each person. Some people have painful attacks with many sores. Others have only mild symptoms.
See your doctor right away if you have symptoms of genital herpes.

How is Genital Herpes diagnosed?
Your doctor can diagnose herpes using one or more tests to detect infection. The most accurate way is to obtain a sample from the sore and see if the virus grows in a special fluid.

What is the treatment for Genital Herpes?
There is no cure for genital herpes. There are, however, oral medications to help control the course of the disease. Medication can shorten the length of an outbreak and help reduce discomfort.

How do I avoid recurrence?
Although herpes sores heal in days or weeks, herpes does not leave your body. The virus travels to nerve cells near your spine. It stays there until some event triggers a new bout. No one is sure why some people have recurrences of herpes.

About 90% of people with herpes have repeat outbreaks. How often these outbreaks occur varies greatly from person to person.

How can I prevent Genital Herpes?
If you or your partner have oral or genital herpes, avoid sex from the time of prodromal symptoms until a few days after the scabs have gone away.
Using a condom may reduce your risk of passing or getting genital herpes, but does not protect against all cases.

How does Genital Herpes effect pregnancy?
If you are pregnant and have herpes, tell your doctor. During pregnancy, there are increased risks to the baby, especially if it is the mother’s first outbreak.

Finally...
Herpes affects millions of people in the United States. It can be a source of concern and discomfort. Simple measures can ease the symptoms of herpes, and medication can promote healing. Over time, most people with herpes find ways to cope with the disease.

Stats from The Rubino OB/GYN Office on the Procedure:
At 24 months, 91% of patients were very or extremely satisfied with treatment results. A full 96% of patients would recommend Her Option to a friend.

What is Her Option and how does it treat heavy periods?
Her Option is a safe and effective treatment that uses sub-zero temperatures to destroy the tissue lining of the uterus (endometrium). It is this tissue that sheds during your period that causes bleeding. By destroying most or all of this lining, your periods will be reduced or eliminated.
There are many reasons that women choose Her Option:
• High success rate in reducing bleeding with no incisions
•No need to remove the uterus or to disrupt the natural hormones
• The treatment can be performed in the comfort of a doctors office

Is it Her Option Right for Me?
Her Option is not recommended for everyone. You will need to be evaluated by your doctor to find out if it is right for you.

If you intend to become pregnant, you would not be a candidate for Her Option because the procedure destroys the endometrial lining that must be intact during a normal pregnancy. Her Option also is not recommended for patients with uterine cancer, an active urinary tract infection, pelvic inflammatory disease, an IUD or some types of uterine abnormality.

Is Her Option Therapy covered by insurance?
Her Option Therapy from AMS generally is covered by health insurance, as are other endometrial ablation procedures. Medicare also covers the Her Option procedure.

How will the Her Option treatment be performed?
Your doctor may perform Her Option in the office. During the treatment, your bladder will be full to allow your doctor to monitor the progress of the treatment using an abdominal ultrasound. A slender probe will be gently inserted through your vagina into your uterus and is cooled until it reaches sub-zero temperatures. Typically, multiple ice zones are formed. The procedure should take twenty to thirty minutes.

What happens immediately after the treatment?
Immediately following the treatment, some patients feel cramping similar to a menstrual period. Your doctor may give you a mild medication such as ibuprofen to keep you comfortable. A heating pad may also help.
You should plan on having someone drive you home and you may want to take it easy for the rest of the day. Most patients can return to normal activities the next day.

You may experience a watery discharge for up to three weeks following the treatment as the tissue heals. This is normal.

Your doctor may ask you to hold off on sexual activity until after your first check-up. Your doctor will provide you with additional information on how to care for yourself after the treatment.

When will I see results and what will my bleeding be like?
Within the first three months following the treatment you should experience a reduction in bleeding. It is not unusual to experience two or three normal menstrual cycles before you see the treatment take effect, although some patients see results immediately.

The decrease in bleeding varies from women to women. Some women find that their periods return to more normal levels. Other women will find that their bleeding is completely eliminated or will only spot for a few days a month.

What else can I expect?
In a clinical study with Her Option 94% of treatments were successful. In addition, patients who undergo the treatment often report a reduction in PMS symptoms, such as fatigue, irritability, and cramping.
Furthermore, the treatment should not change your desire or your enjoyment in sexual activity.

You should only have Her Option if you no longer desire to have children. However, it is possible to become pregnant following the treatment. Such a pregnancy would be high risk for the woman and the fetus. Therefore, a reliable form of birth control is necessary following treatment.

Every medical treatment has risks and complications, and you should talk to your doctor to be sure that you understand the potential complications and results you can expect.

If you experience any of these symptoms following the treatment, contact your doctor immediately:

• Vaginal bleeding heavier than your normal period
• Fever above 100.4
• Severe abdominal cramping or pain
• Nausea or vomiting

1. Townsend DE, Duleba AJ, Wilkes MM. Durability of treatment effects after endometrial cryoablation versus rollerball electroablation for abnormal uterine bleeding: two-year results of a multicenter randomized trial. Am J Obstet Gynecol Mar. 2003 v. 188(3) p.699-701.

What is the HPV Vaccine?
The Advisory Committee on Immunization Practices (ACIP) recommended the first vaccine developed to prevent cervical cancer and other diseases in females caused by certain types of genital human papillomavirus (HPV). The vaccine, Gardasil®, protects against four HPV types, which are responsible for 70 percent of cervical cancers and 90 percent of genital warts. This HPV vaccine was recently licensed by the Food and Drug Administration (FDA) for use in girls/women, ages 9 to 26 years.

Who Should Get This Vaccine?
This vaccine is recommended for 11 to 12 year-old girls. The vaccine can be given to girls as young as 9 years old, at the discretion (judgment) of the healthcare provider. The vaccine is also recommended for 13 to 26 year-old girls/women who have not yet received or completed the vaccine series. These recommendations were made by the federal Advisory Committee on Immunization Practices (ACIP) — a national group of leading experts, which advises the Centers for Disease Control and Prevention (CDC) on vaccine issues. The ACIP decides whether vaccines should be recommended, and if so, who should get them, and at what ages.

How Effective Is This Vaccine?
The vaccine has mainly been studied in young women who had not been exposed to any of the four vaccine HPV types. These studies found the vaccine to be 100 percent effective in preventing cervical precancers caused by the vaccine HPV types. These studies also found it to be almost 100 percent effective in preventing precancers of the vulva and vagina, and genital warts that are caused by the vaccine HPV types. The vaccine was less effective in young women who had already been exposed to a vaccine HPV type. This vaccine does not treat existing HPV, genital warts, precancers or cancers.

Will Sexually Active Females Benefit From the Vaccine?
Females who are sexually active may also benefit from the vaccine. But they may get less benefit from the vaccine since they may have already acquired one or more vaccine HPV type(s). Still, they would get protection against the vaccine HPV types they have not yet acquired. Few young women are infected with all four vaccine HPV types. Currently, there is no test available to tell whether a girl/woman has had any or all of the four vaccine HPV types.

How and When Is the Vaccine Delivered?
The vaccine is given through a series of three injections over a six-month period. The second and third doses should be given two and six months (respectively) after the first dose.

Is the HPV Vaccine Safe?
The FDA has approved the HPV vaccine as safe and effective. This vaccine has been tested in over 11,000 females (ages 9 to 26 years) in many countries around the world. These studies have shown no serious side effects. The most common side effect is soreness at the injection site.

Does This Vaccine Contain Thimerosal or Mercury?
No. There is no thimerosal or mercury in the HPV vaccine. It is made up of proteins from the outer coat of the virus (HPV). There is no infectious material in this vaccine.

How Much Will the HPV Vaccine Cost?
The retail price of the vaccine is $120 per dose ($360 for full series).

Will Girls/Women Who Have Been Vaccinated Still Need Cervical Cancer Screening?
Yes. There are three reasons why women will still need regular cervical cancer screening. First, the vaccine will NOT provide protection against all types of HPV that cause cervical cancer, so vaccinated women will still be at risk for some cancers. Second, some women may not get all required doses of the vaccine (or they may not get them at the right times), so they may not get the vaccine’s full benefits. Third, women may not get the full benefit of the vaccine if they receive it after they’ve already acquired a vaccine HPV type.

Will the HPV Vaccine Be Covered By Insurance Plans?
While some insurance companies may cover the vaccine, others may not. Most large group insurance plans usually cover the costs of recommended vaccines. However, there is often a short lag-time after a vaccine is recommended, before it is available and covered by health plans.

What Kind of Government Programs May Be Available To Cover HPV Vaccine?
Federal health programs such as Vaccines for Children (VFC) will cover the HPV vaccine. The VFC program provides free vaccines to children and adolescents under 19 years of age, who are either uninsured, Medicaid-eligible, American Indian or Alaska Native. There are over 45,000 sites that provide VFC vaccines, including hospital, private and public clinics. The VFC Program also allows children and adolescents to get VFC vaccines through Federally Qualified Health Centers or Rural Health Centers, if their private health insurance does not cover the vaccine.

Some states also provide free or low-cost vaccines at public health department clinics to people without health insurance coverage for vaccines.

Why Is HPV Important?
Genital HPV is a common virus that is passed on through genital contact, most often during vaginal and anal sex. About 40 types of HPV can infect the genital areas of men and women. While most HPV types cause no symptoms and go away on their own, some types can cause cervical cancer in women. These types also have been linked to other less common genital cancers, including cancers of the anus, vagina and vulva (area around the opening of the vagina). Other types of HPV can cause warts in the genital areas of men and women, called genital warts.

How Common Is HPV?
At least 50 percent of sexually active people will get HPV at some time in their lives. Every year in the United States, about 6.2 million people get HPV. HPV is most common in young women and men who are in their late teens and early 20s.
Anyone who has ever had genital contact with another person can get HPV. Both men and women can get it — and pass it on to their sex partners — without even realizing it.

How Common Are Genital Warts?
About 1 percent of sexually active adults in the U.S. (about 1 million people) have visible genital warts at any point in time.

Is HPV the Same Thing as HIV or Herpes?
HPV is NOT the same as HIV or Herpes (Herpes simplex virus or HSV). While these are all viruses that can be sexually transmitted — HIV and HSV do not cause the same symptoms or health problems as HPV.

Can HPV and Its Associated Diseases Be Treated?
There is no treatment for HPV. But there are treatments for the health problems that HPV can cause, such as genital warts, cervical cell changes, and cancers of the cervix, vulva, vagina and anus.

How Is HPV Related to Cervical Cancer?
Some types of HPV can infect a woman’s cervix (lower part of the womb) and cause the cells to change. Most of the time, HPV goes away on its own. When HPV is gone, the cervix cells go back to normal. But sometimes, HPV does not go away. Instead, it lingers (persists) and continues to change the cells on a woman’s cervix. These cell changes can lead to cancer over time, if they are not treated.

How Common Is Cervical Cancer in the United States? How Many Women Die From It?
The American Cancer Society estimates that in 2006, over 9,700 women will be diagnosed with cervical cancer and 3,700 women will die from this cancer in the United States.

Are There Other Ways To Prevent Cervical Cancer?
Regular Pap tests and follow-up can prevent most, but not all, cases of cervical cancer. Pap tests can detect cell changes (or “precancers”) in the cervix before they turn into cancer. Pap tests can also detect most, but not all, cervical cancers at an early, curable stage. Most women diagnosed with cervical cancer in the U.S. have either never had a Pap test, or not had a Pap test in the last five years.
There is also an HPV DNA test available for use with the Pap test, as part of cervical cancer screening. This test is used for women over 30 or for women who get an unclear (borderline) Pap test result. While this test can tell if a woman has HPV on her cervix, it cannot tell which types of HPV she has.

What HPV Types Does the Vaccine Protect Against?
The new HPV vaccine protects against the two HPV types that cause most (70 percent) cervical cancers (types 16 and 18), and the two HPV types that cause most (90 percent) genital warts (types 6 and 11).

What Does the Vaccine Not Protect Against?
Because the vaccine does not protect against all types of HPV, it will not prevent all cases of cervical cancer or genital warts. About 30 percent of cervical cancers will not be prevented by the vaccine, so it will be important for women to continue getting screened for cervical cancer (regular Pap tests). Also, the vaccine does not prevent about 10 percent of genital warts — nor will it prevent other STIs — so it will still be important for sexually active adults to reduce exposure to HPV and other STIs.

How Long Does Vaccine Protection Last? Will a Booster Shot Be Needed?
The length of vaccine protection (immunity) is usually not known when a vaccine is first introduced. So far, studies have followed women for five years and found that they are protected. More research is being done to find out how long protection will last, and if a booster vaccine is needed years later.

Why Is the Vaccine Only Recommended for Girls/Women Ages 9 To 26?
The vaccine has been extensively tested in 9-to-26 year-old girls/women, but research on the vaccine’s efficacy has only recently begun with males, and with women older than 26 years of age. The FDA will consider licensing the vaccine for these other groups when the research is completed to show that it is safe and effective in those groups.

Why Is HPV Vaccine Recommended for Such Young Girls?
Ideally, females should get the vaccine before they are sexually active — since this vaccine is most effective in girls/women who have not yet acquired any of the HPV vaccine types. Girls/women who have not been infected with any vaccine HPV type will get the full benefits of the vaccine.

Should Girls/Women Be Screened Before Getting Vaccinated?
No. Girls/women should not get an HPV test or Pap test to determine if they should get the vaccine. An HPV test or a Pap test can tell that a woman may have HPV, but these tests cannot tell the specific HPV type(s) that a woman has. Even girls/women with one vaccine HPV type could get protection against the other vaccine HPV types they have not yet acquired.

What About Vaccinating Boys?
We do not yet know if the vaccine is effective in boys or men. It is possible that vaccinating males will have health benefits for them by preventing genital warts and rare cancers, such as penile and anal cancer. It is also possible that vaccinating boys/men will have indirect health benefits for girls/women. Studies are now being done to find out if the vaccine works to prevent HPV infection and disease in males. When more information is available, this vaccine may be licensed and recommended for boys/men as well. Currently, the vaccine is licensed only for use in females ages 9 to 26.

Should Pregnant Women Be Vaccinated?
The vaccine is not recommended for pregnant women. There has been limited research looking at vaccine safety for pregnant women and their developing fetus. So far, studies suggest that the vaccine has not caused health problems during pregnancy, nor has it caused health problems for the infant — but more research is still needed. For now, pregnant women should complete their pregnancy before getting the vaccine. If a woman finds out she is pregnant after she has started getting the vaccine series, she should complete her pregnancy before finishing the three-dose series.

Will Girls/Women Be Protected Against HPV and Related Diseases, Even if They Don’t Get all Three Doses?
It is not yet known how much protection girls/women would get from receiving only one or two doses of the vaccine. For this reason, it is very important that girls/women get all three doses of the vaccine.

Will Girls Be Required To Get Vaccinated Before They Enter School?
There are no federal laws that require children or adolescents to get vaccinated. All school and daycare entry laws are state laws — so they vary from state to state. To find out what vaccines are needed for children or adolescents to enter school or daycare in your state, check with your state health department or board of education.

Are There Other HPV Vaccines in Development?
Another HPV vaccine is in the final stages of clinical testing, but it is not yet licensed. This vaccine would protect against the two types of HPV that cause most (70 percent) cervical cancers (types 16, 18).

Are There Other Ways To Prevent HPV?
The only sure way to prevent HPV is to abstain from all sexual activity. Sexually active adults can reduce their risk by being in a mutually faithful relationship with someone who has had no other or few sex partners, or by limiting their number of sex partners. But even persons with only one lifetime sex partner can get HPV, if their partner has had previous partners.

It is not known how much protection condoms provide against HPV, since areas that are not covered by a condom can be exposed to the virus. However, condoms may reduce the risk of genital warts and cervical cancer. They can also reduce the risk of HIV and some other sexually transmitted infections (STIs), when used consistently and correctly (i.e. all the time and the right way).

Sources
American Cancer Society. Detailed Guide: Cervical Cancer. What are the Key Statistics about Cervical Cancer? Last updated October 31, 2005.
Food and Drug Administration (FDA). FDA News: FDA Licenses New Vaccine for Prevention of Cervical Cancer and Other Diseases in Females Caused by Human Papillomavirus.
Harper DM, Franco EL, Wheeler C, et al; HPV Vaccine Study Group. Sustained efficacy up to 4.5 years of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18: follow-up from a randomised controlled trial. Lancet. 2006; 367(9518): 1247-1255.
Ho GY, Bierman R, Beardsley L, et al. Natural history of cervicovaginal papillomavirus infection as measured by repeated DNA testing in adolescent and young women. N Engl J Med. 1998; 338(7):423-428.
Koutsky LA. Epidemiology of genital human papillomavirus infection. Am J Med. 1997; 102(5A):3-8.
Mao C, Koutsky LA, Ault KA, et al. Efficacy of human papillomavirus-16 vaccine to prevent cervical intraepithelial neoplasia: a randomized controlled trial. Obstet Gynecol. 2006; 107(1):18-27.
National Institutes of Health (NIH). NIH Consensus Statement: Cervical Cancer. 1996; 14:1-38.
Villa LL, Costa RLR, Petta CA, et al. Prophylactic quadrivalent human papillomavirus (types 6, 11, 16, and 18) L1 virus-like particle vaccine in young women: a randomised double-blind placebo-controlled multicentre phase II efficacy trial. The Lancet Oncology, 2005; 6(5): 271-278.
Weinstock H, Berman S, Cates W, Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004; 36(1):6-10.
Publication Date: 12/22/2009
Source: Centers for Disease Control and Prevention

What is the average age of Menopause?
Average age of menopause is 51; 90% by age 55

When does Perimenopause start?
Most women transition about age 47

How long does Perimenopause last?
Perimenopause usually lasts 4-5 years, may last only 2

What are the Perimenopausal changes?
Change in amount or duration of flow
Change in length of cycle
Skipping periods
Risk of unintended pregnancy

What are the symptoms associated with the loss of Estrogen?

• Vasomotor: hot flashes, day and night sweats
• Vaginal dryness

Other Symptoms associated with estrogen deficiency:

• Insomnia/sleep disturbances
• Urinary leakage or urinary tract infections
• Changes in libido
• Discomfort with intercourse
• Mood slings, irritability

What diseases have been associated with Menopause?

• Osteoporosis
• Macular degeneration (leading cause of blindness in elderly)
• Vaginal atrophy
• Decrease in Colon polyps, possible decrease in colon cancer
• Possibly Coronary artery disease and Alzheimer’s

What lifestyle changes can I make to help me cope with Menopause?

• Dress in cotton layers
• Decrease alcohol consumption
• Avoid caffeine
• Avoid spicy foods
• Stop tobacco - people who smoke enter menopause on average of 2 years earlier and have an increased risk of osteoporosis
• Get adequate exercise (DO NOT initiate a new exercise routine until speaking to your physician): promotes restorative sleep, some women report decreased hot flashes, weight bearing exercise improves bones and helps prevent osteoporosis
• Healthy diet: balanced, low in saturated fats, high in fibers, fruits and vegetables
• Multivitamin: Calcium 1500 mg/ day - can take supplement or TUMS if multivitamin does not give you this much; Vitamin D 400-800 IU per day
• Decrease stress
• Relaxation techniques/ meditation: some women report decreased hot flashes

What can I use for vaginal dryness?
Vaginal Lubricants can be used for vaginal dryness:

• water soluble (Astroglide),
• moisturizers (Replens, KY Jelly)

These act directly on tissue to make less dry

ONLY use products designed for the vagina! Hand creams, oil based (Vaseline) can lead to vaginal irritations and infections

What are the different types of Estrogen preparations available?
Prescription Hormone and Replacement Estrogen

Many approaches include: Systemic and Local: usually not absorbed in high enough doses to help with hot flashes -- only vaginal dryness

Prescription estrogen creams can be helpful with vaginal atrophy like the FDA-approved estrogen rings

Combination Estrogen and Progesterone
**If you haven’t had a hysterectomy and still have your uterus, you need both estrogen and progesterone
Taking estrogen only will lead to uterine cancer

Women who should not take Hormone Replacement Therapy are women who have:

• known or suspected pregnancy
• history of breast cancer
• history of a hormone-sensitive cancer
• unexplained uterine bleeding
• history of blood clotting disorder

What are possible side effects of Hormone Replacement Therapy?

• uterine bleeding
• breast tendernes
• nausea
• abdominal bloating
• fluid retention
• change of shape of cornea (leading to contact lens intolerance)
• headaches (migraines)
• dizziness
• increased breast density (makes mammograms harder to interpret)

DOES NOT CAUSE WEIGHT GAIN

What are the alternatives to using Estrogen?
Progesterone for hot flashes:
Medroxyprogesterone in doses of 20-40 mg per day can significantly decrease hot flashes compared to placebo (Schiff et al., JAMA 1980; 244:1443-5.)

Megestrerol Acetate:
Has been shown to significantly reduce the frequency of hot flashes
With doses of 20, 40, 80 mg per day there is a step wise reduction in hot flashes
(Loprinzi et al, N Engl J Med 1994: 331: 347-52.)

Tibolone:
Not currently available in US
Metabolites have tissue specific estrogen, androgen and progestational activity
(Hammar et al, Br J Obstet Gynecol. 1998, 105:904-11.)

Clonidine:
alpha 2 blocker
transdermal 100 micrograms per day
(Nagamani et al, Am J Ob Gyn, 1987. 2156: 561-5.)

Selective Serotonin reuptake Inhibitors (SSRI?s):
Effexor, Paxil
Have been shown to have decrease in hot flashes
(Loprinzi et al, J Clin Oncol 1998: 16: 2377-81.)
(Quella at al, J Urol 1999: 162: 98-102.)
(tearns et al, Ann Oncol 2000; 11: 17-22.)

What are the Herbal Alternatives? Are these safe?
Herbal Alternatives:

Red Clover:
No statistical significance in decreasing hot flashes

Vitamin E:
400 IU or more per day
Some women report decreased hot flashes
Studies do not support this

Oil of Evening Primrose:
1500-3000 mg/day
No scientific evidence that helps menopausal symptoms
Side effects: nausea, diarrhea, blood clots

DO NOT TAKE: being treated for epilepsy, on blood thinners (Aspirin, Warfarin), or on phenothiazides

Ginseng:
Lack of scientific evidence for treating menopausal symptoms
Side effects: vaginal bleeding, worsening menopausal symptoms, headaches, high blood pressure, insomnia

Gingko:
Lack of scientific evidence for treating menopausal symptoms; use not recommended for menopausal symptoms
Side effects: bleeding

DO NOT USE : on blood thinners
Discontinue 2-3 weeks before surgery

Kava: No Scientific Evidence to help menopausal symptoms
May be ADDICTIVE
Side Effects include GI upset

DO NOT USE IF: using psychiatric medications, antihistamines or alcohol

St. John?s Wort:
No Scientific evidence to help menopausal symptoms
Side Effects: GI upset, sensitivity to sunlight

MUST STOP few weeks before undergoing anesthesia

Wild Yam:
No Scientific evidence to help menopausal symptoms
Can be made in lab into progesterone

Dong Quai:
No statistical significance
(Hirata et al, Fertil Steril 1997: 68: 981-6.)
Potentially toxic
Some concern that consumption may increase risk of sun exposure-related skin cancers

Black Cohosh:
Studied by German Commission E reported significant improvement in mood and hot flashes over placebo
May be helpful in the short term (6 months or less) for treatment of hot flashes and night sweats (ACOG)

Typical dose: 160 per day
Possible side effects:
nausea/vomiting
dizziness
visual disturbances
excessive sweating

DO NOT USE: if taking estrogen replacement or blood pressure medication

WARNINGS:
Herbal Preparations in General
NOT regulated by the FDA
Frequently have not been tested in humans
No standards for dosages, so the active ingredient may vary

How can Soy be helpful?
Soy and isoflavones are similar in chemical structure to estrogen
May be helpful in short term (<2 years) for hot flashes and night sweats

Consuming extraordinary amounts may interact with estrogen and may be harmful to women with the history of an estrogen-dependent cancer and possibly to other women as well. (ACOG)

Typical Asian diet consists of 20-150 mg of isoflavones, or 20-50 mg of soy

Are there resources available where I can get more information?

• American College of Obstetricians and Gynecologists - www.acog.org
• North American Menopause Society - www.menopause.org

How does ParaGard work?
ParaGard prevents sperm from reaching the egg and fertilizing it. It may also prevent the egg from attaching to the uterus. ParaGard does not alter your body’s natural menstrual cycle.

When does it start working?
Right away, as soon as your healthcare professional inserts it.

Is it OK to have copper in my body?
Yes. ParaGard doesn’t raise the level of copper naturally found in your body. In fact, the copper released daily by ParaGard is less than the amount of cooper found in the foods you eat on an average day.

Will I feel it? Will my partner feel it?
No. It’s designed to fit comforably in your uterus. Neither you nor your partner will feel it. Also, ParaGard doesn’t interffer with tampons.

Do I have to use ParaGard for 10 years?
ParaGard is effective for up to 10 years, but gives you the flexibility to change your mind. You can use it for 2 years, 5 years - however long you and your healthcare professional choose.

Does ParaGard protect against sexually transmitted diseases?
No. Only condoms protect against STDs.

Can I use ParaGard if I’m breast-feeding?
Yes. Unlike other methods, it’s hormone-free. In fact, The American College of Obstetricians and Gynecologists recommends it as a choice for nursing mothers.

How does ParaGard compare in price with other birth control methods?
If you plan to use birth control for at least 2 years, an IC is the least expensive option available. That’s because you only pay for it once, when it’s inserted.

Where can I get ParaGard?
You can get ParaGard from your healthcare professional. Or you may order ParaGard yourself, as long as you know your healthcare professional’s telephone or fax number. Your ParaGard will be delivered to your healthcare professional’s office. To order your ParaGard by phone, call 1-877 ParaGard (727-2427)

How do I pay for ParaGard?
Many health insurance companies cover ParaGard. Call your provider to see if they cover ParaGard. If so, ask how much they cover. If your provider doesn’t cover ParaGard, or if you don’t have insurance, the ParaGard Patient Payment Plan lets you pay for ParaGard with 12 monthly payments. Call 1-877 ParaGard (727-2427) for more details.

What should I expect?
If you decide to use ParaGard, your healthcare professional will place it in your uterus during a routine office visit. It should only take a few minutes. You might feel some mild cramping or a pinching sensation. You may feel slightly faint or dizzy for a few moments.
Once ParaGard is inserted, you won’t even know it’s there - you won’t be able to feel it (and neither will your partner.) All you have to do is check the threads every month.

Are there any possible side effects?
ParaGard is different from the birth control methods you may know. But just like them, ParaGard affects some women differently. So call your healthcare professional if you experience any of the following:

• Signs or symptoms that make you think you could be pregnant
  
• Pelvic pain or pain during sex
• Unusual vaginal discharge or genital sores
• Unexplained fever
• A missed period
• Severe or prolonged vaginal bleeding
• Exposure to any STDs, or if you or your partner have become HIV positive
• If you can’t feel your ParaGard threads during your monthly self-check, if the threads feel much longer, or if you feel any other part of ParaGard besides the threads

What is a PMS Calendar?
The PMS calendar is essential for the diagnosis of PMS. In addition, it is the only way to monitor your response to treatment. The PMS calendar should be completed according to the following instructions:

1. Mark the date of the first day of your menstrual period that corresponds to the first day of your cycle (the first day of bleeding). If you do not have periods, simply begin with the first day of each month.
2. Each morning before arising, take your temperature orally with a basal temperature thermometer. With a red pencil, put a dot below the appropriate date and opposite the temperature.
3. Weigh yourself unclothed each morning before you eat or drink, after you empty your bladder and, if possible, your bowels. Record the results.
4. Note any medications taken or dietary changes made under the heading “Treatment.” Write the name and dose of medication (e.g., progesterone suppositories, 200 mg). Note the number of times that medication was taken on a given day by writing the appropriate number in the box opposite the medication and below the date.
5. Choose the most common or severe physical and emotional symptoms that you experience with PMS from the symptom list below and write them in the blanks on the PMS calendar. (Remember, the list below is not complete. Add any other recurring symptoms you can identify to your calendar). Your list should be in the same order on each sheet of the calendar.
6. Note at the end of each day if you have experienced any of the physical or mental symptoms during the day. If you have experienced a symptom, estimate the severity of that symptom from 1 (mild) to 7 (severe) and write the number in the box opposite the symptom and below the appropriate date.
7. When you have completed 2 menstrual cycles, mail your charting into the PMS Center prior to your appointment. For safety, keep copies for yourself.
8. Also, bring or send a written description of how severe your PMS was during the month, how effective the treatment was, suggestions and any questions you wish to have answered.

What are physical symptoms of PMS?
Physical symptoms include:

• Abdominal bloating.
• Acne outbreaks.
• Backache.
• Breast tenderness and swelling.
• Constipation.
• Craving for sweet or salty foods.
• Diffuse, dull, pelvic ache.
• Edema.
• Headaches or migraines.
• Herpes (cold sores) outbreaks.
• Incoordination or clumsiness.
• Increased appetite and thirst.
• Sleep disturbances.
• Visual disturbances.
• Weight gain.

What are emotional symptoms of PMS?

• Anxiety.
• Changes in sexual desire.
• Depressed mood.
• Fatigue.
• Inability to cope.
• Irritability.
• Mood slings.
• Mental and physical aggression.
• Nervousness.
• Poor concentration or distractibility.
• Restlessness.
• Sadness.
• Social withdrawal.
• Suicidal thoughts
• Tearfulness

Early Screen First Trimester; Prenatal Screening and Ultrasound Exam (aka Nuchal Fold Test, Ultrascreen)

What is Early Screen^®?
Early Screen is a blood test combined with an 11-13 week ultrasound exam that tells you if you have an increased chance of having a baby with Down syndrome, Trisomy-18 or ?13. These disorders result from an extra chromosome in each cell. The extra chromosome causes birth defects and mental retardation. The risk of having a baby with an extra chromosome disorder increases with the mother’s age, but can occur at any age.

What are Down syndrome, Trisomy 18 and Trisomy 13?
Down syndrome occurs when the baby has an extra copy of chromosome 21. Babies with Down syndrome have mental retardation and usually have physical anomalies, like heart defects.

Trisomy 18 is caused by an extra chromosome 18 and trisomy 13 by an extra chromosome 13. Both these disorders cause profound mental retardation and multiple birth defects. While trisomy 18 and trisomy 13 are more severe than Down syndrome, they are less common.

How is Early Screen Performed?
Blood is taken from your arm or through a finger stick to measure the levels of two proteins (freeBeta and PAPP-A) in your blood. These two proteins are normally found in your blood. Your ultrasound exam will measure your baby?s nuchal translucency (NT), a fluid filled space at the back of the baby?s neck and may examine the nasal bone.

What If My Screening Test Shows My Risk Is Increased?
It does not mean a chromosomal abnormality has been diagnosed. It means your chance of having a baby with a chromosome abnormality is high enough to offer further testing. You will be offered genetic counseling, and a safe diagnostic amniocentesis or CVS test. CVS is a test in which a small amount of placental tissue is collected. Amniocentesis is a test in which a small amount of fluid from around the baby is collected for chromosome analysis.

What If My Early Screen Test Does Not Show An increased Risk?
This reduces your risk but does not rule out Down syndrome, trisomy-18 or ?13. They makeup only about half of all chromosomal abnormalities. Early Screen will detect some but not all of the other half of chromosomal abnormalities.

Who Should Be Offered Early Screen?
Early Screen should be offered to all women who will be less than 35 at delivery and have no family history of chromosomal abnormalities.

All women who will be 35 or older at delivery or have a positive family history are routinely offered Amniocentesis or Chorionic Villus Sampling (CVS) for prenatal chromosomal testing to diagnose 99.9% of all chromosomal abnormalities.

Early Screen is a screening test which does not diagnose or rule out any specific condition.

Women who decline amniocentesis may have Early Screen, but need to know Early Screen is not a substitute for Amniocentesis, because:

1) It does not give a diagnosis.
2) It estimates a risk for only 3 chromosomal abnormalities.
3) It will miss some chromosomal abnormalities which would be diagnosed by amniocentesis or CVS.
4) It may falsely reassure some patients who after screening still have an increased chromosomal abnormality risk due to age or family history.

What Other Tests Should I Have?
An Alpha-Fetoprotein (AFP) blood test or an ultrasound exam to screen for 98% of open spine.

Should I Have An Additional Second Trimester Screening for Down Syndrome and Trisomy 18?
NO. Repeating a second chromosomal screen is not recommended as standard of care. Why?

Because Early Screen is more accurate and less likely to give a false risk result than a repeat test. Any follow-up chromosomal screen test is more likely to give a false risk result and is unlikely to improve detection.

Should I Have Screening If I Plan To Continue The Pregnancy Under Any Circumstance?
You are being offered Early Screen because your physician feels it may provide information which will be helpful to you and your husband. It is entirely up to the patient if they want to pursue testing, it is not mandatory, as is any medical test, the patient has ultimate authority if they want to get a test or decline one.

What is formal Urodynamic Testing?
This is a special test to evaluate how the bladder functions. The study is recommended when a patient voices their concerns about their bladder or problems with loss of urine.

How to I prepare for Urodynamic Testing?
For the test to be beneficial, you must present to the office with a full bladder. If you do not feel you will be able to hold your urine, you may present to the office 30-45 minutes prior to the procedure and drink at least 32oz (4 glasses) of water while in the office.

What happens during the testing?
For the first part of the test you will be asked to simply empty your bladder.

The second part of the test evaluates the bladder function, which involves placing a very small catheter in the bladder and rectum.

Your bladder is then filled with fluid and several tests are conducted to evaluate how it functions

You should feel no pain or discomfort.

The entire test takes 30 minutes.

What is Uterine Prolapse?
A prolapsed uterus is one which has moved downward from its normal location in the pelvis causing it to bulge into the vagina. Sometimes the urethra and bladder are also affected (respectively called Urethrocele and Cystocele) and possibly the rectum (Rectocele).

How does Uterine Prolapse happen?
This situation happens when ligaments and muscles in the region become stretched. This can occur during childbirth or simply due to aging. Repeated vaginal delivery is the most likely reason although even one pregnancy can eventually cause a prolapse.

What are some other conditions that may lead to a prolapsed uterus?
Other conditions include: obesity, tumors, chronic coughing, chronic constipation, being out-of-shape and jobs requiring continuous heavy lifting.

Is a Prolapsed Uterus a health risk?
A prolapsed uterus is not a health risk and is usually treated non-surgically using exercises to improve muscle function.

What are signs and symptoms of a prolapsed uterus?
Signs and symptoms include:

• A vaginal mass or lump either on the side of the vagina or protruding from it.
• Discomfort when urinating.
• Leakage of urine when coughing, sneezing, lifting, laughing, etc. (stress incontinence).
• Low backache, worse with lifting.
• Painful intercourse.
• Painful or difficult bowel movements.

How is a prolapsed uterus diagnosed?
Diagnosis includes clinical appearance, URODYNAMICS testing (a test to identify the causes of incontinence), ultrasound or CT, IVP (intravenous pyelogram to study the urinary tract and kidneys). Other tests may include Pap smear and possible uterine biopsy.

What is the treatment for a prolapsed uterus?

• Kegel exercises to tighten muscles in the pelvic region.
• Hormone (estrogen) therapy. Estrogens increase blood flow to vaginal tissue increasing its strength and elasticity.
• Pessary inserted into vagina to help keep uterus in place, may be an alternative to hysterectomy
• Surgery to reattach the uterus, urethra or bladder.
• Hysterectomy may be necessary.
• Lose unnecessary weight.
• Try and prevent constipation; eat a diet rich in fiber and drink lots of fluids.

What happens if a prolapsed uterus is not treated?
If not treated, a prolapsed uterus can lead to cervical ulceration, blockage of the urinary tract and an increased infection risk to pelvic organs.
* CONSULT A UROGYNECOLOGIST. AUDREY ROMERO, MD FACOG of Rubino OB/GYN is a Urogynecologist