Being Well 1205: Women’s Health Issues


[music playing]
Lori:They’re the ones who raise the bar. The ones dedicated to providing care in the
most demanding of circumstances. The ones that understand the healing benefits
of kindness and compassion. They’re the people of Sarah Bush Lincoln,
and they set the bar high. Sarah Bush Lincoln, trusted, compassionate
care, right here, close to home. Male Voice:Carle is redefining healthcare
around you. Innovating new solutions, and offering all
levels of care, when and where you need it. Investing in technology and research to optimize
healthcare, Carle with Health Alliance, is always at the forefront to help you thrive. Rameen:
Meeting the ever changing in healthcare needs of our communities. Paris Community Hospital/Family Medical Center
is now Horizon Health, with the same ownership, management, providers and employees. Horizon Health provides patient care and promotes
wellness to the communities of East Central Illinois. Jeff:
At HSHS St. Anthony’s Memorial Hospital we are at work transforming heart care, rebuilding
knees and hips, delivering new generations, and focused on providing healthcare to you. We are HSHS St. Anthony’s Memorial Hospital. Ke’an: Hi, thank you so much for joining us
today for this episode of Being Well. I’m your host Ke’an Armstrong. We are going to be talking about a variety
of health issues concerning women’s health, and we’re going to focus primarily on pap
smears and abnormal bleeding. Joining me today is Dr. Maria Horvat with
Horizon Health. Thank you so much for coming today. Maria: Thanks for inviting me. Ke’an: This is a really important topic for
women and for the loved ones in their lives to understand some things that are happening
in their loved ones lives as well. Maria: Right. Well there’s a lot of, what we’re going to
talk about today are common problems that I see in the office. I thought it’d be a good topic to talk about
because it probably affects a lot of different people, or certainly people have experienced
these various things we’ll get to. Hopefully people will learn today. Ke’an: Yeah, I think so because lots of women
struggle with abnormal bleeding. Maria: Yes. Right. Ke’an: Which is a pain really [crosstalk]. Maria: A literal pain. Literally a pain in more ways than one. Ke’an: Yeah, so let’s talk about that. I want you to start to lead the conversation
here. What’s some things that people bring to you
for concerns when it comes to abnormal bleeding? Maria: Well, there’s a lot of different approaches
to abnormal bleeding. We can have a young patient, somebody who’s
11, 12, 13, 14 that the mother will bring to me with heavy menstrual cycles. For instance, most recently I had a patient
with that. Maybe the problem can be solved with birth
control pills, even though it sounds like they’re very young, but you can place a young
adolescent on oral contraceptive pills to control the heavy bleeding because they’re
missing school. But the other thing you’ve got to think about,
do they secretly have Von Willebrands, or do they have hemophilia that’s not diagnosed,
so you also have to be thinking of those particular problems. One form of bleeding in that age group is
just they have regular cycles, but it’s heavy. Then there’s the other group in the adolescent
group that has abnormal bleeding in that they’ll go four months without a cycle and then they’ll
bleed for 42 days, and then no cycle for nine months, and then finally some sort of cycle
for 14 days. That can be a sign of you’re not ovulating
the way you’re supposed to. It’s dysfunctional. A lot of those patients might have polycystic
ovarian syndrome, which is a common cause in that age group to have that sort of irregularity. Another reason for that sort of irregularity
may be just that their hypothalamic system between the ovary and the brain isn’t quite
developed yet. Ke’an: Is that due to their age, being younger? Maria: Due to the young age. Just like if you have a daughter who’s 11,
12 and starting her periods, it might be irregular at first, but then by the time they’re 13,
14 it becomes more regular. But if it’s not, you’ve got to think that’s
abnormal bleeding. The other concern in the younger adolescent
group would be they’re not having menstrual cycles. That can occur with ballet dancers, long distance
runners, because they don’t have enough fat to have a regular cycle. Those patients need to come in. Usually we put them on birth control pills
because when they don’t have a period it means they’re not getting enough estrogen. In that age group either you’re having regular
cycles, or you have the opposite, not enough cycles but then prolonged bleeding, or you’re
having semi-regular cycles with heavy bleeding. That’s all abnormal bleeding problems that
we can help you with. Ke’an: Are there tests to help you diagnose
one from the other and what may be going on? Maria: There is. One of the things that’s really helpful when
someone comes in is to have a menstrual calendar. To come in and a lot of times people have
well I think in December I had a period but I didn’t, but if it’s written down it’s so
extremely helpful to see what the pattern is. That’s number one, I need to see how long
has it been going on and what the pattern. Then usually with a young woman it’s blood
tests. There’s blood tests to help you determine
if there’s polycystic ovarian syndrome. There’s blood tests to determine if you have
some sort of bleeding disorder that’s been undiagnosed so far. Ke’an: Okay. Now are these things that can be handled primarily
with birth control, like you said? Is it something that’s longterm? Is it curable? Maria: Well, PCOS, which is polycystic ovarian
syndrome, isn’t curable. You pretty much have it and there’s nothing
you can do to take out the genetics of it. Usually to manage PCOS we approach the symptom,
what’s the symptom. Irregular periods and probably birth control
pills would be the answer, hirsutism, which is a lot of hair growth, birth control pills
can help with that and there’s another medicine called Aldactone. It depends what the symptom is. Or maybe you’re a little bit older and you
have PCOS and you want to be pregnant and you go nine months without a cycle. You’re not going to get pregnant if you’re
not ovulating. Then the treatments is a different approach. It kind of just depends what the particular
problem is with PCOS. If you just have run of the mill heavy cycles
that some people have and there’s nothing necessarily wrong but you have heavy periods,
probably the best option would be to go with the birth control pills because that will
decrease the flow at least 50%, if you’re on the right pill. Ke’an: All right. With the abnormal bleeding and the heavy bleeding,
I mean it’s such a struggle to deal with, and then sometimes you don’t know when it’s
going to start and sometimes you don’t know how long it’s going to last. Maria: Right. Ke’an: I mean it’s really an emotional roller
coaster too. Maria: Yeah, for a lot of people it really
is. Some people … Let’s go to the next age group
after the adolescent group. Then we go to the next age group, pretty much
you can say 17 to menopause. Then you have patients that just bleed super
heavy and there’s more options for treatment for those patients. We should talk about that a little bit. Ke’an: Yeah. Maria: Pretty much if you’re changing a pad
or tampon every two to three hours, that’s pretty much in the heavier side. Sometimes patients will come in and they’ll
think the period’s heavy, but they’re changing four pads a day. If I quantitate that, it’s probably not that
much changing a pad or tampon every six hours. But really if you’re changing every one hour,
two hours, three hours, I have patients that have to change every 30 minutes and they’re
staining their clothes. They are staining their sheets at night. Those patients should really come in to talk
about options. Ke’an: Well because it’s affecting their life. Maria: It is. Ke’an: They can’t really live because this
is such a drastic thing happening to them. Maria: I don’t have the exact numbers, but
the time off of work and the money that it costs with time off of work it actually goes
into the hundreds of millions of dollars in the United States. Ke’an: Oh yeah. Maria: So to control heavy bleeding, it just
buys you your life back. Unless you’re happy being at home sitting
having a heavy period- Ke’an: Which nobody is. Maria: No, no, no. You want to go to the ballgames. You want to live your life. You want to go to the wedding without-
Ke’an: And feel good. Maria: Yeah and feel good, not be anemic and
that sort of thing. The workup when somebody who’s older, again
the menstrual calendar kind of helps me determine a lot of different things. There’s two types of abnormal bleeding. There’s ovulatory bleeding, meaning you’re
ovulating, you’re having pretty much a cycle every 25 to 35 days, which is considered fairly
regular. Not everyone’s a perfect 28 days. Those patients tend to have more anatomic
problems such as a fibroid, which can cause heavy bleeding. Another reason for heavy bleeding would be
adenomyosis, which is actually endometriosis into the wall of the uterus. Those uteruses tend to be a little bit enlarged,
a little soft and boggy if I do surgery on them. But those would be the anatomical reasons
for heavy bleeding. Polyps can cause heavy bleeding, but you’ve
got to think off the grid sometimes. What if you haven’t seen a doctor in a while
and you have cervical cancer and that’s why you’re bleeding. Then there’s anovulatory bleeding, which means
it’s unpredictable. You’re bleeding for 42 days in a row. Ke’an: That just sounds miserable. Maria: It is. I’ve had patients, they come in, their hemoglobin
is four or five and I have to transfuse blood, get the situation under control in the short
run, and then decide upon a plan. Ke’an: Yeah, so people should really go to
the doctor regularly and get their annual checkups. Maria: Right. Ke’an: To make sure that they know what’s
going on with their body and if they are struggling with something like this that there are answers
and there could be help for them. Maria: Right. Then I stress again the menstrual calendar. Maybe little notes, super heavy today, or
super heavy for three days, because that gives me a clue that I should start a workup, which
we should talk about. In the average adult woman the workup would
be A, make sure you’re not pregnant and we’re not secretly dealing with a miscarriage or
something of that nature. B, what’s your blood count, are you anemic
or not anemic. C, I always get a thyroid test to see if somebody
is hyperthyroid. Usually it’s normal to tell you the truth,
but I still check it. Then, D, I always get a sonogram to see what
the size of the uterus is and see if there’s any big fibroids or something of that, something
unpredictable. I also have to make sure you’re up to date
on your pap smears. I might want to do something called an office
endometrial biopsy to make sure the lining is okay. Ke’an: Okay. Maria: What that entails, it’s usually a separate
office visit. The speculum is in the vagina and I have to
pass a small pipelle into the uterus and obtain just a little bit of tissue to send to the
pathologist. Ke’an: All right. Do you do that like a pap smear is done? Or explain the pap smear, the procedure for
that because there may be younger people watching who, or pass this information on to help explain
it to someone who’s never had one. Maria: Yes. Well, the pap smear and the endometrial biopsy
are two different things. Pap smear, most people would be familiar,
but if someone’s watching that’s younger what it entails is we place a speculum into the
vagina. Then we can visualize the cervix. Then we take a swab of the cervix and send
it to the laboratory. At the lab, in the old days it was called
a pap smear because literally it was a slide with a smear and we fixed it with hairspray
or a fixative, and a human being would be looking at that smear, but now it’s computer. It’s all, if you notice your pap smear specimen
we swirl it in a little cup and it goes to lab and with computer technology they’re picking
up the abnormal cells. It’s actually improved on. There’s less false negative, so we’re getting
more true positives by doing that. Ke’an: Yeah, which is good because when you
get something that’s concerning then you’re thinking oh my goodness, there’s something
wrong, something really wrong. But then sometimes you go back and it comes
back okay the second time and it was worry for nothing. Maria: Yeah, and that can definitely happen. Then an office endometrial biopsy is different
because the speculum is in the vagina, but I have to go higher up. I would say it’s more uncomfortable, but you
definitely have to go higher up and get that tissue to make sure everything’s okay. Ke’an: Yeah, it’s going to pinch. Maria: Yeah. I give locally anesthetic. Not all doctors do, but I do because I personally
wouldn’t want to feel so much of what’s going. Ke’an: Well, it’s [crosstalk 00:12:08]. Maria: Local anesthetic is always a good thing,
I think. We’ll get back to the pap smears in a bit,
but going back to the heavy bleeding, so options when somebody older are in general there’s
a shot called Depo Provera. It works well. It can stop your periods. You come in every three months. The problem is some people have an increased
appetite and can gain weight, so a lot of people don’t like that. Birth control pills can be okay, but if you’re
over 35 and smoke you can’t take the birth control pill. If you have hypertension, you can’t take the
birth control pill. There’s a lot of contraindications to that. We just, that’s something that you have to
discuss with your doctor about that. The third option would be a great option for
a lot of people is the Mirena intrauterine device. It’s one of my favorite choices for stopping
heavy bleeding. It provides contraception also, if you need
that, and it will stop your heavy bleeding. The side effects are some people can have
irregular spotting, and then some people can say they can feel it. But having done this for a long time, I’m
going to say 85% of people are satisfied. Another option would be an ablation procedure
where we actually burn the inside lining of the uterus, but we need you to be in the operating
room to do that. But some people do it in their office, but
you still have to have anesthesia in the office. I personally do it in the operating room because
that’s the setup that I have currently. Ke’an: Is it considered outpatient and you
go home that same day? Maria: Yeah. Ke’an: Okay. Maria: It’s an outpatient procedure. What it entails is preoperatively your biopsy
has to be okay, your pap smear has to be normal, your ultrasound has to meet some criteria. The other thing is you need permanent contraception,
so you can’t, you should not get pregnant when you have an ablation. I’ll get into that in a minute, but either
you had to have a tubal ligation or your partner has to have a vasectomy. The reason is once your uterus has scarred
and burned and in the healing process, if there was a conception, it’s not going to
grow normally. You can have an ectopic pregnancy, or it could
be up in the corner of the uterus and it can’t grow and it could actually blow out the corner
of your uterus because it can’t get into the uterine cavity. It’s almost a complete disaster, so you really
have to make sure that you are done having children before you have an ablation. Ke’an: Or if you are planning to have children
maybe talk about some of these other choices before you get to that point. Maria: Absolutely. Ke’an: Maybe that can come later down the
line if you still need it. Maria: Yeah, birth control pills, the Depo,
and the Mirena IUD is really great for somebody who’s not quite sure if they’re going to have
more children because all of these things are reversible. Ke’an: All right. Now the Mirena IUD, do you still have a regular
period if you have that? Maria: No, it stops. Ke’an: Okay. Maria: But when of the side effects is before
your period stops is you might spot spot, spot, spot, spot. It’s more annoying than it’s heavy. It’d be really rare, I mean maybe a couple
times I’ve had a patient expel the IUD because of the heavy flow, but maybe once every two
years that would happen and I place a lot of these. Then with these options a lot of people come
and say well my mom had a hysterectomy, my grandmother had a hysterectomy. I can tell you in the 90s, and I was in this
area in the 90s, I probably I would say 6 to 14 hysterectomies a month just depending
what was going on. Now it’s one hysterectomy like every two months. It has markedly decreased the need for hysterectomy. Ke’an: Wow. Maria: Yeah with these more modern outpatient
mechanisms. Ke’an: Yeah, there’s a lot more choices these
days. Maria: Right. Yeah. There’s still a role for hysterectomy, but
it’s really decreased because of these noninvasive ways. Ke’an: Yeah. Well speaking of hysterectomy, and you mentioned
pap smears earlier, I mean is there a need for women to still have a pap smear after
they have a hysterectomy? Maria: Depends on the reason that they had
the hysterectomy. If you had it for benign reasons like just
abnormal bleeding, chronic pelvic pain, fibroids, you do not need a pap smear at all after that
hysterectomy. If you had a hysterectomy for endometrial
cancer or cervical cancer, you need to continue to have pap smears. Ke’an: You mentioned birth control pills could
could be started at age 11- Maria: I’d probably hesitate, I would probably
say more like 12 and a half, 13. Ke’an: Okay, a little older. Maria: Yeah, a little bit older. Ke’an: Okay. Then is there a point where women need to
stop taking birth control? Maria: Oh. Well, not really. This is the thing about birth control pills. A lot of people, they think they need a break. I’ve been on it for four years I need to take
a break. You don’t need to take a break. In terms of future fertility, when you want
to have a child you stop the pill. Some people start to ovulate in one month,
but sometimes it takes up to nine months before you’re having regular periods after being
on the pill for a while. That can be, you have to put that into the
equation of when you want to stop. But the pills actually protective against
ovarian cancer and it’s protective against uterine cancer. Ke’an: Okay, that’s good to know. Maria: And so there’s no reason to stop. I have some patients as they’re transitioning
through menopause, let’s say you’re 50, you’re having bad periods, you don’t smoke and your
blood pressure is okay, you can go on birth control pills. Ke’an: Really, at 50? Maria: Yes. Ke’an: And for people who haven’t reached
that point in time where their body is changing and is done with that part of your life? Maria: Right. Ke’an: Really? Huh. Maria: But I use a lot of oral contraceptive
pills. Let’s say someone came in and they had heavier
menstrual cycles, we did our workup, nothing’s wrong, they’re busy, don’t want to do the
ablation. There’s nothing wrong with being on the pill
until you transition to menopause. A lot of people don’t know that that’s definitely
an option. Ke’an: Okay. Maria: Yeah. Ke’an: I want to go back to something you
mentioned earlier. It just came back to me what I wanted to ask
you about fibroids. Maria: Yes. Ke’an: Those can be removed as well. Maria: They can. If someone’s going to have a myomectomy, usually
that procedure is done more if you’re preserving your fertility. A myomectomy is actually much bloodier and
technically more complicated, especially if you’re doing it through the laparoscope, than
just doing a hysterectomy. Because what happens is you scoop out the
fibroid and there’s kind of a raw surface where the fibroid used to be and you have
to put it back together. There could be more blood loss with that than
the plain old hysterectomy. If someone’s done childbearing, I probably
would say why don’t you just do the hysterectomy. But if you’re going to have more children,
than I would say yes, just do the myomectomy is the name of the procedure. Ke’an: Okay. Maria: Sometimes people have fibroids not
just on the outside of the uterus, but inside the uterus. That I can approach vaginally and using certain
equipment I can remove a fibroid inside, whether or not you’re going to have more children
or not. Sometimes that can help some patients too. But if it’s on the outside and let’s say it’s
a five or six centimeter fibroid, you’d have to look at your future fertility and what
your wishes are. Ke’an: Yeah, so more choices, decisions to
make. Maria: Yeah, more choices. Yeah and the other choice we haven’t even
talked about is there’s an embolization procedure where you can have emboli that the radiology
department send to the fibroid and it causes it to become necrotic and shrink up. Ke’an: Oh. Isn’t that something. Maria: And that can help some people. Yeah, it’s interesting that that can be done. Ke’an: It is, so many different things. Maria: Yeah, there’s definitely options. Ke’an: Well we have just a couple of minutes
left. What have we not covered yet? Maria: Well, the pap smear schedules. We haven’t gotten to that. Ke’an: Okay. Maria: The age for the first pap smear is
21, which is a big change from you would start as soon as you’re sexually active. Now we wait til you’re 21. Then it’s every three years as long as your
pap smear was normal. Ke’an: Okay, so you don’t have to go every
year now. Maria: Well, you have to go in for your annual
exam, but the pap smear is just a lab part. We might not send the pap smear every year,
but we still want to see you in the office every year. Ke’an: Okay, so don’t skip it. Go every year. Maria: No. It doesn’t mean you get to skip seeing me. Ke’an: Well it’s not something people really
look forward to. Maria: No. Ke’an: You’re like oh I’ve got to go do this,
but it’s something you need to keep in check. Maria: Yeah, well everyone who comes in, even
this morning someone’s like I hate this. I’m just like we all do and I’d probably be
disturbed if you said you liked it. I know it’s like going to the dentist, or
like for me to go to the dentist, so I know that it’s not our favorite thing, but we do
have to take care of ourselves and get it done. But anyways, the pap smears are every three
years. If you’re a normal pap and HPV negative, you
can go every five years. In my book that’s a little bit long, but the
studies say we can do it. The maximum I’ll go is every three years. That’s what I’m comfortable with. Ke’an: Okay. Maria: We’ll have to see you more often if
the pap smears is abnormal. If it is abnormal, you’ll get that phone call
that it’s abnormal that we need to see you back and do a procedure called colposcopy,
where the speculum is in the vagina and I place a vinegar solution against the cervix. Abnormal cells pick up the vinegar solution
so that it turns white with the vinegar, so I know what I’m aiming for when I do a biopsy. I’ll take a few biopsies. That tells me for sure if something’s abnormal. If you get that phone call that you have abnormal
pap, it’s really a red flag. It doesn’t tell you what’s wrong. The biopsy, the actual tissue biopsy, will
tell me if you need further treatment or if we can just watch you. Ke’an: All right. Well, I’ll tell you what, this has been so
informative. Maria: Thanks. Ke’an: Being a woman myself, I mean just knowing
that there’s choices out there, you don’t have to put up with this in your life, and
knowing that you can make a change is really, really helpful. I really appreciate you being on the show
today. Maria: Oh, yeah. Well, thanks for inviting me. Ke’an: Yeah, thank you. We hope that you have received some helpful
information in this episode of Being Well, and we hope to see you next week. Jeff:
At HSHS St. Anthony’s Memorial Hospital we are at work transforming heart care, rebuilding
knees and hips, delivering new generations, and focused on providing healthcare to you. We are HSHS St. Anthony’s Memorial Hospital. Rameen:
Meeting the ever changing in healthcare needs of our communities. Paris Community Hospital/Family Medical Center
is now Horizon Health, with the same ownership, management, providers and employees. Horizon Health provides patient care and promotes
wellness to the communities of East Central Illinois. Male Voice:Carle is redefining healthcare
around you. Innovating new solutions, and offering all
levels of care, when and where you need it. Investing in technology and research to optimize
healthcare, Carle with Health Alliance, is always at the forefront to help you thrive. Lori:They’re the ones who raise the bar. The ones dedicated to providing care in the
most demanding of circumstances. The ones that understand the healing benefits
of kindness and compassion. They’re the people of Sarah Bush Lincoln,
and they set the bar high. Sarah Bush Lincoln, trusted, compassionate
care, right here, close to home. [music playing]

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