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Some comments from our patients regarding the popular timed-release testosterone pellets:
"I feel more energetic and excited about life in general, but especially about my husband. I thought sex was over for me until I discovered the pellets."
"I had a hysterectomy with my ovaries removed a year ago. My sex drive had been waning before the surgery, but after I had the ovaries out it was gone. Now, with the pellets, I feel much sexier than I did before surgery!"
"I am so accustomed to how I feel with the pellets that I am always surprised at how badly I feel when they start to wear off. My husband usually notices it first, and calls to make my appointment for me."
"The pellets make me feel sharper and generally more excited about life. I was taking enough estrogen to eliminate my hot flashes, but I was still waking up into a dark cloud. A few days after I got the testosterone pellet, I started to feel happier and more energetic. I waited to see if my good mood would go away, but it did not!"
Testosterone timed-release pellets are inserted under the skin using a local anesthetic. The effects generally last for 2 1/2 to 3 months. If a woman needs estrogen, a combination of estrogen and testosterone pellets can be used.
If you think you would benefit from pellets, talk to your practitioner.
| Testosterone Timed- Release Pellets
Abnormal Bleeding - Hysterectomy or Medical Management |
It is with great excitement that I announce the addition of Nina Dereska, MD, to our practice. Nina has fellowship training in Urogynecology at Mayo Clinic. She is highly skilled in the area of pelvic reconstruction and advanced laparoscopic surgery. She will be seeing patients in consultation for surgery as well as providing general Gynecologic care.
Pelvic reconstructive surgery is necessary when a woman develops relaxation of the pelvic floor. Generally, childbirth provides the initial trauma to the tissue, but pelvic relaxation can develop in women who have not given birth, also. A woman may not be symptomatic for a long time, but after years of gravity and the deterioration of tissue strength that comes with age, she begins to notice symptoms. When a woman gives birth vaginally, the process can result in hernias of the strong fascial sheath around the vagina and the pelvic floor. These hernias can eventually result in bulging of the vaginal tissues and uterine prolapse. Symptoms include loss of urine with coughing or sneezing, difficulty having bowel movements, and the feeling that something is coming out of the vagina. Women with pelvic prolapse often feel a constant pressure in the pelvic area, especially with standing for long periods of time. Back pain can be a symptom, also. In extreme cases, the uterus or the vagina actually protrude.
Sexual problems are common in women with prolapse. They complain of feeling "loose" and "open." Sometimes they feel that something is blocking the vagina and intercourse is difficult. Women with prolapse almost universally feel that intercourse is less than satisfying.
Dr. Dereska, with her specialized training in Urogynecology, specializes in surgical correction of these problems. She performs surgery to correct urinary incontinence, cystocele, rectocele, and uterine prolapse. Many recent advances have been made in the area of prolapse surgery, and with her training at Mayo Clinic, she is on the cutting edge.
I know that Dr. Dereska will be an extremely valuable addition to our practice. She will be the only Urogynecologist at Scottsdale Hospital, and only one of four Urogynecologists in the Valley of the Sun. We are honored to have her.
Audubon is now undertaking a major initiative to bring the experience and love of all nature to a much broader population - school children and the families to which they belong, especially children and families in areas of the state that have little opportunity to commune with and appreciate nature. Audubon Arizona, to this end, is currently in the process of building a nature center along the Rio Salado project. This will be a place where families can come and learn about the value and beauty of nature and the importance of preserving our precious and rapidly diminishing natural resources.
Dr. Wilson will be doing a Bird-A-Thon with a long time Audubon member and bird watcher extraordinaire, Frank Brandt on Saturday, June 19. As you know, she is bird lover and wants to do her part to protect our natural resources. On her Bird-A-Thon, she plans to go out in search of as many species as possible in one day. She is asking for her bird lover friends to pledge a dollar amount ($1.00 suggested) per bird species that she and Frank spot or a flat dollar amount. ALL of the proceeds will go to Audubon Arizona to carry out its work.
How do you support and pledge the Bird-A-Thon?
1. E-mail your pledge of a dollar amount per bird species spotted, or a flat dollar amount to: birdathon@drwilsonobgyn.com (Subject Line: Bird-A-Thon Pledge)
2. We will let you know after June 19 how many bird species Dr. Wilson and Frank spotted and you can then send your tax deductible donations to:
- Audubon Arizona
4250 East Camelback Road
Phoenix, AZ 85018 - Or call 602-468-6470 to pay with credit card (VISA, MasterCard, American Express)
For more information about Audubon Arizona, you can e-mail them at jlayne@audubon.org.
Please be generous and think of Dr. Wilson trudging around the Kachina Wetlands in Flagstaff on a rainy morning in June while you are out by your pool. Thank you, Audubon thanks you, and the birds and other creatures thank you.
Urinary incontinence is the eighth most common chronic medical condition among women in the United States, and has a significant social, medical, and financial impact. Thirteen million adults suffer from urinary incontinence, with annual health care costs estimated in excess of 12 billion dollars for women in the United States alone. Despite these statistics, many women do not seek care for urinary incontinence as they are too embarrassed to discuss the condition with a physician, or because they consider it a normal outcome of the aging process.
Multiple forms of urinary incontinence exist including stress urinary incontinence, urgency incontinence, overflow incontinence, nocturia (urine loss at night only), and urethral sphincter deficiency. It is important for your physician to perform a thorough history and evaluation to determine which type of incontinence is present, as each type has different characteristics and different treatments. This article will focus on stress urinary incontinence (SUI), the most common type of incontinence in women. This type of incontinence is characterized by instantaneous leakage of urine with physical activity or straining such as coughing, laughing, sneezing, or heavy lifting. The exact cause of SUI is still unknown and poorly understood, but certain risk factors can increase your chances of developing the condition. Certain medical conditions such as obesity, diabetes, chronic lung disease (asthma, chronic obstructive pulmonary disease), and congestive heart failure are considered risk factors. Additionally, neurologic problems such as multiple sclerosis and stroke can also predispose to the development of SUI. Birth history in women is also very important, but controversial regarding its true impact on SUI. Information that will be helpful to your physician includes the number of births (vaginal vs. C/Section), the weight of each child, the use of a vacuum or forceps to deliver each child, and the need for an episiotomy to facilitate the birth of your child. It is generally accepted that multiple vaginal births result in injury to the structures within the pelvic floor (muscle, nerves, and connective tissue), and can lead to SUI. Finally, lifestyle habits and certain medications can also contribute to the development of SUI. It is important to provide a list of all medications and herbal remedies you use on a regular basis to you physician, whether they are prescription medications or over-the-counter medications.
Evaluation for SUI will involve a combination of detailed medical history, physical examination, and diagnostic tests. In addition to providing your medical and surgical history, many physicians will ask you to fill out a voiding diary for 3-7 days to better assess your symptoms at home. This will involve information about the amount of fluid you drink per day, how many times you urinate, how many times you leak urine, and what activities were associated with the loss of urine. The physical examination will include a pelvic examination where your physician will assess the support of the bladder and pelvic floor. Additionally, a neurologic exam will be performed to evaluate the reflexes and sensation of the pelvic floor muscles. Several diagnostic tests may be performed to better characterize the type of incontinence before discussing treatment options. The first test is cystometry, or the "bladder fill," where the bladder is slowly filled to capacity through a temporary catheter placed in the urethra (the tube leading to the bladder). Once the bladder is full, the catheter is removed and various exercises are performed in attempt to elicit urinary leakage. A more detailed test that the physician may recommend is called urodynamics, which is usually performed by a nurse or practitioner with specialized skill in the area. This will provide the physician with information about the bladder size, bladder activity and pressure, ability of the bladder to empty properly, presence of urinary incontinence, and problems with the structure of the urethra.
Once the diagnosis of SUI has been established, various treatment options are available. Information from your medical history, physical examination, and diagnostic tests will be helpful in determining the best treatment options. Fortunately, there are both surgical and non-surgical options available. Non-surgical treatments can include re-training of the pelvic floor/bladder muscles, behavior/habit modification, voiding strategies, and temporary devices inserted into the vagina or urethra to prevent urinary leakage. Minor surgery is an option for some patients with a weakness in the urethra, where certain "bulking agents" can be injected into the muscle of the urethra to enhance its strength. Finally, surgery can be performed to suspend the bladder and urethra in the proper position to avoid leakage of urine with activity. Depending on the severity of incontinence and physical examination findings, surgery may be performed either through a small abdominal incision or via a small incision on the vagina beneath the bladder. It may be necessary to place permanent materials during surgery that function to suspend the bladder and urethra. Following surgery, it is important to preserve the repair by refraining from heavy lifting and vigorous exercise for at least six weeks. Long-term care following surgery may also involve regular pelvic floor exercises, and of course, good judgement regarding physical activity is mandatory for a successful procedure.
Hot flashes can occur infrequently (monthly or weekly), or hourly. Hot flash frequency peaks in the early evening hours, about 3 hours after the peak in core temperature. Estimates are that 75% of women experience hot flashes.
Women who have their ovaries surgically removed experience more dramatic symptoms than women who go through menopause naturally, but over time, symptoms become similar.
Various lifestyle and social factors are related to hot flash frequency:
- Warmer temperatures increase a woman's core temperature and make her more likely to reach the sweating threshold.
- Cigarette smoking increases the risk of hot flashes.
- Less physical active women have more hot flashes, but women who do exercise may experience symptoms while exercising.
- Emotional stress and consuming spicy or thermally hot foods may bring on hot flashes.
In the 5 to 60 seconds before a hot flash occurs, skin temperature, blood flow to the skin vessels, and heart rate begin to increase. An individual hot flash generally lasts 1 to 5 minutes. During a hot flash, skin temperatures rise as a result of dilation of the skin vessels.
Most women experience a wave of heat sensation that spreads over the body; particularly the upper body and face. Sweating occurs primarily on the face and head. Modest heart rate increases of about 7 to 15 beats per minute occur.
Lifestyle modification can reduce the frequency and severity of hot flashes.
- Lowering temperature by using a fan or consuming cool liquid. Increase daily physical activity.
- Stop smoking.
- Slow, controlled breathing can decrease the severity of a hot flush when performed when a hot flash begins.
Non-prescription remedies:
- Soy isoflavones can reduce symptoms slightly. Women convert one of the isoflavones found in soy to equol, which is a very mild estrogen.
- Black cohosh has not been scientifically proven to reduce hot flashes, but anecdotally, it works.
- Dong Quai, a Chinese herb, reduces the incidence of hot flashes by 25-30%.
- Topical progesterone products vary widely in their make-up and how they are used, and clinical trials have had mixed results.
Prescription therapies are the most effective means of controlling or eliminating hot flashes. Estrogen therapy, although controversial, will effectively eliminate hot flashes in the proper doses and dosing schedules. If a woman has had a hysterectomy, estrogen can be taken alone. However, if a woman has a uterus, progesterone must be taken along with estrogen. There is evidence that the combination of estrogen and progesterone can increase the risk of breast cancer.
Progesterone alone can be used to control hot flashes as well. Both synthetic and "natural" progesterone seems to be effective, although bloating, weight gain, fatigue, and irritability can be side effects.
For women who cannot take hormones, the anti-depressant Venlafaxine (Effexor) is quite effective in reducing hot flash frequency. The effect is relatively rapid, with full effect noted in 1 to 2 weeks. Fluoxetine (Prozac) works well, also.
The antihypertensive, Clonidine, will reduce hot flashes. Clonidine, unfortunately, has side effects that many women cannot tolerate, such as dry mouth, drowsiness, constipation, and itchiness under the patch.
In conclusion, for mild hot flashes, lifestyle changes alone or combined with a non-prescription remedy should be considered. Prescription hormones remain the gold standard for treating moderate-to-severe menopause-related hot flashes, but hormone treatment is controversial. If you are uncomfortable taking hormones, or you have a medical condition that prohibits you from using hormones, ask your practitioner about an alternative such as Effexor or Prozac.
When a woman comes into the office with abnormal uterine bleeding, we recommend a standard workup. We obtain an aspiration of the cells lining the uterus and send it to the pathology lab. The pathologist looks for abnormalities such as hyperplasia (overgrowth of the uterine lining), and cancer of the uterus, which can cause abnormal bleeding.
We order an ultrasound, which will tell us if the bleeding may be due to fibroids, adenomyosis, or polyps. We may follow with an office hysteroscopy, which involves placing a skinny camera inside the uterus to look for polyps or fibroids growing into the uterine cavity, a common cause of bleeding.
Depending on the results of the testing, we will make a recommendation. If the patient has large fibroids, significant adenomyosis, or cancer, a hysterectomy will be recommended, because medical management will not be successful in these patients. If we have found polyps, we may recommend removing the polyps.
If the pathologist describes hyperplasia, we generally recommend one trial of medical management using high dose progesterone. A three month course of therapy results in a "chemical D&C" and often cures the problem.
Some patients bleed for no apparent reason, however. The biopsy and the ultrasound can be completely normal. In these patients, we generally recommend medical management in the form of progesterone or combination estrogen/progesterone. If medical management is unsuccessful, then surgery is considered.
This article confirms what I have observed; the women who undergo hysterectomy for abnormal bleeding are generally happier. Medical management can sometimes clear up a bleeding problem swiftly, but often the bleeding is only partially relieved. Even if the bleeding is stopped, the effect can be only temporary.
Most insurance companies demand that women who are suffering with abnormal uterine bleeding undergo a "trial of medical therapy" unless the condition is clearly treatable only by surgical intervention. If the therapy fails, however, surgery is usually accepted as the proper treatment.
Hysterectomy used to be considered major surgery, requiring five or more days in the hospital and six weeks recovery. The risks were significant and the procedure was saved as a last resort. These days, laparoscopic hysterectomy is appropriate for almost any patient requiring a hysterectomy. The procedure itself is rarely complicated, and the recovery is swift. Most patients are back to their normal level of functioning in a week or so. We generally keep our patients in the hospital overnight, but many centers send laparoscopic hysterectomy patients home the evening of the surgery. Given all of these factors, I am of the opinion that a woman should have the option of pursuing a hysterectomy if uterine bleeding is compromising her lifestyle and comfort.
Q. Suzanne Somers says that I should be on "bioidentical" hormones. Should I switch?
A. You probably already are on bioidentical hormones if you have had them prescribed by this office. Any formulation of estradiol (Estrace, Climara patch, Vivelle patch, Gynediol, estrogen pellets, etc.) is bioidentical. Premarin is not bioidentical, since it is obtained from pregnant mare's urine. Prometrium is a bioidentical progesterone, but provera (medroxyprogesterone acetate) and aygestin are not. You can also obtain bioidentical hormone preparations from compounding pharmacies, such as Apothecary. The advantage of doing this is that these pharmacies formulate a combination of micronized hormones tailor-made for your needs. The disadvantage is that your insurance company may not pay for this.
Q. Suzanne Somers says in her book that my sex drive can be completely rejuvenated by using estrogen and testosterone. Is this true? I am 62 years old and have not felt a sex drive in years.
A. In my opinion, while some sexual desire can be stimulated, you cannot expect to feel the way you did when you were 30. Sex drive in a woman is a combination of estrogen, testosterone, and psychology. We can replace estrogen and testosterone, but we can't do much for the other part. In a normal woman, estrogen levels start to drop in the late 30's and continue to slide until she reaches menopause at approximately age 50. Testosterone levels drop later and low levels of testosterone persist for a few years after menopause, but eventually disappear also. If a woman has had her ovaries removed, estrogen and testosterone plummet to almost zero as soon as the surgery is completed. Estrogen replacement is available in pill form, patches, timed-release pellets, and creams or gels. Testosterone is available in pill form, creams or gels, and timed-release pellets.
Q. Suzanne Somers says that even though I am in my late 50's, it is important for me to take my estrogen and progesterone in such a way that I bleed once a month. Right now I am on the Climara patch and a Prometrium pill daily. I don't bleed at all, and I like it that way. Is there any reason to change?
A. While I appreciate Suzanne Somers for writing a book that discusses the positive aspects of hormone replacement therapy, I disagree with her on this point. She states that a regimen of daily estrogen and progesterone, which is meant to avoid bleeding episodes, is unhealthy because it simulates the pregnant state. This is inaccurate. The pregnant state does involve steady levels of estrogen and progesterone, as opposed to the cyclic estrogen and progesterone levels produced by the ovary in the non-pregnant state. But the levels of hormones produced by the body during pregnancy are much, much higher that what you are receiving in your HRT prescription. In fact, it can be argued that because we are having fewer babies and not breast-feeding as long as we did years ago, we women are having many more periods than we are designed for in our lifetimes.
Q. Suzanne Somers says that I should have my blood hormone levels checked regularly. Is this true?
A. I am much more interested in how you feel than what your blood levels are. If you want your levels checked, we would be happy to do it for you, but remember that a certain blood level of estradiol may feel great to you and inadequate to someone else. I generally start a patient on what I think would be an adequate hormone dose and adjust it according to symptoms. I will draw a blood level if I raise her dose a few times and she is still symptomatic, or if she is having symptoms of too much estrogen. Particularly when we are using estrogen pills, we find that absorbtion can be a problem and we may need to consider switching to another route of administration, such as the patch or the pellet.
Q. Suzanne Somers has had breast cancer and is taking estrogen. I have had breast cancer, and my oncologist has clearly stated that under no circumstances am I ever to even think of taking estrogen. Why are her doctors prescribing it to her if it is so dangerous?
A. Hormone replacement therapy in a woman who has breast cancer is very controversial. The generally accepted rule is that hormones can stimulate residual breast cancer cells and increase the breast cancer recurrence rate. In fact, research does not necessarily support this, but you will not find many doctors to write you a prescription for hormones, nevertheless. The bottom line is that we really don't know whether hormones increase the risk of recurrence, but the consequences of a mistake are so grave that most of us are not willing to take the chance.
If you are interested in an extremely informative book on menopause written by a well-respected physician, read Elizabeth Vliet's book Screaming to be Heard.
As nice as this shelter will be, these pets have a common dream; a family to love, a warm lap to lie in, or a gentle pat on the head.
Currently, on the Navajo reservation, 5,500 dogs are euthanized per year. Due to the lack of funds and shelter space, one of the current solutions is to subject stray dogs to "round-ups" and extermination by gunfire. A few shelters exist, but due to lack of funding, all animals in the shelters are euthanized on Fridays, since there is no staffing on
weekends. This means that a dog could enter a shelter on Friday afternoon at 2 pm and be euthanized at 4 pm.
The Coconino Humane Association in Flagstaff until recently euthanized 50% of their adoptable dogs and cats, approximately 2,500 annually. Fortunately, PetSmart opened a store in Flagstaff in 2003, and is taking small dogs and cats off the euthanasia list and adopting them to people who visit the store. This, however, still leaves the large dogs, and many of them are euthanized. Dr. Wilson has adopted 7 dogs and 3 cats from Coconino Humane. In fact, Noah, who you may have met at the office, was at Coconino Humane for 2 weeks and came close to being euthanized.
One of the saddest aspects of this abysmal situation is that any animal that is sick, injured, or too young to live in a traditional shelter environment is euthanized immediately. Many of these animals could be saved with a small amount of treatment...or simply with the gift of time.
Against this backdrop of uncared-for animals being put to death for lack of space, staff, and money, there are thousands of homes wanting to adopt dogs and cats. Animals from the reservation seem to be particularly appealing, and if there were space to hold them, extremely adoptable.
Second Chance Center will open its doors in September of this year. We envision a day when all companion animals in Arizona have a good home and all unnecessary euthanization is eliminated. Second Chance Shelter is a state-of-the-art animal shelter that will provide adoption services and care for homeless pets. It will also offer low cost spay and neuter services as a complement to the already existing Plateauland Mobile Veterinary Clinic, which offers spay/neuter clinics on the Navajo Reservation and other disadvantaged areas.
The 2 dogs listed below are currently on the euthanasia list at Coconino Humane Association. Can you help find them a home? We also have many cats, and particularly need homes for mama cats after their kittens are adopted out. Call Dr. Wilson if you can help!
Rottweiler. Male, approximately 6 years old. Friendly, healthy. Came in as a stray, nobody claimed him. Desperately needs a home- preferably someone who is familiar with this wonderful breed.
Shepard mix. Male, approximately 3 years old. Black and white. Very friendly and sociable. Has been there since April 12 and will be euthanized if no one claims him. Stray, no history available, but obviously belonged to someone who loved him.
If you are interested in more information about Second Chance Center for Animals, in receiving the "Second Chance Scoop" newsletter, or making a tax-deductible donation, contact us at www.secondchancecenter.org.
Illustrations: "Types of pelvic support problems."; Copyright ©September 1999 by the American College of Obstetricians and Gynecologists.
Copyright ©2004 Dr. Deborah Wilson, eNews Design and Bird Photography ©2004 The Rogers Group, Inc. All Rights Reserved.