Because of our location in the Texas Medical Center, our combined years in practice, and our extensive experience, we are frequently asked for consultative opinions by patients or by other physicians. We are happy to provide this service for you. We can be most efficient for you if you can provide your old records, or records pertaining to your consult to us before or at the time of your consultation visit. With your permission, we will send a letter communicating our findings to your personal physician.

PAP SMEARS/DYSPLASIA
We are frequently consulted about the management of abnormal pap smears, and find that many women have been advised to have surgical procedures which may be unnecessary. Recent research indicates that “watchful waiting” may be the most appropriate therapy, and surgery may not be required. Also, when we determine that some form of surgery is necessary, we are often able to give you the option of having this done in our office rather than having to go into the hospital.

HYSTERECTOMY
Many patients want to know if their medical condition necessitates hysterectomy. Obviously, each case must be evaluated on an individual basis, and we will work with you to make the best decision. We may determine that no surgery is required, or that a procedure named endometrial ablation, which stops many problems with excessive uterine bleeding, may be a reasonable alternative to hysterectomy. If we determine that hysterectomy is required, it has often been our opinion that what has been proposed to you as having to be done as an abdominal case can in fact be done by us as a vaginal procedure. This will result in less time in the hospital, less pain, faster recovery, and no incision on the abdomen.

A new technology named focused high density ultrasound may also be an alternative to hysterectomy for uterine fibroids.

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Studies by epidemiologists eventually confirmed what had long been suspected, that being that abnormal pap smears have a sexual origin. Women who have never been sexually active do not develop abnormal pap smears, or cancer of the cervix, and men transmit this virus from one woman to another. In other words, cancer of the cervix is actually a sexually transmitted disease. Further, we have discovered that the maturing adolescent cervical cells are the most vulnerable to infection by the human papilloma virus (HPV). Virgins do not develop abnormal pap smears, and women in mutually monogamous relationships will not be at risk.

We also know that being infected with HPV does not mean that disease is bound to occur. Most women with an intact immune system will eventually be able to eliminate this virus and its effects from their bodies. However, not all will be able to, and this is partially due to the particular virus causing the infection. Some viruses are more aggressive than others, but we still do not know why some women develop cancer and others do not. Having multiple sexual partners, starting sexual activity at a younger age, and smoking are risk factors for developing cancer.

Using DNA technology, we have broadly categorized HPV into two types, those which are at "low risk" for inducing cancer, and those that are at "high risk" for causing malignancy. The DNA science will confirm whether the patient with an abnormal smear has been infected with a low or high-risk virus, or whether she has even been infected at all. Part of the imperfection in the Pap smear is that it can be over-read, i.e., the suspicion that the smear is abnormal is not confirmed if there is no HPV detected by DNA testing. Minimally abnormal smears without proof of HPV infection do not need further investigation or treatment.

With all of this relatively new information, the American College of Obstetrics and Gynecology (ACOG) and several government agencies have recommended that we consider changing the frequency with which we obtain pap smears, or ask the laboratory to perform different tests with the smear. We know that it takes about three years for newly infected cervical cells to manifest themselves, so Pap smears should commence three years after the onset of sexual activity, and be repeated annually in young women. After age thirty, assuming a mutually monogamous relationship (and that may be a huge assumption in modern society), it may be satisfactory to obtain a Pap smear combined with DNA testing every three years, rather than a Pap annually. The problem with this ACOG approach is that many women equate the "Pap smear" with "the annual gynecological exam", and many problems we detect early with the annual exam, such as uterine fibroids, ovarian masses, and breast problems will be delayed if patients think they need to come only every third year for a Pap smear. Medicare now will also pay for the Pap smear only every other year.

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Will you please do the Ca-125 blood test for ovarian cancer?
Often (and incorrectly) described on the internet as "The Test Your Doctor Doesn't Know About," the Ca-125 blood test is designed to aid in the detection of ovarian cancer, and the lay press encourages women to ask their physicians to obtain this test every year as part of their gynecological exam. The fear that women have regarding ovarian cancer is understandable-in 2002, there were about 23,000 cases in the U.S., and about 14,000 deaths, with the poor outcome due primarily to the advanced stage of the disease present when the diagnosis is made. Ovarian cancer is second in frequency only to cancer of the uterine endometrium, and there are more deaths from ovarian cancer than from the combination of cervical and uterine cancer deaths.

However, this is not a silent cancer. Some 70% of women recall having symptoms for 3 months before going to see their doctor, 35% had symptoms for 6 months, and only 5% were asymptomatic. The best method of detection is for both patient and physician to know the presenting signs and symptoms, and to maintain a high index of suspicion for this problem. The symptoms include abdominal bloating, an increase in abdominal girth, abdominal and pelvic pain, inability to eat normally (getting "full" too quickly),constipation, urinary frequency (from pressure on the bladder), and unexplained weight loss. When experiencing these symptoms, the gynecologist should perform a thorough pelvic exam, and obtain imaging studies of the pelvis, such as an ultrasound. In pre-menopausal women, the problem with the Ca-125 test is that it is exquisitely sensitive, but also quite non-specific. This means that it can be falsely elevated due to common benign conditions other than ovarian cancer, such as uterine fibroids, pelvic infections, endometriosis, adenomyosis, pregnancy, and even menstruation.

Additionally, the Ca-125 test is not always elevated in ovarian cancer. About 50% of early stage cancers, and 25% of advanced malignancies are associated with normal test values. In the largest study of test accuracy, some 22,000 women were screened with the blood test, and pelvic ultrasound if the blood test was elevated. 98% of the enrollees had a normal blood test, and 41(0.1%) had elevated blood test values and abnormal ultrasounds. These 41 patients were taken to surgery, and only 11 of them (0.05% of all of the women screened), had ovarian cancer. The false positive rate was 73% of those women who had surgery.

Unfortunately, there is not yet a really good test for this frightening pelvic malignancy. We do think it is appropriate when your symptoms suggest that there may be a problem, or if you have a first-degree relative (your mother or your sister) with a history of ovarian cancer. For the present, however, we do not believe that this test should be a "routine" part of every annual gynecological exam, and if it were to be done with the frequency with which it is requested, it would lead to a lot of unnecessary surgery, especially in the pre-menopausal population.

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When Should My Daughter Have Her First Visit to the Gynecologist?
The simple answer to this question is that she should be seen whenever she has a significant gynecological problem. We are comfortable seeing any age patient in our practice, and even infants can have gynecological issues which merit the attention of a gynecologist. However, the usual question is, "When does my teenage daughter need to see a gynecologist for the first time"? In Health Care for Adolescents, published by the American College of Obstetrics and Gynecology in 2003, the suggestion is made that the initial visit should be between the ages of 13 and 15. As ob/gyns, we are comfortable providing primary care for the adolescent, or we will be happy to work in a collaborative role as consultant to the adolescent's primary health care physician. The initial visit does not necessarily need to involve a pelvic exam, but instead it can be simply to establish rapport and to serve as a question-and-answer session regarding adolescent development, and a screening visit for common teen-age eating disorders.

What Methods of Contraception Are Available At Your Office?

1. Prescriptions for birth control pills, including the progestin-only pill suitable for use while breast-feeding.
2. Prescriptions for the "morning after" pill.
3. Prescriptions for birth control patches.
4. Prescriptions for birth control vaginal rings.
5. Prescriptions for diaphragms.
6. Out-patient surgical procedures for permanent sterilization, including laparoscopic bilateral tubal ligation, and the Essure procedure, a hysteroscopic technique that blocks the tubes at their entrance into the uterus.

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