Within the last few weeks there has been some controversy generated in the media concerning a procedure called uterine artery embolization, which is a therapeutic technique to treat uterine leiomyomata (fibroids in the uterus). The controversy resulted from a front page article in the Wall Street Journal, suggesting that gynecologists were not recommending the procedure because it would prevent them from doing hysterectomies. The response from the American College of Obstetrics and Gynecology (www.acog.org) is worth your time if you are interested.

Here at University Ob/Gyn of Texas, we have been actively recommending this treatment option to our patients when it is appropriate. The technique is actually done by an invasive radiologist as part of a scheduled 23 hour outpatient admission to Methodist hospital. The radiologist inserts a catheter into the femoral artery (located in the groin) and then threads the catheter into the uterine arteries, and injects polyvinyl alcohol pellets into the arteries to block the blood supply to the fibroids. The fibroids, deprived of their blood supply, usually shrink significantly and are no longer a problem. The hospital’s pain service is also utilized, as the degenerating fibroids can be quite painful, and an epidural anesthetic is required for pain relief prior to, during, and following the procedure.

The advantages are that this procedure does not involve removal of the uterus. The potential complications include the fact that the procedure does not always work, and the process does not prevent more fibroids from growing in the future. Additionally, the patient should not plan to have any more children, as the process weakens the walls of the uterus, and a pregnancy following the procedure could result in uterine rupture during pregnancy. Also, the fibroids need to be in a quite specific location or the procedure is not going to work.

An MRI of the pelvis is necessary to localize the fibroids in the uterus and determine if they are amenable to embolization. From a cost standpoint, adding the cost of MRI to the cost of the procedure itself means that it is essentially the same price as vaginal hysterectomy. There is the potential benefit of being able to go back to work a few days earlier following embolization, but we are usually able to allow our patients to go to work within 10 days of vaginal hysterectomy.

The bottom line is that the embolization procedure is available, and if fibroids are a problem for you, we will be happy to discuss embolization as well as other treatment options.

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There are challenging articles in a recent issue of the New England Journal of Medicine regarding pregnancy in women who have an underactive thyroid gland and who are taking supplemental thyroid hormone. The study by Alexander and the accompanying editorial by Toft suggest that the requirements for thyroid hormone increase rapidly and early in pregnancy, possibly as early as the fifth week of gestation, which is practically the time when many of our patients are getting their pregnancy tests done and confirming their pregnancy.
Currently, thyroid function tests are not a standard part of the pregnancy test panel, but studies like these will increase the likelihood that they may become so in the future. The reason for the importance off proper thyroid function, or for supplementing the underactive thyroid is that mothers who have untreated or undertreated hypothyroidism in pregnancy are statistically more likely to have children with impaired neuropsychological development and lower IQ test scores.
The simple, safe way to avoid the problem is to see us for thyroid testing prior to a planned pregnancy if you are hypothyroid, and be sure you are on the right dose of thyroid hormone. Testing prior to conception is also indicated if there is a strong positive family history of thyroid disease, or if there is an organ specific type of autoimmune disease, such as diabetes or lupus.
For the patient who is taking thyroid supplement, until you can get in for testing, it is safe and reasonable to take two extra doses of your current thyroid medication per week in early pregnancy. This would mean taking an extra dose on Tuesday and Friday, for instance. Then schedule that appointment with us and let us confirm you are on the right dosage..

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As the summer has come to an end and cooler temperatures approach, we are once again impressed with the number of cases of vaginitis, or inflammation of the vagina we have seen in the past several months of hot weather. In our hot, humid Houston climate, patients are at increased risk for developing yeast infections in the vagina and on the labia. The yeast organism is usually present routinely on labial and vaginal wall surfaces, and is not problematic unless overgrowth of this organism occurs. This is more likely in a dark, warm, moist environment, so we encourage loose fitting clothing, all cotton underwear, and not wearing underwear to sleep in at night. Also, staying in a wet bathing suit or in gym clothes after a workout increases the risk for yeast infection.
Taking antibiotics will occasionally kill the normal healthy bacteria which inhabit the vagina, and yeast overgrowth may occur in that circumstance, and diabetic women are at increased risk for yeast infection.
Symptoms of yeast infection frequently include a thick, curdy, white vaginal discharge accompanied by itching. Therapy is with over-the-counter preparations designed specifically for yeast infection, or with an oral prescription tablet that needs to be taken only one time for most women to eradicate the infection.

Not all vaginitis is caused by yeast. The problem may also result from a bacterial infection, and is called bacterial vaginosis. In this instance, there is occasionally a grayish-white discharge with a fishy odor. This type of infection is probably not sexually transmitted, and usually responds to oral antibiotic therapy with a drug named metronidazole or with a vaginal antibiotic cream named clindamycin.

Another form of vaginitis is called trichomoniasis, and is caused by a protozoal organism named Trichomonas vaginalis. This is considered to be a sexually transmitted disease, and therapy for both partners is indicated when this diagnosis is made. The therapy for this infection is also metronidazole or a newer drug named tinidazole. When we make a diagnosis of trichomoniasis, we are always concerned that there could be other sexually transmitted diseases, so we will routinely screen the patient for the possible presence of other infections.

In the post-menopausal patient, we are frequently confronted with atrophic vaginitis, which results in dry, thin, pale vaginal mucosa and painful intercourse. This is due to lack of estrogen hormone production, and can usually be remedied with topical estrogen creams.

It is extraordinarily difficult for us to make the correct diagnosis over the telephone. Since the advent of over-the-counter therapy for yeast infection, studies have shown that women frequently delay getting the appropriate therapy for vaginitis by using a medication for a yeast infection when another problem is present. If you think you have a vaginal problem, make an appointment and let us take a look and be sure you get the right therapy.

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Oral contraceptives have been in use now for well over 40 years. For the generation currently using them and other hormonal forms of contraception, it is hard to imagine what birth control was like before they came into existence. Like many other medicines, the longer they are available, the more we learn about them and how to use them effectively.
Within the last several years, we have encouraged some women who have menstrual migraine, severe pre-menstrual syndrome (PMS), or heavy bleeding in the week off of the pill to stay on pills all of the time. This means that they will take an “active ingredient” pill every day and not stop the pill to have a programmed menstrual cycle.
There is now a new pill on the market (Seasonale) which is designed to approximate this concept, in that the active ingredient pill is taken for 84 days in a row, and then no pills for 7 days, causing the patient to menstruate 4 times in twelve months.
While it is biologically true that a non-pregnant, non-nursing, non-pill taking woman will menstruate normally every month, it is also true that only in the last century that women are in fact doing this. In prior, primarily agricultural economies around the world, women of childbearing age were usually either pregnant or nursing, and not menstruating with near the frequency that women in 2004 do.
The concept of using pills “continually” and not menstruating has been around now for about a decade, and the track record is excellent. This is safe, proven effective therapy for a lot of menstrually related problems, and the end result can be achieved using pills, patches, or vaginal contraceptive rings. If you’re miserable for whatever reason when you menstruate, come see us and we can make that stop.

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We are frequently asked by women who initiate their pregnancy care with us if it is safe to consume alcohol in "light" or "moderate" amounts throughout the course of their pregnancy, or if it is okay to drink wine or beer as opposed to "hard liquor."
A recent article by Sokol et al in the Journal of the American Medical Association discusses this issue in detail, defining "light" alcohol consumption as 1.2 drinks per day, "moderate" consumption as 2.2 drinks per day, and "heavy" drinking as 3.5 drinks or more drinks per day. With those definitions in mind, it is also important to realize that there is no difference in the alcohol in any drink--there is just as much alcohol in 12 ounces of beer as in 5 ounces of wine as in 1.5 ounces of liquor.
Sokol's article stresses the fact that we do not know what constitutes a safe "threshold" for alcohol consumption during pregnancy, in that recent reports demonstrate impairment for the infant if the mother has consumed the equivalent of only 1/2 drink per day during the course of the pregnancy. The adverse effects for an infant run across a wide spectrum, from learning problems and mental retardation to mood disorders and impulse control disturbance.
It is not possible to quantify exactly how much alcohol is required to cause full-blown fetal alcohol syndrome, but there is probably a correlation with the amount of alcohol consumed and the extent of adverse effect on the fetus.
Excess maternal consumption of alcohol during pregnancy has been identified as the leading cause of preventable birth defects in the United States. Both the American College of Obstetrics and Gynecology and the American Academy of Pediatrics have endorsed a policy of abstinence for both preconceptional and pregnant women. Will a single glass of champagne during the course of your pregnancy impair your infant for life? Probably not, but we do not know how much alcohol is safe during pregnancy, and we will never be able to design a study that can ethically answer that question. We do know that alcohol is not on the list of required nutrients for you to have a healthy infant, and we strongly encourage you to abstain if you are pregnant or trying to conceive.

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Within the last several months, there seems to be increasing public awareness of the obesity epidemic which is confronting the United States and the world. Newspaper articles, television reports, and federal commissions are looking at the problem. As obstetricians, we have a long standing concern with this condition and the risk that it brings to the pregnant mother. Obesity is, as you may imagine, a difficult subject to discuss with the newly pregnant patient. Pretending the problem is not there is not going to make it go away. Fifty years ago, expectant mothers were told to limit their weight gain to 12-18 pounds, because there were concerns that excess weight gain would result in gestational hypertension and pre-eclampsia. We now know that excess weight gain is not the sole cause of this problem, but we also know that we do observe more of this problem when the mother is overweight at the beginning of the pregnancy. Additionally, obese mothers are at increased risk for developing gestational diabetes, having cesarean sections because of having babies too large to deliver vaginally, and having blood clots (thromboembolic disease) during the pregnancy.

We also have recent evidence confirming that children born to obese women are twice as likely to be obese by the time they are four years of age, and unfortunately, obese children are more likely to be overweight as adults. Therefore, our recommendation to the woman considering pregnancy is to get within ideal body weight limits before conceiving, and stay within the recommended weight gain of 22-27 pounds during pregnancy.

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An excellent article appears in the May 6, 2004 issue of the New England Journal of Medicine by Drs. Kimberlin and Rouse, regarding genital herpes. Abstracted below are pertinent facts from their report.

The incidence of genital herpes is increasing in the United States, with a 30% increase in the detection rate of antibody to herpes simplex virus type 2 (HSV-2, usually considered the type associated with genital herpes) since the late ‘70’s. Now, among adults over 30, one in four has HSV-2, but most do not know they are infected. Additionally, herpes type 1, (HSV-1) which causes oral fever blisters, can also be transmitted to the labia by oral-genital contact, and this accounts for about 20% of the symptomatic cases of herpes in the U.S.

Once infected, the herpes virus can remain in a latent state in the nerve tissue indefinitely, with periodic reactivation being caused by fever, stress, or other illness. Recurrent disease is not always symptomatic, but even without symptoms, recurrent disease increases the risk of viral shedding and infection of a sexual partner.

Incubation after exposure is about 4 days (range, 2-12), and in the classic case, presents with blisters, crusting, and ulcers, all of which are painful. However, acute infection does not always have these profound symptoms, and primary infection can occasionally be asymptomatic.

Within one year of initial infection, 90% of patients will have at least 1 recurrence, 38% will have 6 or more recurrences, and 20% will have more than 10. These are not always symptomatic. Viral shedding, and the potential for infecting a partner, are increased during these episodes of recurrence.

The risk of having recurrent disease, and the risk of giving the infection to a partner can be reduced by taking antiviral drugs on a continuous basis, and condom use will also decrease the transmission risk, but neither is 100% effective.

As obstetricians, one of our main concerns is the possibility of transmitting the herpes virus to an infant as it comes through the birth canal. This risk is greatest if the mother is experiencing her first ever episode of herpes as the child is being born. Cesarean section can significantly decrease the risk of this infection, and while the definitive evidence to support the concept is missing, most obstetricians use suppressive therapy to try to reduce the risk of recurrent infection in the last several weeks of a pregnancy.

The correct diagnosis is always the right place to start, and this is a problem that needs in-office visualization and culture for confirmation. If you think you have a problem with herpes, please come in for an exam.

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Effective May 1, 2004, we can now perform bone mineral density testing in our office with a new, state of the art DEXA machine, which measures bone density in both hips and the lumbar spine. This painless test is designed to diagnose and monitor treatment for osteoporosis, a “silent” disease with no early warning symptoms.

A recent study of over 200,000 women by the National Osteoporosis Foundation determined that 50% of them had undiagnosed low bone mass (either osteopenia or osteoporosis). If untreated, this disease can result in fractures of the wrist, spine and hip. Over 50% of patients with hip fractures require admission to the nursing home, and another 25% of these patients will die within the year from complications of the hip fracture. We are especially concerned in 2004 about this disease because so many women have stopped taking hormone therapy, which has been proven in multiple studies to prevent bone loss.

If you are menopausal, and have not been tested, or have been diagnosed with osteopenia or osteoporosis, please inquire about getting the DEXA study done in our office at your next visit.

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Until the test has been validated by clinical trials in large numbers of patients, it should be used only to screen the high-risk patient population, that being the woman with an ovarian mass suspicious for ovarian cancer, the woman who has a first-degree relative (mother or sister) with ovarian cancer, or the woman who is positive for BRCA1 or BRCA2, which places her at genetic risk for ovarian cancer. It is widely anticipated that the increased accuracy of this test will allow it to replace the Ca-125 blood test, which is problematic because it has such a high false positive error rate.

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