GYNECOLOGY

Please use the next few pages for general information about how our practice may approach common issues for women. This information does not intend to be all inclusive or replace office discussion or care.

About the Gynecologist
Bleeding
Endometrial Ablation
Vaginal Infections
Urinary Tract Infections
Vaginal Dryness in Menopause
Menopause/HRT/Bioidenticals/Herbals
Birth Control Topics
Essure Incisionless Tubal Ligation

Dr. Stephanie Paluda has been in practice with Mission for 13 years. A graduate of Albion College with a degree in Chemistry, she went on to Wayne State Medical School and earned her M.D.. She graduated from residency from Beaumont as an OB/GYN and has been in practice with Mission ever since. A mother of three and full time OB/GYN, Stephanie has little down time, but when she finds it, enjoys skiing and hiking with her husband and kids at her Shanty Creek get away up north.

Dr. Kristen Wuckert has been with Mission for 8 years. She attended Michigan State (though you would never know it as Kristen is a dedicated Michigan GO BLUE fan!) for undergrad and earned a B.S. in Physiology. She then began her medical training at Wisconsin School of Medicine, but transferred after one year to be closer to family, to finish her degree at Wayne School of Medicine. She also was a graduate of Beaumont's OB/GYN residency program. She is the mother of two boys. In her spare time, which she used to have, Kristen enjoys playing tennis and spending time 'at the lake' with her husband and kids in the summer.

Dr. Caprice McGrail, has been with Mission for 4 years. She began her schooling at the University of Michigan earning her undergraduate degree in Cellular and Molecular Biology. Going from there to medical school, she, like her partners, earned her M.D. from Wayne State School of Medicine. She spent her first year of residency at Hutzel Hospital and then transferred to St. Joseph Mercy Hospital in Ann Arbor to complete her OB/GYN training. Despite being mother of three, Caprice finds time to escape to the yoga studio and to train for her yearly marathon pursuits. She enjoys traveling with her husband whenever time permits.

Dr. Jay Fisher has been in practice since 1996. He earned his undergraduate degree from the University of Michigan and medical degree at Wayne State University School of Medicine. Dr. Fisher completed his training at William Beaumont Hospital’s Residency Program in Obstetrics and Gynecology. He and his wife, Lisa, have three wonderful children ( Ben, Jessica, and Daniel ) and he enjoys biking, swimming, and coaching T-ball.

Dr. Lori Shoha has been in private practice since 1996. She earned her undergraduate degree and medical degree from the University of Michigan. Dr. Shoha completed her residency at Lutheran General Hospital in Chicago. She has been in private practice since 1996. Dr. Shoha and her husband, Steve have two lovely children (Charlie and Stella). She enjoys being a mother, yoga, watercolor painting, playing guitar, and water skiing.

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Bleeding

Abnormal bleeding is one of the most common problems we handle in practice. The approach in general is based upon the patient's age and the pattern of bleeding which will usually hint to its cause.

For adolescent and young women irregular cycles are very common in the first few years after menarche, the first period. If cycles are still irregular after two years further evaluation is warranted. Lab work including thyroid function, prolactin (milk hormone), testosterone (male hormone), adrenal hormones and female hormones are assessed. We also look for other bleeding or clotting abnormality. Commonly, polycystic ovary syndrome is diagnosed. We may occasionally perform a pelvic ultrasound and physical exam to evaluate irregular bleeding but a full pelvic and pap can often be delayed until a girl is sexually active.

Most teenagers appreciate the regularity of a low dose birth control pill and can be safely started. On current low dose pills, weight gain, mood swings and are minimal as are more serious side effects such as blood clot, heart attack and stroke. We ask that patients do not smoke while on the pill (or ever).

For women with very heavy cycles again basic labs are drawn including a hemoglobin to look for anemia, thyroid check and female hormone levels including menopause levels. An ultrasound is usually done in our office to evaluate for polyps and fibroids. This is best done on day 4-7 of the menstrual cycle to allow the endometrium to be assessed at its thinnest. Please call us on day 1 of your cycle to schedule this appointment. A sonohysterogram is similar to an ultrasound but allows us to further evaluate the lining by placing a small amount of sterile fluid into the cavity. It causes a small amount of cramping which can be minimized by using Motrin 6oo mg 1 hour prior to the appointment. It is also best done early in the cycle. If we find a fibroid or poly, an outpatient surgical procedure called Hysteroscopy and, D&C (dilation and curettage) will be considered to remove the source of bleeding. If the ultrasound is normal, often hormonal correction can be obtained through low dose birth control pills and other hormonal remedies. We also routinely offer endometrial ablation to help minimize menstrual flow in women who have completed childbearing. Another effective method of controlling flow is Mirena, an intrauterine progesterone insert placed easily in the office with minimal side effects.

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Endometrial Ablation

The lining of the uterus, the endometrium is shed by bleeding each month during a woman's menstrual cycle. Sometimes the bleeding is too much or too long and treatment is needed. The ablation procedure treats the lining to control bleeding without hormones and does not remove the uterus. Indeed it has replaced hysterectomy in many cases as a less invasive, easy and safe alternative. A pretreatment with a minipill is used for 6-8 weeks prior to the procedure.

The ablation can be accomplished as an outpatient procedure. A short acting anesthesia keeps a patient asleep and comfortable during treatment. Novasure uses an electrical grid to cauterize the surfaces of the cavity. This takes 9o seconds and will be successful for most cases.

HTA or hydrothermablation uses a water bath approach with hot water accomplishing the cautery effect. This is very useful if the uterus has fibroids or any unusual contour. In either case the lining will shed and the patient will note a watery, bloody discharge for a few weeks. Cycles are typically absent or markedly diminished. Please note that one may not become pregnant after ablation and birth control must be used at all times. Although not yet FDA approved, Essure can be performed concurrently with HTA if desired. One theoretical concern with ablation is the difficulty of detected uterine cancer years after an ablation is performed. The uterine lining will be scarred shut in many cases making it difficulty to evaluate abnormal bleeding. Also, occasionally cyclic pain can occur if pockets of untreated endometrium are left near the opening of the tubes. This is less likely with HTA.

For more information on Ablation please visit : www.bostonscientific.com/gynecology

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Vaginal Infections

Most women will have occasional yeast infections. Typically the classic symptoms are white "cottage cheese" discharge, external redness and itching. Monistat is available over-the-counter and we advise 3 day regimens as opposed to one day treatment. If your symptoms are not resolved within a few days, you will need to be seen. Cultures will be more accurate if done prior to using over-the-counter inserts. You may also use Domboro compresses made by putting this solution on a warm washcloth and applying 3x/ day for 15 minutes. Recurrent yeast infections could indicate resistant yeast or bacteria, herpes, diabetes, hormone imbalance or immune problems so please see us if this problem is recurrent and come in when symptoms are acting up prior to self treatment.

If your symptoms include external blisters, a yellow discharge or pain or any abdominal pain, fever or urinary symptoms, call us immediately and avoid self treating.

Urinary Tract Infections

Many women will suffer from an occasional urinary tract infection. Cystitis, a simple bladder infection, will usually cause burning, urgency, painful urination, and frequency. A typical feeling is a strong urgency just after you have already emptied your bladder. We recommend a culture be done prior to treatment whenever possible to document which bacteria caused the problem. Many bacteria are now resistant to treatment and may not be cured by standard regimens. Sometimes the urine is sterile and the problem was not a bladder infection at all. Please do not self treat bladder infections but come in for evaluation and treatment.

Try to call us during office hours and do not wait all day with this problem.

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Vaginal Dryness in Menopause

Topical Moisturizers There are several topical vaginal moisturizers available without a prescription at your pharmacy. Some examples are Replens, Silken Secret and Lubrin. They come as either a gel with an applicator or as a tablet that melts once inserted. Replens is used daily for 5 days, then 3 times/week. Some patients find them messy. They can relieve daily personal dryness, unrelated to sexual activity and may prevent recurrent vaginal infections caused by pH imbalance.

Vaginal Lubricants are used to help with painful intercourse. Liquid lubricants are usually water-based and seem to work better than gels, but can be messy. Examples are Astroglide Liquid or KY Liquid. Lubrin is also a lubricant that can be inserted ahead of intercourse and may be less messy and more discreet Lubricants should be applied directly to the vaginal area and your partner before and during intercourse. A silicone-based lubricant called Eros is available for order over the Internet. Some patients may find silicone based lubricants more effective but they may stain the sheets as they are not water soluble.

Topical Vaginal Estrogens Oral, patch and transdermal creams will resolve vaginal dryness and painful intercourse due to estrogen deficiency. This problem becomes much more common the further out a woman, is from menopause. There is a controversy concerning the safety of estrogen use for women especially those surviving breast cancer or at higher risk for cardiovascular disease.

Two topical estrogen products are available with prescription with a low level of absorption into the blood and less controversy. These are Vagifem, a tablet and Estring, small ring insert. These release estrogen onto the lining of the vagina with minimal absorption into the blood.

The Estring is a 2 inch diameter rubber ring with estrogens inside that is placed in the vagina and left there for three months. After insertion estrogens are absorbed into the blood for 2-3 days and on subsequent days there are minimal or no detectable blood levels of estrogen.

Vagifem is a small tablet inserted at night through an applicator for 14 days followed by twice weekly insertion. The tablets are absorbed at night, with some estrogens appearing in the blood for several hours. Both products take about 2-3 weeks to relieve vaginal symptoms.

Definitive research studies in breast cancer survivors to determine if there is a breast cancer risk from Estring and Vagifem have not been performed: however, the theory of safety with both products is good. Indeed, breast cancer prevention research studies through the National Cancer Institute allowed the use of both Estring and Vagifem. Side effects are few and include a slight discharge. The ring is difficult for some women to place and may need to be removed prior to intercourse.

Estrogen vaginal creams are also extremely effective in treating dryness and painful intercourse. These are used 2 times per week at night and can be very soothing. Absorption in general is slightly higher than that of Estring or Vagifem but less than that of oral pills.

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Menopause/HRT/Bioidenticals/Herbals

The severity of symptoms women experience in menopause varies widely and no one knows why some women are asymptomatic and others are absolutely miserable. The approach to menopause has evolved dramatically since I have been in practice especially following the release of the Womens' Health Initiative (WHI) study. This study documented the slight increased risk of breast cancer, heart attack, stroke and blood clot in women in their mid 6os given Prempro comparing them to women given placebo.Much confusion over study results arose from media coverage.

In general our goal has become to use the lowest dose of hormone for the shortest duration (preferably less than 5 years) to treat hot flashes and night sweats surrounding menopause. Fortunately, many products have become available to help meet this goal since the study was released. Unfortunately, it seems doubtful that these products will undergo such intense study as was done during the WHI. Much of the current "new" findings is simply reanalysis of the same data in WHI and does not involve new product or study.

Theoretically, transdermal approach through patch or cream will be less likely to cause blood clotting abnormality and therefore fewer heart attacks and stoke. Theoretically "natural" progesterone may be less likely to cause clotting problem as well. As far as cancer risk, natural does not necessarily mean less risky.

What I do like about "bioidenticals" is the ability to manipulate dose and delivery to meet an individual's needs. This can be ultra low dosing through a skin cream. Again, I make no reassurances about risk being any different than that found in WHI and each patient must assess her own goals of HRT and decide for herself if her symptoms warrant treatment. Each year we review how she is doing and try to decrease dosing or wean off if possible.

Testosterone therapy can be delivered with bioidentical or traditional pharmacy. Women definitely have lower testosterone levels after menopause. Each person's sex drive is affected differently by this decline. Replacement can be useful but also can cause side effects such as weight gain, acne and hair growth. We also have to watch cholesterol and assess for cardiovascular risk when using testosterone. In general I like to avoid higher doses but often give a low dose a try if desired.

Medical alternatives for hot flashes include Clonidine patch, a blood pressure medicine, Bellergal S tabs, an opiate that does help short term, and some serotonin medications typically used for depression such as Effexor or Zoloft. I use these options frequently in my practice and have found them helpful.

Many herbal alternatives have been tried for menopausal symptoms. There are no conclusive studies in my opinion on the benefits and safety of this approach. Soy products contain isoflavones, a phytoestrogen or plant estrogen, which acts like a weak form of estrogen hormone in the body. Isoflavone is found in foods such as flaxseed, legumes (peas, beans, peanuts) and whole grains (oats, wheat, corn). However, when soy is processed some benefit is lost.

Healthy Woman's Soy Menopause is one example of a soy supplement by Mead and Johnson which can relieve symptoms. Black Cohosh is a North American plant that may act like estrogen. It is found in Remifemin, an herbal menopause supplement. It may help symptoms for a short while but can cause upset stomach and low blood pressure. Wild yam is available but unproven, Don Quai is the root of Angelica Sinesis and commonly given by Chinese herbal specialists for regularity, dryness and hot flashes. Watch for sunburn and blood clotting issues.

Evening Primrose is a North American wildflower-again unproven. Ginseng is said to boost immunity and help with stress and increase sex chive- unproven. It has not been shown to help with hot flashes. Chasteberry or vitex is the dried ripe fruit of the chaste tree. It is said to decrease dryness and help with depression but is unproven. I say "Beware of all of this stuff." I have doubts about long term usefulness and am somewhat skeptical that anyone knows exactly what is contained in supplements which are largely unregulated.

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Birth Control Topics

We choose from a wide variety of birth control pills depending upon a patient's medical needs and with the goal of maximizing efficiency, minimizing side effects and keeping costs as low as possible. Please keep us posted if you are paying for your pills or your deductible is very high as we may be able to change products or help with coupons for you.

Please allow 3 months for your body to adjust to the pill. Side effects such as spotting, breast tenderness, mild nausea and acne often resolve over time. Serious complications are rare and include heart attack, blood clot and stroke. If you have chest pain, shortness of breath, leg pain/swelling or unusual headaches/visual changes, call us immediately.

Now available are seasonal type pills allowing you to have cycles only once every 3 months. This is safe and very helpful for many women. Ask us how to do this with your pill if you prefer or we can write for a product designed for this purpose. See www.SEASONIQUE.com for extra information.

To delay your cycle you can insert an extra row of active pills prior to your placebo if all of your pills are identical (monophasic pill). This will help with upcoming weddings and vacations. Don't be alarmed if you spot a little during the extra pill week.

We also can recommend NuvaRing, a 2 inch ring inserted into the vagina for 3 weeks and removed for one. This contains estrogen and progesterone similar to the pill and is very low in dose, easy to use and wonderful for minimizing side effects. See www.NUVARING.com for added information.

Essure Incisionless Tubal Ligation

Essure is a permanent birth control procedure that works with your body to create a natural barrier against pregnancy. It is 99.8% effective, does not involve hormones and requires no incisions. It involves placing a micro insert of nickel in each fallopian tube done in an outpatient setting. If you are contemplating tubal ligation this may be an excellent option for you.

Please visit Essure.com or call 1-877-Essure-1 for more information.

Intrauterine Devices (IUDs)

Another excellent option for contraception, IUDs are easily placed in the office and provide easy, safe prevention. In general these devises are best placed for women in monogamous situations as exposure the sexually transmitted disease can lead to more severe infection and fertility complications in the future.

Mirena contains a low dose of progesterone delivered to the uterus. This allows for 8o% reduction in menstrual flow and cramping. Side effects are minimal and include acne and irregular spotting especially initially. This device works for 5 years.

Paragard is a copper IUD which is non hormonal. It is effective for 10 years but is associated with slightly heavier, crampier cycles for some women.

Check your insurance for coverage. We do require payment up front if you do not have contraceptive benefits. Call us immediately with the first day of your cycle for an appointment which will typically be preferred on day 4-5 of flow.

You can take Motrin 600 mg or Tylenol extra strength 1 hour prior to your appointment. You can expect a small amount of discomfort with placement but most women can resume normal activity upon leaving the office. We can remove your IUD at any time desired and pregnancy can occur after the next ovulation.

Implanon

Implanon is an implantable contraceptive rod placed in your arm for pregnancy prevention. It can be very helpful to those who have trouble with remembering the pill and other side effects from estrogen. We offer this to our patients in the office setting. Please visit www.IMPLANON-USA.com for details.

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Cancer Screening Guidelines

Despite recent controversy in the media, we continue to follow the American College of Obstetrics and Gynecology guidelines in mammogram recommendations. This includes monthly self breast exam (ask us how if you are uncertain), yearly clinical breast exams and mammograms.

We recommend a baseline mammogram at 35 and then yearly mammograms beginning at age 40. We know and are most comfortable with the radiologists at Beaumont Hospital and the equipment used involves Digital Mammogram which is particularly helpful in younger women.

Please know that about 15% of patients will need added views. DO NOT PANIC. This is a precaution in most cases. You will usually be informed prior to leaving the department if a biopsy will be indicated. Again, DO NOT PANIC. We will contact you immediately when we receive a report. This may take up to 7 days. If you have any atypical findings, we will refer you to the Breast Cancer Surgeons at Beaumont who are wonderful. They have a large amount of experience, excellent surgical skills and compassionate bedside manner. Drs. Dekne, Lerman and Rivers are available at 248-551-2200. They can usually see patients within 1-2 weeks. Please call us if there is any difficulty in arranging your appointment.

Overall American women have a 1 in 10 chance of developing breast cancer and a 1 in 55 chance of developing ovarian cancer during their lifetime. Many patients have a very strong cancer history in the family. Particularly concerning would be first degree relatives such as a mother, daughter or sister with breast cancer especially prior to menopause or ovarian cancer at any age. This may indicate a gene mutation in the family. Ashkenazi Jewish patients of European Jewish descent are particularly at risk. Genetic testing provides information on the likelihood of developing these diseases in the future. Knowing your cancer risk may help you to make better informed decisions about screening and prevention options. Genetic testing for breast and ovarian cancer is a way to determine if you or a family member carries a gene mutation that increases the risk of these diseases. This testing is available in our office and may be covered by your insurance. The decision to test is extremely personal and genetic specialists are also available to sort through complicated family history and help provide extensive information about options if testing is positive or negative. (contact genetics) Please ask us about your risk and keep us updated about your family history. For more information on genetic testing, visit www.myriad.com.

Colon cancer screening is encouraged for most patients with a baseline colonoscopy recommended by age 50 and rectal exams and tests for blood in the stool annually on exam. The good news is that screening has become easier with improved prep regimens and excellent anesthesia options for comfortable testing. We will refer you for colonoscopy baseline and encourage proper follow up which may be every 3 to 10 years depending on your history. Some families share a gene for colon cancer called the Lynch mutation. Please keep us updated on family history of colon, uterine, ovarian, stomach, kidney/urinary tract, brain, biliary and small bowel cancers in your family. For further information on genetic testing for Lynch Syndrome, Attenuated Familial Adenomatous Polyposis and MYH-associated polyposis, please visit www.myriad.com or ask us.

Ovarian cancer screening unfortunately has not proven very successful despite many clinical trials aimed at early detection. Ovarian cancer does tend to present as late stage disease but recent approaches with aggressive surgery and chemotherapy have been able to improve lifespan and quality of life. Symptoms are vague and include bloating, gastrointestinal distress, pelvic cramping or fullness, fatigue and weight loss. Testing includes a pelvic exam, ultrasound and occasionally blood work such as CA125. This last blood test has caused a bit of controversy over the last decade. This test is not recommended for routine screening because of false positives and negatives. Unlike the PSA made exclusively in the male prostate, CA125 is made by the entire peritoneal lining and can be elevated falsely in many non cancer situations. I will never deny a patient access to this test but discourage its use as a routine as it may prompt unnecessary surgery and tremendous anxiety if elevated. However, if you have symptoms you are concerned about, please share them with me and mention you are worried about ovarian cancer so that we can discuss your concerns fully.

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Infertility

The evaluation of fertility should take place any time a couple is trying to get pregnant and has concerns. In general, 2o% of couples having unprotected intercourse midcycle will conceive, with 6o% getting pregnant by 3-4 months and 85% by one year. Please do not wait if you have concerns especially after the age of 30 or if you have irregular cycles.

The basic evaluation includes checking for the "seeds" (sperm and eggs) and checking that these seeds can meet (Cervical mucus, uterus and tubes). The amount and order of testing is customized depending on a couple's medical history but may include the following:

• Temperature Chart. Check upon rising with digital thermometer. Temperature should rise .5 degrees after ovulation. Bring your chart in for us to evaluate at your appointment.

• LH First Response Ovulation Prediction Kit. Begin day 1o-12 until positive. Try to conceive for 2 days following a positive LH surge. Look for clear mucus at this time. Record your finding on your temperature chart.
  

• FSH blood test. Day 3-5 of cycle, this checks for ovarian aging and rises to >10 indicate possible decreased fertilization rates and premature ovarian aging.
  

• Progesterone level Day 24-26 (10 days after ovulation). This test will show progesterone in your system which only occurs if you have ovulated.
  

• Other blood tests: Testosterone, Prolactin, TSH, DHEAS, LH/FSH ratio These blood tests evaluate your hormones and assess for other conditions which can inhibit ovulation.
  
  

• Semen Analysis: This tests male fertility including amount of sperm, motility and shapes. If abnormal, suggestions may include a male fertility urology consult to look for varicose veins and hormonal abnormality. Couples with male infertility issues may benefit from intrauterine insemination done in our office or may be referred for ICSI, a special form of IVF-in-vitro fertilization.

  A semen analysis can be done by:
  Hollander, Mitchell MD 248-539-9036
  RMA 248-619-3100
  Gago Fertility 810-227-3232
  Mersol-Barg 248-593-6990

• Post Coital Test: This test is done around the time of ovulation. Please Call us to work in your appointment if your LH kit becomes positive. We will check for cervical mucus and sperm presence in the mucus. Timing is about 2-3 hours after sexual intercourse. We will also do an ultrasound to check uterus shape and evaluate the ovary for eggs. We also check the uterine lining to see if it is prepared for implantation.
  

• Hysterosalpingogram (HSG) This x-ray of the tubes and ovaries is done at Beaumont on day 5-8 of your cycle. Dye is placed through the cervix using a speculum and small straw and x-rays assess the shape of the uterus and if the tubes are open and spill dye. Surgery may help you if your tubes are block or IVF may be considered. This test can cause cramping so take Motrin 600 mg 1 hour prior. Please remind us if you have a history of PID, Chlamydia or any other STD as you may benefit from antibiotics prior to the test to prevent infection.

Additional information can be found at www.FertilityJourney.com.

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CLOMID/IUI/Other Fertility Options

Once the basic testing is completed, Clomid may be tried alone or with insemination for 3 to 6 months. As an alternative a diagnostic laparoscopy may be suggested especially if endometriosis or adhesions are suspected from your history.

INDICATIONS: Clomid (clomiphene citrate) is indicated for the treatment of ovulatory abnormality in patients desiring pregnancy. Clomid may be used empirically to increase the number of follicles per cycle to improve chances of conceiving. It may help in timing ovulation and treating luteal phase defects by increasing Progesterone in the second half of the cycle.

CONTRAINDICATIONS: Clomid should not be given during pregnancy, in patients with liver disease or those with large ovarian cysts or unresolved bleeding.

RISKS: Clomid side effects are rare and include hot flashes, pain, headache or visual change or ovarian cysts. Ovarian cysts would mandate a cycle off Clomid and observation until the cyst resolves. In one study, among 2369 pregnancies 92% were single, 6.9% were twin, .5% triplet and very rarely higher multiples occurred, Birth defects were 2.4%, a rate about the same as the general population.

PROTOCOL: Clomid requires close monitoring with each cycle.

• Ultrasound is done day 1-5 prior to writing the monthly dose.

• Clomid is taken days 5-9.

• Estrogen is given to improve cervical mucus after the last Clomid pill and is often Premarin 1.25 mg 2X/day from days 10-16. ,

• LH kits begin on day 10. Please call with a positive kit if IUI is to be performed. This is usually done day 14 or the day following a positive kit. If this will fall on a Saturday, RMA can perform both the semen wash and IUI. Please let us know so we can arrange this for you.

• Occasionally HCG is given to simulate LH surge around day 14 to trigger ovulation. Patients must pick this up from the pharmacy and bring it to the office. This is given if a 2cm follicle is seen. IUI or attempts to conceive should occur for the next 48 hours.

• Progesterone supplements begin around day 18 and usually involves CRINONE 8% Gel daily until the menses. A pregnancy test is taken 14 days after ovulation and progesterone can be stopped if negative. Call us as soon as your period occurs to arrange a follow up visit and the next cycle. IF pregnancy, continue progesterone until first prenatal visit.

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Gardisil Vaccine

An important advancement in women's health care, this vaccine for HPV helps prevent cervical cancer and genital warts. Gardisil is typically given between ages 9 and 26 in a series of 3 shots (initially, 2 months later and 6 months after first dose). We are happy to administer this to you. Please check with your insurance and arrange to come in for a
brief consultation and first dose.

Please visit www.Gardisil.com for more information.

Colposcopy

Colposcopy is a way of looking at the cervix through a magnifying device that enlarges our view by up to 60 times. This is performed to identify abnormal patches of cells that are shedding suspicious cells on a pap smear. We will recommend colposcopy if your pap has atypical cells, mild, moderate or severe dysplasia. It is best done when not on one's menstrual cycle.

A speculum is inserted and a cotton swab is used to apply a solution to your cervix. Most often a small biopsy is taken from any unusual appearing area. This feels like small cramp. The procedure lasts for 5-10 minutes. You may be lightly sore for 1-2 days following the procedure and may have a dark discharge from the solution applied to your cervix. Do not put anything into the vagina until all bleeding and discharge have resolved.

Biopsies are sent to Beaumont and results are available within 7 days. We will call with your results but feel free to call us if you have not heard from us in 7 days. Most often, mild dysplasia can be watched with pap smears being done every 3 to 6 months.

I often recommend immune support measures such as avoiding smoke, exercise, healthy diet and Folic Acid 1mg supplements. Careful follow up is mandatory as progression from mild to severe dysplasia occurs in about 15-20% of women. For moderate or severe dysplasia treatment will be customized to the patient.

On occasion in a younger patient, moderate dysplasia can be monitored. Often a LEEP procedure is recommended. (See below). For severe dysplasia, LEEP is usually recommended. Occasionally a laser or cold knife conization will be a considered alternative.

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Leep (Loop electrical excisional procedure)

Cells on the cervix grow and shed all the time. Sometimes these cells change and become abnormal, usually as a result of HPV infection. Leep uses a thin wire loop that acts like a scalpel (surgical knife). An electric current is passed through the loop which cuts away a thin layer of surface cells. This is done with local anesthesia very comfortably in the office. If you are very nervous, we can prescribe a mild tranquilizer such as valium an hour ahead. Motrin 600mg also will help with cramps. Please eat something prior to your procedure. You will feel a dull ache or cramping after the procedure and resting that day is advised.

Problems are rare and include heavy bleeding, fever, foul-smelling discharge, and severe abdominal pain. Please call immediately with these concerns. A small amount of bleeding and brown-black discharge from the monsel solution is expected and normal. Please avoid sex, tampons or douching until seen in the office in 2 weeks. Results are expected in 7 days. Please call us if you haven't heard from us in 7 days.

On occasion we can do LEEP at the hospital under heavy sedation if a patient is particularly nervous or if her anatomy or bleeding risks are a concern.

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Healthy Living: Fitness and Diet

It can be a chore to keep your body in shape but the rewards are great in terms of prevention of disease such as heart disease, cancer, arthritis and joint disease, osteoporosis and depression to name a few!

Kathy and I are famous for our PEP talks which try to motivate you to improve your health through good nutrition and fitness. Don't ever feel embarrassed to ask us about your weight or for suggestions about diet and exercise. We also know that some women do not want to step on the scale and that's fine with us as well. We are here to help you woman to woman with these challenging issues.

I have had great luck with exercise my entire life. In high school it was tennis, dance and pompoms. In college, aerobics and running and walking all over Ann Arbor kept me fit even if I did gain the Freshman 15. Medical school and residency-not so good about diet but steady exercise with circuit training and running and swimming. (My hair was really fried at that point in my life anyways.) By the time I went into practice, I had completed two pregnancies and time was limited but I always put gym clothes in my car and never went home without going to the sports club first. I loved step aerobics and low impact classes and used the stair climber and cross trainer as alternatives on days I missed class. After Nikolas, I took up spinning which was great for a quick 10 pound weight loss. My current passion is called precision bar ballet which involves leg lifts and core exercises at the ballet bar mixed with floor abdominal "pilates" style work. The teacher and music make the class. I do these 3 days a week and spin 2-3 days depending on my call schedule. Many of my patients are in class with me and I love it. Together we chat about the stress of the day to distract us from whatever torture teacher Lisa wants to throw at us. Honestly, group exercise is the way to go for me.

I also love, love, love my trainer. She nags me about diet while I sweat like crazy in her basement gym. This is private personalized time that I treat myself to whenever I can so that she can keep my regimen current. Variety makes a lot of sense for exercise.

Dieting is not my strength. You name it and I've definitely tried it to see if I could recommend it to others. I do have great success on protein based diets as do so many women.

When I'm good, I journal every night and count points. Every day is a new day and you have to wake up, eat breakfast and keep trying even if yesterday was a bad day. I have books, referrals and time to talk to you if you need help. Never stop trying. I am not usually quick to embrace diet pills or fad diets. Some women will find Metformin (Glucophage) helpful as an "antibuse" for curbs and occasionally the anti-depressant Wellbutrin can break binge eating and provide help for atypical depression and eating. Again, come in and consult if you need help.

References:

Laurie Gornbien (My Trainer) 248-736-7271
Beverly Price (Dietician) 248-390-4150

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