2016 Issue 2, Quarterly Newsletter

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WOMEN’S HEALTH

Welcome to the second issue of Women’s Health, a quarterly newsletter focused on relevant health issues to women of all ages. This issue will have some practice updates, but will mostly focus on alternative treatments for common problems.

Our practice has undergone a lot of changes and growth over the last 18 months. With the expansion in our services, adding and training support staff was difficult to keep up with. This has created a lot of frustration for some of our patients and is now our primary area of focus. In 2016, we hope to redouble our commitment to the care of our patients and ensure your experience in our office is welcoming and efficient. We welcome your comments and feedback about how we’re doing and what else we can do to support you in achieving and maintaining good health.

The last few years have been an exciting time for women’s health with new treatments for problems women have endured for centuries. These treatments are opening new doors for women. This issue, I hope, will help you learn about something for you or someone you love, to make your life a little more comfortable.

We look forward to a productive and healthy 2016, and wish each of you and all your loved ones the same!

Sarah Azad, MD

In this issue:

Our San Jose Office is now open

A message from Ruth Ann Crystal, MD

Welcome back Nurse Barb!

Innovations in the treatment of vaginal atrophy (vaginal dryness)

Premenstrual Syndrome, how can we approach it?

Options for dealing with the hot flashes that come with menopause

Managing pain in pregnancy

Medicare Updates

Highlights from the Women’s Health Blog

OUR SAN JOSE OFFICE IS NOW OPEN

Amidst a fury of work and chaos, we welcomed our first patient to our new San Jose office on March 2, 2016. The office is now fully up and running. Conveniently located in Willow Glen, the office is open on Wednesdays and Thursdays from 11-7. Over the next few months we hope to add nutrition and mental health services here in addition to our Mountain View office.

A MESSAGE FROM RUTH ANN CRYSTAL, MD

Last year was very difficult for me as two of my family members were hospitalized several times and both needed emergency surgery.  I have been working as a part-time OB hospitalist at El Camino Hospital since January 2015 after my Palo Alto office rent doubled.  Doing shift type work at the hospital in Labor and Delivery as an OB hospitalist has allowed me to better take care of my family.  For these reasons, I have decided to postpone my return to clinic indefinitely.  

I feel very fortunate to have the El Camino Women’s Medical Group take over my practice and they will continue to see my patients, refill prescriptions and order and review tests as needed.  You are in very good hands.  

I am happy to report that both of my family members (my dad and my daughter) are now doing much better.

Take care,

Dr. Crystal

P.S. Please continue to send your Holiday cards to my new address.  I really look forward to your cards every year.

WELCOME BACK NURSE BARB!

We’re happy to announce that Barbara Dehn, a Women’s Health Nurse Practitioner, is ready to start seeing patients with us at El Camino Women’s Group on April 14th.  Barb, who you may know as Nurse Barb, and who worked with Dr. Sutherland and Dr. Litwin for over 25 years is now back from her leave of absence. During that time, she was volunteering in a hospital in Tanzania, Africa and speaking at conferences.

Here’s a little background on Barb: In addition to caring for women as a nurse practitioner, she is also a guest lecturer at Stanford, writes a health blog at www.NurseBarb.com and is a certified Menopause Practitioner by the North American Menopause Society. You may also see her on TV or on-line as a health expert, or hiking in the nearby hills. Barb is married and has a son in college.

INNOVATIONS IN THE TREATMENT OF VAGINAL ATROPHY (VAGINAL DRYNESS)

By Sarah Azad, MD

What does menopause do to the vagina?

The low estrogen levels of menopause affect a woman’s body in many areas and in many different ways. In the vagina, the low estrogen is associated with vaginal or vulvar dryness, discharge, itching and painful sex. At a cellular level, there is a thinning of the vaginal tissue which accounts for most symptoms that trouble women: vaginal dryness, irritation, itching, discharge, or pain with urination. Unlike the decrease of symptoms like hot flashes and night sweats, the vaginal changes do not eventually go away without treatment.

These changes are commonly called “vulvovaginal atrophy (VVA)”. During a conference in May of 2013, the North American Menopause Society (NAMS) in conjunction with the International Society for the Study of Women’s Sexual Health (ISSWSH) created new terminology for these changes: Genitourinary syndrome of menopause (GSM). The new terminology includes a wider range of symptoms associated with menopause and was found to be more acceptable to the general public.

Regardless of the terminology, by 2025, we expect more than 1 billion women to be in menopause, the majority will likely be affected by GSM. The need for more and more diverse treatment options is pressing

How common are these problems?

This is a field that is growing in information every day. We now estimate that half of all women in menopause in the US have symptoms related to the vaginal changes that negatively affect their quality of life. This includes their comfort during routine daily activities, consequences to their sex life , effects on their marriage or relationships, and effects on their self-esteem. Most of them never proactively seek medical attention.

What options are out there?

Hormones

The most common and oldest treatment is estrogen. Locally administered estrogen (tablets, creams, ring), is the primary treatment for complaints related to GSM. Different formulations of this estrogen have mostly been shown to be equal to one another and they all show improvement in both vaginal pain, irritation, painful sex as well as urinary issues like frequency, urgency, mild incontinence and recurrent UTIs. However, estrogen needs to be applied every day for sustained relief. There is also a small concern that even a low dose estrogen applied vaginally, when done so daily for years, may affect the uterine lining and increase the risk of uterine cancer. The WHI data caused the FDA to put a “black box” warning on all hormone use after menopause.

Ospemifene

A newer, non-hormonal option is Ospemifene. An estrogen agonist and antagonist that selectively stimulates or inhibits estrogen receptors of different target tissues (SERM) was released in 2013. Taken as a daily tablet, Ospemifene slowly helps stimulate growth of the vaginal epithelium and by 3 months, patients are noting marked relief of symptoms. This drug has been studied in daily use for up to 52 weeks without any adverse effects on the endometrial lining or to breast health. While well tolerated, the most common complaints of patients taking Ospemifene include vaginal discharge, muscle spasms, hot flashes and excessive sweating.

Vaginal lubricants and moisturizers

Women who are not interested in pharmaceutical treatments have long resorted to vaginal lubricants and moisturizers. Silicone-based or water-based vaginal lubricants and moisturizers can alleviate the symptoms of GSM. Lubricants are intended to relieve the friction and dyspareunia related to vaginal dryness during intercourse. Moisturizers are meant to help improve vaginal dryness, pH balance and elasticity.

An emerging therapy: fractional CO2 laser

The MonaLisa Touch was cleared by the FDA for use in September of 2014, for the treatment of various aspects of vaginal and urinary health. The device is a CO2 laser system that has been used and studied in Europe and Australia for some time. From a small metal probe, the laser rapidly supplies energy to the vaginal wall with a very specific pulse. This pattern of laser treatment helps ablate tissue that then causes the growth of new collagen and related components in the deeper layers of the vaginal wall.

Since the symptoms of GSM are related to the atrophy and poor blood flow that comes with menopause, this stimulation of new collagen growth results in new growth of capillaries and an increase in glycogen. As the pH stabilizes with this healthier vaginal wall, the bacteria living in the vagina remain in a better balance. These changes result in improved vaginal health as quickly as 2 weeks after the first treatment and maximize after the third treatment (performed at 6 week intervals). Patients note improvement in lubrication, comfort with sex, and bladder comfort and control while noticing less dryness, itching, infections and general irritation.

To date, more than 20,000 women worldwide with GSM have been treated with fractional CO2 laser therapy and the data has been very promising. Fractional CO2 laser has been used by dermatologists and plastic surgeons on the face, neck, and chest for decades without any known harm or long term adverse effects.

Treatment occurs in the office setting, without any anesthesia and is quite comfortable. The actual treatment lasts about 5 minutes, is performed every 6 weeks for three treatments. Generally a maintenance treatment is needed every 9-12 months to maintain the noted benefits.

We are quite excited to be able to provide this treatment option in our office. For more information on the MonaLisa touch, you can learn about it on our website or contact Shar at 650-396-8110 or moc.n1679337471emowo1679337471nimac1679337471le@ra1679337471hS1679337471 to ask questions or book a consultation.

Disclaimer: There is no financial relationship between any of the physicians or staff at El Camino Women’s Medical Group with the makers of Ospemifene or the MonaLisa Touch.

PREMENSTRUAL SYNDROME, HOW CAN WE APPROACH IT?

By Erika Balassiano, MD

What is PMS?

Many women struggle with emotional and physical changes in the days leading up to their menstrual periods, and when these symptoms are cyclic, they are recognized as a condition called premenstrual syndrome, commonly referred to as PMS. Some of the most common symptoms of PMS can be divided into physical symptoms and emotional symptoms.

Physical symptoms include: weight gain, bloating, food cravings, cramps and breast tenderness, headaches, swelling of the hands or feet, aches and pains, skin problems, and fatigue.

Emotional symptoms include irritability, mood fluctuations, dysphoria (a general feeling of uneasiness or dissatisfaction), crying spells, anxiety, social withdrawal, insomnia and changes in libido.  

At times, PMS symptoms are severe enough to cause problems in the work environment and/ or with personal relationships. This severe form of PMS can some women and is called premenstrual dysphoric disorder (PMDD).

I really don’t feel like myself when I have my PMS. What can I do about it?

First and foremost, come in and speak with us.  Your OB/GYN is the best person to review your health history and discuss what treatments are best suited to your symptoms and which are also safe in the context of your personal and family history.   

If your PMS symptoms begin to interfere with your life, you may decide to seek medical treatment. Treatment will depend on how severe your symptoms are. For mild to moderate symptoms, changes in diet and lifestyle might be all you need. In more severe cases, your health care provider may recommend medication.

Pharmacological Therapy

There are a few types of prescription medications recognized by the American Congress of Obstetricians and Gynecologists (ACOG) as being able to help with certain symptoms of PMS.

Oral contraceptive pills (OCP) can help to regulate your hormones and, subsequently, regulate your cycles.  OCP can treat physical symptoms of PMS, but it might not be as helpful if you have prominent emotional symptoms.

Another option available is low dose antidepressants, which have been shown to be moderately effective in treating emotional and mood symptoms. Many women find taking an antidepressant for 10-14 days out of the month to significantly reduce their mood changes just before their period.  Anti-depressants can also be taken throughout the cycle for continuous treatment.

If water retention is a major symptom for you, then a prescription diuretic may work better. If anxiety is your biggest concern, then an anti-anxiety drug can be tried if other treatments do not seem to help. These drugs can be taken as needed when you have symptoms.

These options require prescriptions and as with all pharmaceuticals, there are risks and side effects that need to be balanced.

Non- Pharmacological Therapy

There are some over the counter products out there the ACOG recognizes as being somewhat effective in treating both the emotional and physical symptoms of PMS. Taking 1,200 mg of calcium a day can potentially improve PMS symptoms. Although evidence is limited, magnesium supplements may also decrease bloating, breast tenderness, and mood symptoms. One study has shown that vitamin E may help reduce symptoms of PMS.

For patients averse to pharmaceuticals, these supplements are worth trying in regular doses in an attempt to improve symptoms. I would caution you to avoid other products that promise to cure your PMS.  There are a lot of over the counter products targeting women with PMS that have no evidence behind their claims.

In 2015, a new dietary supplement came out called Serenol. The ingredients in Serenol have shown improvement in physical and emotional symptoms of PMS accross double-blind controlled studies with no side effects any different from the placebo group. Serenol is comprised of a flower pollen extract (which works to reduce the emotional symptoms of PMS), Chromax ® chromium picolinate (which helps body metabolism and drives reductions in physical symptoms), and a low dose Royal Jelly. It should be noted that Royal Jelly is a bee product and therefore any patient with a severe bee allergy should avoid taking this product.

Always talk to your provider before starting a new medical therapy. Your doctor will help determine what is the right treatment for you.

Disclaimer: There is no financial relationship between any of the physicians or staff at El

Camino Women’s Medical Group with any pharmaceutical companies.

OPTIONS FOR DEALING WITH THE HOT FLASHES THAT COME WITH MENOPAUSE

By Amy Teng, DO

April showers bring May flowers, and for those dealing with disruptive hot flashes and night sweats during menopause, it seemed like a good time to review treatment options available including a new supplement that’s on the market that has good results.

The American Congress of Obstetricians and Gynecologists (ACOG), notes that three out of every four women will experience hot flashes during menopause. Hot flashes can last a few seconds, or several minutes. They can happen a few times a month or a few times an hour. They can bother you for a few weeks or for the rest of your life. Sometimes hot flashes don’t even wait for menopause to begin, and can begin to occur during perimenopause, which is the five to ten years leading up to menopause. Perimenopause is a time where you might have irregular periods, and experience bouts of hot flashes. A recent study found that women who start having hot flashes during perimenopause can experience these symptoms, on average, for nearly twelve years! For those that start having hot flashes during menopause, on average symptoms occur for over seven years. Of course, for every woman, these symptoms occur at varying levels of frequency and intensity, and many times the hot flashes are accompanied by night sweats, sleeping problems, fatigue, and irritability, all of which contribute to a significant hindrance to quality of life.

I don’t want to suffer through these symptoms any more. What can I do?

There are many treatment options out there, including both hormonal and non-hormonal therapy, and the option that is best for you depends on a number of different factors. As always, it’s best to come in and discuss your symptoms and your health history to determine what options are appropriate for you. Hormone therapy is widely recognized to be an effective treatment for hot flashes and night sweats and has been used for years. Hormone therapy (estrogen, progesterone, or a combination) can be taken as a pill, worn as a patch, put on as a cream or gel, or placed vaginally. Due to risks such as breast cancer, venous thromboembolism, and stroke, ACOG advises using the lowest effective dose of hormone therapy for the shortest duration of time, for two to five years at most. Additionally, some personal or family history may exclude you from using exogenous hormones.

Another option for hot flashes are a class of anti-depressants. Taken at lower doses than used for depression, SSRIs and SNRIs have been shown effective in reducing the frequency and severity of hot flashes.

Black cohosh is an alternative “herbal” therapy that has been touted for a long time as helping women transition through menopause. With few side effects, it’s reasonable to give it a try, but the data hasn’t been convincing. For every study that shows it benefits women, there’s another showing that it’s the same as placebo.

Released is 2014, Relizen is a great option for any patient seeking relief from hot flashes and night sweats. It has been used in Europe for more than a decade. A dietary supplement made of highly purified flower pollen extract, Relizen is a non-hormonal, non-pharmaceutical option shown to help with the symptoms of menopause. Relizen has been shown in multiple clinical studies to significantly reduce both the frequency and intensity of hot flashes and night sweats, and improve quality of sleep, fatigue, irritability, and overall quality of life, while resulting in minimal to no side effects. Relizen has been shown in multiple studies to have no hormonal effect—it is not a hormone and it doesn’t act like one in the body.

How can I order Relizen?

We advise that our patients stay on Relizen for at least three full months, taking two tablets per day, to see if the product is a fit for them. Clinical studies have shown that for most women, the relief that Relizen provides begins after six to eight weeks of treatment, but for some, it can occur as early as two weeks. All of the clinical data supporting Relizen shows that the product works better and better over time, becoming fully effective after three full months of therapy. Relizen can be ordered online, at www.Relizen.com. Use the discount code: 3091411 when ordering, it should cost you about a dollar a day. Since it’s not a prescription, your insurance won’t cover it, but if you have a Healthcare Flexible Spending Account, you may be able to use it.

Disclaimer: There is no financial relationship between any of the physicians or staff at El Camino Women’s Medical Group with the makers of Relizen.

MANAGING PAIN IN PREGNANCY

Sarah Azad, MD

Pregnancy is a wonderful, hopeful time in life as a baby inside us grows and our body goes through so many changes in just 9 months. Some of those changes, however, can be quite uncomfortable. From upper and lower back pain to pelvic pain to leg cramps and heel pain, there are many aches and pains in pregnancy that we just aren’t used to in our daily lives.

For generalized body pain in pregnancy, that comes from the strain of the pregnancy itself (larger cup size, larger belly), regular exercise that builds your core and pelvic muscles is essential. We encourage every patient at their first visit to begin a regular class of prenatal yoga or Pilates to help strengthen these muscles. This helps from the very beginning to make the body more powerful and more resistant to strain as the baby continues to grow.

Morning and evening stretches, even just 5 minutes, also helps prevent strain during daily activities and leaves you feeling stronger and less tired at the end of the day.

For patients still having pain in their backs, arms and legs, having a prenatal massage is a wonderful treatment (and a relaxing moment!) that you will never regret. Lindsay at The Mommy Spa is one of our favorite massage therapists with a lot of experience with women who are pregnant. You will never meet a woman who regrets having gotten one (or several) massages in her pregnancy.

When you need more support than your muscles can give you, trying a brace tailored to your complaint can be helpful. It’s You Babe, a manufacturer of prenatal braces, is an example of just how many different braces are out there. The type you need depends on the location of your pain. There are special belts for twin pregnancies and for women with predominantly hip pain and even for those with vulvar varicosities. Maternal Connections, the gift shop at El Camino Hospital’s Women’s Hospital, has a large dressing room with trained staff that help you try on all different types of maternity braces to find something that will help you feel better.

For patients who suffer from heel pain in pregnancy, make sure you stretch out your legs, calf muscles, and ankles every morning. Also wear shows with low heels (but not flats).

When you’re in pain and would like relief, remember that acetaminophen is safe in pregnancy. Do not take more than the recommended dose on the bottle, but it’s a safe pain reliever to take in pregnancy, even if you need it most days. I know most of us try to avoid medications while we’re pregnant, but sometimes one acetaminophen before bedtime will grant us a good night’s sleep.

MEDICARE UPDATES

As an in-network provider for nearly all commercial services, when we inherited Dr. Sutherland’s practice, we made a huge effort to become contracted with Medicare. This was a new effort for us and has proven very difficult. We are sad to say that though we have completed all requirements of contracting, we have chosen to “opt-out” of Medicare.

Unfortunately, in an effort to contain costs, the number of regulations and restrictions on physicians has only increased in the last 2 years. The last two big ones relate to physician overpayments and to patient outcomes. Physicians are now responsible for any overpayments received from Medicare and refunding that money within 60 days. This requires an in-office auditing program and is also associated with increased auditing from Medicare. While this alone creates a burden of work out of proportion to what a small office can afford, when overpayments are identified (these are overpayments as a result of a mistake that Medicare makes), physicians are not just liable for the overpayment amount, but are at risk of being sued by the federal government under the False Claims Act. The second change makes physicians responsible for patient outcomes, not just healthcare. As physicians committed to educating and caring for patients and keeping them central in their healthcare decision making, we feel that as physicians we should be compensated for our time and services, not the results of what patients choose to do with our advice.

Having chosen to “opt-out” of Medicare does create a few problems. First, we will not be allowed to submit claims to Medicare nor will patients who are Medicare beneficiaries. Medicare beneficiaries who chose to come to our office for care will have to sign agreements (mandated by CMS) stating they will not seek reimbursement from Medicare for these services. Secondly, we will not be able to see any Medicare patients for the current quarter, that is, before July 1, 2016. For any patients currently enrolled in our practice who need appointments during this quarter, please do call and make them, our billing staff will do everything possible to make sure we do everything in a transparent, legal manner in terms of billing. As always, we will continue to manage medication refills and imaging requests as appropriate without requiring an in office visit.

We hope in the near future, Medicare reforms become more welcoming to small physician offices so that we can re-register as participating providers.

HIGHLIGHTS FROM OUR WOMEN’S HEALTH BLOG

Our Women’s Health Blog is a way for us to put out up to date information on various topics. Dr. Teng wrote an article on updates related to the Zika Virus and pregnancy. Dr. Balassiano wrote a review of Minimally Invasive surgical options for patients with fibroids.

General Office Information