2017 Issue 2, Quarterly Newsletter

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WOMEN’S HEALTH

Our Spring 2017, newsletter is finally here!

I hope everyone’s enjoying the warming weather, blooming flowers, and end of tax season.

Having come back from maternity leave with my fourth child, it’s wonderful to return to the office full of wonderful, caring women. Dr. Gupta has settled into the office very well and the office has been a bustling mix of patients, family and staff.  

We’re working diligently to streamline our back office so all patients are seen in a timely manner, and the appointment schedule runs smoothly.  Your feedback, of course, is always welcome. Send any thoughts, suggestions you have directly to Julie, our office manager at moc.n1695898658emowo1695898658nimac1695898658le@ni1695898658mda1695898658 or anonymously via our feedback form.

Do your best to get outside and enjoy the weather,

Sarah Azad, MD

In this issue:

Practice Updates

Reminders for patients of Dr. Sutherland and Crystal

Updates in Carrier Testing for Reproductive Health

Barb Dehn, NP Brings her Clinical Skills to Tanzania

My Challenges with Breastfeeding

Endometriosis in the Literature

When is Bleeding Abnormal

MonaLisa Touch Continues to Prove Successful

Highlights from the Women’s Health Blog

PRACTICE UPDATES

Dr. Gupta joined us on the first of February, after having been in practice for 4 years in Pennsylvania, and has fit right in. We’re happy to have found her and think you will all agree she’s committed to our goal of comprehensive and compassionate care.

Her arrival has allowed us to fully staff our San Jose Office. Opened in March of 2016, the Willow Glen area was chosen as a convenient location for our patients who live in the area or are coming from the East Bay. Though our main operations are all in Mountain View, our San Jose office will be open Monday through Friday. The majority of our mental health services will be offered in San Jose as well. 

At this time we are still only caring for patients at El Camino Hospital, in Mountain View.

Finally, starting in July, we’re shifting our schedule from 15 min increments to 10 min increments. This will allow us more flexibility with scheduling appointments with adequate time for each patient’s needs. If you’ve already scheduled appointments for later in the year, you may notice they are off by 5 min from what you have on your reminder card. You can always check in your patient portal ahead of time to confirm your appointment times and you should still be getting reminder messages a day or two before with the updated time.

REMINDERS FOR THE PATIENTS OF DRS. CRYSTAL AND SUTHERLAND

It’s been almost 20 months since Drs. Crystal and Sutherland have closed their private practices. We are no longer able to honor prescription refills for patients who have not been seen by us and will be making no exceptions. If you are being seen at another office and need your records, please fill out a Release of Information Form and email or fax it to our office.

UPDATES IN CARRIER TESTING FOR REPRODUCTIVE HEALTH

Pooja Gupta MD

What’s carrier screening?

Carrier screening is a term used to describe genetic testing performed on an individual without disease or symptoms to determine whether that person has a mutation within a gene that is associated with a particular disease. Most of these disorders are very lethal resulting in death varying from newborn period to early adulthood. Carrier screening can be performed for one specific condition or for multiple disorders

These disorders vary in prevalence* depending on ethnicities as below.

Since in the present multiracial society, it is increasingly difficult to define an individual’s ancestry and because of the increasing frequency of ethnic admixture of reproductive partners, the American College of OB GYN (ACOG) has now recommended offering all patients pan ethnic or expanded carrier screening during pregnancy or before planning pregnancy. We at El Camino Women’s Medical Group understand the importance of being aware of your genetic makeup and have been offering this for quite some time now. This gives our patients knowledge and options regarding pregnancy planning, genetic counseling and planning for potential treatment options of an affected baby, if needed.  

How can we do the testing?

It is a simple blood test and we would suggest talking to your OB during the visit. At our office, we routinely order expanded carrier screening during your first prenatal visit. Our preferred lab is Horizon by Natera, but depending on your insurance carrier, we may order carrier screening from another lab.

What if I test positive for a disorder?

We recommend testing your partner and if he is negative for that particular disorder there is no risk of your baby being affected. In case he is positive as well, we would discuss genetic counseling and ways to get diagnostic testing to see if your baby is affected or not.

Do I need to get it done every pregnancy?

No it is a one-time test which is valid for your subsequent pregnancies.

You may view these resources at

http://www.acog.org/About-ACOG/ACOG-Departments/Genetics/Carrier-Screening

BARB DEHN, NP, BRINGS HER CLINICAL SKILLS TO TANZANIA

Barb Dehn, NP

 I absolutely love caring for women at El Camino Women’s Medical Group and am so grateful that the physicians and staff have been so supportive of my trips to Tanzania. So many patients have asked what in the world I’m doing over there, that I’m happy to share why I go half way around the world.

 It’s been an honor to be invited to work, learn and share best practices at FAME hospital in Karatu, Tanzania.  FAME stands for Foundation for African Medical Education, and was started by an amazing husband and wife team, Dr. Frank Artress and Susan Gustafson.

 Imagine a place where it’s mostly dirt roads, well, if there are roads, and where the jackals call out at night and you wonder is there something else larger and hungrier out there. This is a captivating place where giraffes graze on tender leaves on the very tops of thorny acacia trees and baboons roam the long steep road that leads up from the bottom of Africa’s Great Rift Valley to the Tanzanian highlands and the gateway to the Ngorogoro Crater and the Serengeti.

This is a place where the traditional Masaai people are wrapped up in the most colorful red, purples and blue plaid shukas, with intricate handmade beaded jewelry dangling from their ears, necks, ankles and wrists. These are some of the people that FAME serves. They are pastoralist, leading traditional lives herding goats and cattle, many still living in traditional mud huts with thatched roofs, known as bomas without water or electricity.

Until Frank and Susan began caring for people out of an old Land Rover, there were only 3 doctors available for over 250,000 people. And now, where there once was a bean farm, there is a small hospital staffed with Tanzanian doctors and nurses.

I was attracted to FAME for many reasons, mostly because their goal is to create sustainability and by the way, FAME’s staff of gardeners still grow most of the food right on the campus for both the staff and patients. FAME is non-denominational and while much of the work is supported through donations, the fees that patients are responsible for are kept at the same level as the government hospitals.

It’s hard to believe that in 99% of clinics and hospitals in Africa, people must bring their own supplies and their own food. That means if someone is sick, their families also come, camp out nearby and cook, bringing sheets for the beds, gloves, and other medical supplies. And some people have no family to help. FAME is different in so many ways. At FAME, we feed the patients 3 meals a day, they have clean linens, and we have a cleaning crew that works constantly around the clock to make certain that the dust is kept away from all of the delicate medical equipment and people can heal in a place that’s clean.

There’s so much more to share, I think this video really captures the heart of FAME.

I feel so lucky. I can work with some of the most amazing group of doctors I’ve ever met here at ECWMG and also see another side of life at FAME in Tanzania.

I’m heading back to FAME in May to help them with a World Health Organization program for evaluating and treating pre-cancer and cancer of the cervix. I’ll also be helping train the staff in responding to obstetrical emergencies and teaching ultrasound. If you’d like to know more about the incredible people at FAME, you can learn more here.

MY CHALLENGES WITH BREASTFEEDING

Amy Teng, DO

As an obstetrician I counsel patients daily regarding the challenges of pregnancy, labor, and breastfeeding.  As most mothers will acknowledge, the expectations and goals that are set for this time in a woman’s life can be numerous, complicated, and sometimes difficult to achieve.  My goal is to make sure our patients feel prepared, educated, and that they trust in our knowledge and judgment during these important times.  However, sometimes despite the number of books you’ve read or classes you’ve taken, you can’t totally prepare yourself for or fathom what that experience will be like until you journey through it yourself.  I want to share my personal experience with the challenges I faced in this time, and hope that in a way patients can feel easier with some decisions they have made or have yet to make. 

I delivered my first child last year, in July 2016.  Fortunately I had a very easy pregnancy.  I had virtually no morning sickness, my energy level was great, and I was able to work and exercise until the few weeks preceding my due date (Hooray, a few goals were met!)  What was yet to come was the hardest thing I’ve ever done in my life.  Breastfeeding.  Many women will say: “Nobody tells you how hard breastfeeding is!”  As one who counseled patients on this issue, I knew how hard breastfeeding was, yet even I was surprised by how much more difficult it turned out to be.  Short of having mastitis, I had practically every other challenge associated with breastfeeding.  My son had latching difficulties in the beginning, which inevitably led to nipple trauma and terrible pain.  He had mild tongue tie which was corrected, yet he still had problems maintaining a deep latch during feedings, and I was in constant pain and discomfort during and after feedings.  It got to a point where I would dread the next nursing session.  As a mother, you want to look forward to that intimate bonding time with your child, a bond that only mothers can have with their babies.  I, on the other hand, was dreading it, fearing the toe-curling pain that felt like daggers stabbing my breasts every time he would latch.  I would tell myself  “It’s not supposed to feel that way.  I must have been doing something wrong!”  Was it me?  Was there something I was missing?  I tried 3 different breast pumps, including a hospital grade pump, with multiple different parts and connectors, hoping that one combination would finally “work.”  I went to physical therapy for recurrent clogged ducts.  It felt like all of my time spent was on “boob care,” as I called it, and I came to a point where I realized that I couldn’t sustain that routine.  I was spending more time stressing and worrying about breastfeeding than I was with my son.  I wanted to be able to enjoy my time with him before I had to return to work, and ultimately that was more important to me than the breastfeeding.  I struggled for 6 weeks.  In the end, I was happy that I was able to breastfeed for those six weeks, and came to terms with the fact that it just didn’t work out this time for us.  The moment I made the decision to wean, I felt a huge stress was lifted.  I was able to fully enjoy my son in the moments of intimacy we had together during the bottle feeds, during the times he communicated with his expressive eyes and smiles.   I had more energy from being able to rest and sleep, which was more energy I could spend with him, reading to him and interacting with him. 

No one can tell you how to be a perfect mother.  In our society there is a tremendous amount of pressure placed on moms.  Pressure to have the perfect pregnancy, the perfect delivery, and the perfect breastfeeding experience.  A lot of groups will sensationalize the experience for specific gains, including financial gains.  Is breastfeeding important?  Of course it is!  It facilitates bonding with your baby and a quicker return to pre-pregnancy weight.  It has proven short-term medical benefits, and it’s cheaper.  However, in certain situations (for example, if the baby is not getting enough milk and could be dehydrated) it is more important to feed the baby than to feed breast milk.  As obstetricians we are all proponents of breastfeeding.  It is also our responsibility to deliver the most accurate and most up to date information regarding the medical benefits of breastfeeding to our patients.

The American Academy of Pediatrics (AAP) recommends 6 months of exclusive breastfeeding, with their most recent policy statement published in 2012.  So should we feel so guilty if we aren’t able to achieve this goal?  What does the science tell us?  Studies show that a group of breastfed infants has an 8% decrease in colds and diarrhea in the first year, which for the average infant is possibly 1 fewer episode of each per year.  The most comprehensive study of breastfeeding benefits thus far published in 2014 looked within families by comparing siblings who were fed differently, which eliminated many of the confounding factors present in previous studies.   They found no significant difference between breastfed and bottle-fed children with regards to rates of obesity, asthma, test scoring, and intelligence scales.  The World Health Organization in 2013 published a systematic review that did not show any evidence of long-term health benefits of breastfeeding, including obesity, blood pressure, diabetes, and intellectual performance. 

Many people have the misconception that breastfeeding is easy; that it just happens like second nature to moms and babies.  The reality is breastfeeding is extremely difficult, for various reasons, and mothers shouldn’t punish themselves or feel guilty if their expectations are not met.  Every woman has a unique experience with pregnancy, labor, and postpartum.  I can say that I was disappointed it didn’t work out better for us, but any breastfeeding is great and I was happy I was able to do it for as long as I did.  My son and I navigated through some tough times together, and it’s an experience I won’t forget.  He is now a healthy 8 months old and is such a happy baby! 

I feel that the whole experience has made me a better person and a better doctor.  It has allowed me to pass on what I feel is important knowledge to my patients.  That includes 1) be as prepared as you can, 2) try your best, 3) ask for help when you need it, and 4) recognize your limits and prioritize what is most important.  In the end, the amount of love you have for your baby is what makes you a good mom.  J

ENDOMETRIOSIS IN THE LITERATURE

One of our doctors, Dr Balassiano, recently published a very interesting article about the association between endometriosis, chronic pelvic pain and the presence of uterine fibroids. Fibroids are a very common condition diagnosed and treated in many women, especially when they are evident on physical exam and/ or ultrasound and accompanied by complaints of pelvic pain and heavy menses. However, in the majority of times (more precisely over 85% according to the study!), endometriosis is also present and under diagnosed. Overlooking the presence of endometriosis leads to persistent complaints of pelvic pain and infertility even after surgery. It is important for patients and physicians to be aware of this association in order to avoid a second procedure and to provide a more comprehensive medical care to women. If trying to conceive or just having painful or heavy cycles, I encourage you to discuss with your provider and consider minimally invasive approaches to potentially diagnose and treat fibroids and endometriosis simultaneously.  Dr. Balassiano is a minimally invasive trained surgeon and she is available at El Camino Women Medical Group to answer any questions you might have.

WHEN IS BLEEDING ABNORMAL?

Barb Dehn, NP

What is normal when it comes to a period?

 It’s estimated that 1.4 million women in the US will experience abnormal uterine bleeding (AUB) each year. For women in perimenopause, about half will experience irregular and/or heavy bleeding. Heavy menstrual bleeding and/or periods that show up unexpectedly can wreak havoc in a woman’s life.

 Many women are busy juggling lots of demands on their time and figure that the bleeding will stop or become regular. Others are concerned about how we diagnose the issues and what types of treatments are available. Many are just too busy to get this evaluated, which is understandable.

Here at El Camino Women’s Medical Group, in most cases we can evaluate and treat a woman’s bleeding right here in our office. So please don’t let worry or concerns interfere with you getting the care you need.

How do we define Abnormal Uterine Bleeding?

The American Congress of Obstetricians and Gynecologists (ACOG) defines Abnormal Uterine Bleeding this way:

ACOG Definition of Abnormal Uterine Bleeding (AUB)

• Bleeding that requires more than 1 pad/hour for more than 1 day
• Bleeding for more than 7 days at a time
• Bleeding intervals that are less than 20 days apart
• Bleeding in excess of 80 cc a month
  • a super tampon or pad can hold approximately 10 cc of blood
• Bleeding that causes anemia
• Bleeding that leads to disruption in life style.

Source: ACOG, Committee Opinion. April 2013 (reaffirmed 2015), number 557.

When evaluating women with bleeding, the very first test that’s done on women under 60 is a pregnancy test. Pregnancy is still one of the most common causes of bleeding in women of reproductive age.

Once it’s determined that the woman isn’t pregnant, our providers may recommend lab testing and an ultrasound.

If it’s necessary to look inside the uterus, we use an in-office camera, known as Endosee® that is attached to a small smart phone sized screen to visualize the inside of the uterine cavity. This can be done in the office in less than 30 minutes. This saves women valuable time and reduces costs, because what was once an outpatient surgical procedure, requiring scheduling with the hospital or Surgery Center operating room can be done without anesthesia and in the convenience of the office.  

In addition, women who have abnormal bleeding may need to have an endometrial biopsy to make sure there isn’t any abnormal cell growth that could be causing the bleeding.

For both the Endosee and an Endometrial biopsy, we use a numbing medicine to reduce discomfort, and most women are able to return to their normal routines within a few hours.

If you have any bleeding that’s heavy, prolonged or if you have any concerns, please do make an appointment with one of our providers.

MONALISA TOUCH CONTINUES TO PROVE SUCCESSFUL

CO2 Fractional Laser treatments for vulvo-vaginal atrophy (VVA), genitourinary syndrome of menopause (GSM), or the vaginal dryness that comes with menopause and also for stress urinary incontinence (SUI) continues to have remarkable results.   Several new studies have been published establishing the MonaLisa Touch treatment modality as both safe (rare, if any harms reported) and effective (90-95% of patients report satisfaction with treatment.   Learn more about this innovate, life-changing technology in our office, or in the literature:

https://www.ncbi.nlm.nih.gov/pubmed/28419911

https://www.ncbi.nlm.nih.gov/pubmed/28169913

https://www.ncbi.nlm.nih.gov/pubmed/25333211

https://www.ncbi.nlm.nih.gov/pubmed/28056209

https://www.ncbi.nlm.nih.gov/pubmed/28364861 

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.  2017 has already told us that breast cancer rates are falling in the US, which is welcome news.  There are also some new discoveries in lab research related to PMS (premenstrual syndrome) and PMDD (premenstrual dysmorphic disorder), that will hopefully lead to more therapeutic options for the 5-10% of women with more severe symptoms. 

GENERAL OFFICE INFORMATION