2018 Issue 4, Quarterly Newsletter

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WOMEN’S HEALTH

It seems too soon to be writing our last newsletter of the year, but here it is.

Last year around this time, I was writing about the fires in Sonoma and Napa as well as the devastation in Puerto Rico after Hurricane Maria. While Napa and Sonoma are slowly rebuilding, there’s still so much to be done in Puerto Rico. The Puerto Rican Civic Club, a local organization made up of Bay Area residents with ties to the region, is still working hard to raise money to help those affected. PRCC has been instrumental in getting donations and supplies directly to those most impacted by last year’s Hurricane. There seems to always be so much political turmoil in the news, it’s heartwarming to work on projects that remind us how much good can come of people working together for others.

With the holiday season upon us, we also are back at full staff with the return of Dr. Teng and the hiring of three new staff in the last month. We look forward to a season full of the compassionate, personalized healthcare that our office strives to provide.

As always, feedback is always welcome on our practice, customer service, and even this newsletter!

Sarah Azad, MD

In this issue:

Practice Updates

The Flu Vaccine

Breast Cancer Screening: What’s the latest news?

Endometriosis: Something New

Medical Scribes: Improving Patient Care

Postpartum: Education, Problems and Patient Needs

Cancer Prevention Recommendations

Adult Acne in Women

The MonaLisa Touch and the FDA

Highlights from our Women’s Health Blog

PRACTICE UPDATES

With the upcoming Thanksgiving and Christmas Holidays, our staff and physicians will be taking off time as well and there will be fewer openings for patient visits some days of the week. For urgent needs, we are always available. However, if you have any medical needs you want to be addressed before the end of the year, please book your appointments soon. During the two weeks of holidays at the end of the year, we will only be scheduling urgent visits and those related to pregnancy, allowing more of our staff time home with their families. Please also make sure you give us enough time for any refills on prescriptions you will need over the holidays.

After 3 months of notices, on July 19th, we started charging for all forms needed by patients. Outside of a quick work/school note, every form required for us to fill out will cost $30. This has been frustrating for many patients and we are doing our best to be transparent. Insurance companies have decided that filling out forms for schools, disability and FMLA are NOT a part of medical care but related to HR issues like pay and time off. Since they do not consider it medical care, they do not pay for these services. We have been doing them as a courtesy for years, but given the healthcare climate we live in, we have been forced to start charging for the administrative cost to the practice.

Our future home in the IMOB has made a lot of progress. If you’re interested in seeing the progress, you can see the progress here. We’re currently in our third home since we opened in July of 2009, and looking forward to settling down in our fourth (and hopefully final) home next summer.

THE FLU VACCINE

The Flu Vaccine for the 2018-2019 flu season is now available. Last year, over 80,000 Americans died from complications of the flu. The CDC recommends that everyone over the age of 6 months gets the Flu Vaccine every year. Especially vulnerable patients include:

• Anyone over the age of 65
• Women who are pregnant or postpartum
• Children under the age of 5
• Children under 6 months of age

There are many ways to get the Flu Vaccine as our society does it’s best to make it convenient and easy:

• We have it in our office and will offer it to all appropriate patients at upcoming appointments
• For the month of October, our patients can walk in on Tuesday or Thursday mornings from 8 am to 1030am
• You can call to arrange another time to walk in, remember we often see patients on weekdays until 7 pm and most Saturday mornings
• All major pharmacies (Target, CVS, Walgreens, Costco, etc.) offer the Flu Vaccine, so you can get it while running errands!
• Many major employers offer it at work for employees.

We encourage everyone to do their best to get vaccinated, for your own health and for the protection of the vulnerable you may come into contact with.

BREAST CANCER SCREENING: WHAT’S THE LATEST NEWS?

October is Breast Cancer Awareness Month! This is a great month to learn about the latest guidelines for breast cancer screening.

The first step is for all women to see their gynecologist once a year for an annual well-woman exam. These visits should be focused on a woman’s overall health and a complete exam. If one has other issues that need to be addressed (heavy periods, painful sex, etc.) it is best to schedule an appointment for those first and have the well-woman exam separately. It’s during these exams that physicians are able to update a woman’s personal and family history, assess risk factors for different common diseases, and help educate women on relevant lifestyle modifications, updated screening guidelines and new technology available for testing.

For women with a family history of breast cancer, it is important to have details on who has had breast cancer and their age of diagnosis. Certain family histories will trigger an offer for genetic counseling and/or genetic testing for hereditary cancer genes like BRCA 1/2. Models like the Gail Model and the Tyrer-Cuzick Model are able to calculate a lifetime risk of developing breast cancer. This type of information helps stratify women into low and high-risk categories.

• For women with certain patterns of breast or ovarian cancer in their family histories, genetic testing is important to properly plan for how best to screen for breast cancer
• For women at a higher risk of breast cancer (greater than a 20% lifetime risk), current recommendations include a clinical breast exam in the doctor’s office every 6 months, an annual mammogram, and potentially an annual breast MRI. The best age to start mammograms and MRIs will depend on specific family history information
• Some women at higher risk of breast cancer are candidates for “chemoprevention” by taking medications that will help prevent the disease from developing.
• For women at a lower risk of breast cancer, an individualized plan should be made between her and her physician to decide when to start and how often to perform screening tests

It is important to know that 85% of women with a diagnosis of breast cancer have no family history of the disease.

In our office, we also offer qualifying low-risk women the Brevagen test. Brevagen uses a woman’s genetic markers as well as information about her health to give a more personalized risk stratification of developing breast cancer in the next 5 years.

El Camino Hospital has events this month to further educate women about breast cancer, updates in screening and treatment. The National Comprehensive Cancer Network also has helpful information about breast cancer and screening in low and high-risk patients.

If it’s not time for your annual exam but you are concerned about your personal risk of breast cancer or have new family history information that you find concerning, you can always schedule a consultation with your gynecologist to discuss this important health issue.

ENDOMETRIOSIS: SOMETHING NEW

Endometriosis is a disease of the pelvis that affects between 1 and 8% of the female population. It can be as high as 50% in women with infertility and is present in as many as 70% of women with pelvic pain.

It’s been over a decade since any new treatments for Endometriosis-associated pain have been released, so it’s exciting to have something new for the very large number of women who deal with this disease on a daily basis.

Endometriosis is defined as have endometrial cells–which are supposed to make up the lining on the inside of the uterus—located outside the uterine cavity. Usually, these endometriotic “implants” are located on the tubes, ovaries, or uterine surface, but have been found on the intestines, diaphragm, lining of the lungs and even in the membranes lining the skull. Some women with endometriosis have minimal to no symptoms, while others suffer from painful periods, painful sex, chronic pelvic pain, and infertility. It’s a disease that can affect women from the time they have their first period, through the reproductive years, and even well after menopause.

This summer, AbbVie won approval for elagolix, which will be marketed under the name “Orilissa”. It’s a gonadotropin-releasing hormone receptor antagonist, like Lupron. Orilissa—which is taken as a daily tablet–only partially blocks the estrogen and progesterone receptors, resulting in decreased pain with less severe side effects. Phase 3 trials have shown it’s well tolerated and successfully reduces pelvic pain, pain with periods, and pain with sex.

Of course, AbbVie has investors to satisfy and has been working on bringing Orilissa to market since 2010. They will be pricing the drug at just over $10,000/year. For those with commercial, employer-sponsored insurance plans, there will be ways to afford this new medication, either through affordable co-pays or with “coupons” that make it affordable. These coupons are also in the news these days as the US government is threatening to ban them.

Ultimately, if you have chronic pelvic pain, painful periods, or other symptoms of endometriosis, bring them up with your OB/GYN. Now’s a great time, there are many treatment options available, and Orilissa is just the newest.

For women who needed or may need surgical evaluation and/or treatment of endometriosis, Dr. Erika Balassiano is fellowship trained in Minimally Invasive Surgery and has expertise in patients with endometriosis. 

MEDICAL SCRIBES: IMPROVING PATIENT CARE

The introduction of electronic medical records (EMRs) to healthcare has been revolutionary. Charts are no longer misplaced. Patients have access to their test results, vital signs, diagnoses and more. And of course, the handwriting is all legible.

There has been another consequence of EMRs: frustration from physicians. Nearly every physician who has transitioned from paper to EMRs (including all of the ones at El Camino Women’s Medical Group) have found that EMRs slow them down. We are not able to chart as quickly and often our charting is more abbreviated than we’d like. The solution we’re often “told” is best: to just be on your computer the entire encounter. The second most common advice: get a medical scribe.

As a patient, you probably agree with us, having your physician turned away from you, on their computer your entire visit is far from ideal. As physicians, it takes away from one of the most important parts of a visit: listening. Body language and facial expression is a big part of listening. Its also hard to develop the type of human, personalized connection we value here at ECWMG, if we have to minimize eye contact in order to look at a screen.

What is a medical scribe?

Here enters the medical scribe. You may have met some already, at an ER visit or maybe with your internist or dermatologist’s office. They are people trained to be in the room during a visit and document the conversation between the physician and the patient as well as the details of the exam and the plan of care. These notes are reviewed by the physician and signed off on at the end of the visit. This saves an enormous amount of time for the physicians, allows for more detailed documentation and actually improves accuracy, since physicians aren’t completing notes late in the evening, several hours later.

There is a large amount of published data that medical scribes improve patient and physician satisfaction. It also frees up physicians to have more direct contact with patients and to increase their availability to other patients as they do not have to stay late charting in EMRs.

Are scribes coming to ECWMG?

We have discussed having scribes at our office several times in the last few years. Due to the sensitivity of our field and intimacy of our exams, we have chosen not to incorporate medical scribes in our office. However, there is now the option of having a virtual medical scribe join us in our visits. This is a trained scribe, located in a HIPAA-secure facility, who listens in on a visit (no images, only sound) and documents for the physician. We have come to the conclusion that this is a necessary addition to our practice if we want to continue providing quality, personalized care without the burden on our physicians of 1-2 hours of extra charting after work. Yes, when a physician choses to be fully engaged with a patient during a visit, EMRs add 1-2 hours of extra time per full clinic day to “chart”.

Over the next few months, we are going to be piloting using a virtual scribe in the office. Of course, you will always be given notice, at any and every visit that has something like a scribe involved. We just wanted everyone to have some background and understanding of the role of medical scribes in modern medical practice.

POSTPARTUM: EDUCATION, PROBLEMS AND PATIENT NEEDS

The support and attention women have postpartum in our area varies greatly from family to family. What we do know, is that taking home a new baby is hard, new parents need help and women are both responsible for an entirely new human being while navigating the physical and emotional changes of having just delivered.

For over 3 years, we have been checking on all our patients 1-2 weeks postpartum. Our RN calls patients at home to see how their mood is and how breastfeeding has been going. She also makes herself available for other questions they may have. Sometimes some basic advice is all new parents need, sometimes they do need to follow up with a pediatrician, lactation consultant, or us—the OBGYNs—in the office.

Fortunately, the unique and overwhelming needs of the postpartum are gaining national attention. This summer ACOG came out with new guidelines on “Optimizing Postpartum Care” which includes evaluation around 2 weeks and ongoing support up to 3 months postpartum. We are very excited about these developments and they will better allow for institutional and insurance investments into this delicate time in a new family’s life.

For about a year, we’ve been working on educational resources for the postpartum, to allow our patients to have a resource for relevant information directly from us, as opposed to the vastness of Google and the internet. By the new year, we hope to launch a series of weekly newsletters to our new parents highlighting brief, relevant information for them, confirming what’s normal and alerting women to what may require a call or visit. Our initial efforts are now live here. We welcome feedback from everyone on what you may have wanted to know when you first went home with a newborn. Send us your comments at moc.n1695643784emowo1695643784nimac1695643784le@of1695643784ni1695643784 or via our feedback link.

CANCER PREVENTION RECOMMENDATIONS

Shyamali Singhal MD
Surgical Oncology

Cancer is Preventable!

In this month where all of us have breast cancer on our minds, it seems that all of us know someone with cancer. It seems so much more common than ever before. As a surgical oncologist, every day I wish we did not have so many patients with cancer. If there was something we could do to decrease risk, we all should do it.

In the US in 2018 there an estimated 1.73 million new cases of cancer diagnosed and 600,000 of those will die of the disease. The most common cancers in descending order of frequency breast, lung, prostate, colon and rectum, melanoma, bladder, Non-Hodgkin’s lymphoma, kidney cancer, endometrial cancer, leukemia, pancreatic cancer, thyroid cancer, and liver cancer.

We talk about the genetic origins of cancer which really only account for about 10% of patients and cannot be modified. What is less well known is that 30-50% of new cancer diagnoses are preventable with minimal changes to your lifestyle. The two obvious lifestyle ones are 1) quit smoking and 2) stay out of the sun. The less obvious, diet and exercise have a tremendous impact on the risk of developing cancer.

We recommend a diet rich in fruits and vegetables, exercise to exceed 150 minutes a week, and maintaining BMI less than 25.

Cancer Prevention Recommendations

These ten cancer prevention recommendations are drawn from the AICR/WCRF Third Expert Report.

Be a healthy weight

Keep your weight within the healthy range and avoid weight gain in adult life

Next to not smoking, maintaining a healthy weight is the most important thing you can do to reduce your risk of cancer. Aim to be at the lower end of the healthy Body Mass Index (BMI) range.

Body fat doesn’t just sit there on our waists – it acts like a ‘hormone pump’ releasing insulin, estrogen and other hormones into the bloodstream, which can spur cancer growth. See Recommendations 2 and 3 for strategies for weight management.

Be physically active

Be physically active as part of everyday life— walk more and sit less

Physical activity in any form helps to lower cancer risk. Aim to build more activity, like brisk walking, into your daily routine.

As well as helping us avoid weight gain, activity itself can help to prevent cancer. Studies show that regular activity can help to keep hormone levels in check, which is important because having high levels of some hormones can increase your cancer risk.

For maximum health benefits, scientists recommend that we aim for 150 minutes of moderate, or 75 minutes of vigorous, physical activity a week.

Emerging research is showing that extended periods of inactivity – sitting at a computer, watching tv, etc. – increase many indicators for cancer risk. Break up your day by getting up and walking around a few minutes every hour.

Eat a diet rich in whole grains, vegetables, fruits and beans

Make whole grains, vegetables, fruits and pulses (legumes) such as beans and lentils a major part of your usual daily diet

Basing our diets around plant foods (like vegetables, fruits, whole grains, and beans), which contain fiber and other nutrients, can reduce our risk of cancer.

For good health, we recommend that we base all of our meals on plant foods. When preparing a meal, aim to fill at least two-thirds of your plate with vegetables, fruits, whole grains, and beans.

As well as containing vitamins and minerals, plant foods are good sources of substances called phytochemicals. These are biologically active compounds, which can help to protect cells in the body from damage that can lead to cancer.

Plant foods can also help us to maintain a healthy weight because many of them are lower in energy density (calories).

Limit consumption of “fast foods” and other processed foods high in fat, starches or sugars

Limiting these foods helps control calorie intake and maintain a healthy weight

There is strong evidence that consuming “fast-foods” and a “Western-type” diet are causes of weight gain, overweight and obesity, which are linked to 12 cancers.

Glycemic load also increases the risk of endometrial cancer.

Limit consumption of red and processed meat

Eat no more than moderate amounts of red meat, such as beef, pork, and lamb. Eat little, if any, processed meat

The evidence that red meat (beef, pork, and lamb) is a cause of colorectal cancer is convincing. Studies show, however, that we can consume modest amounts — 12 to 18 ounces (cooked) per week — without a measurable increase in colorectal cancer risk.

But when it comes to processed meat (ham, bacon, salami, hot dogs, sausages) the evidence is just as convincing, and cancer risk begins to increase with even very low consumption.

This is why the expert panel advises limiting red meat and avoiding processed meat.

Limit consumption of sugar-sweetened drinks

Drink mostly water and unsweetened drinks

There is strong evidence that consuming sugar-sweetened beverages causes weight gain, overweight, and obesity, linked to 12 cancers.

Sugar-sweetened beverages provide energy, but may not influence appetite in the same way as food does and can promote overconsumption of calories.

Limit alcohol consumption

For cancer prevention, it’s best not to drink alcohol

Previous research has shown that modest amounts of alcohol may have a protective effect against coronary heart disease.

But for cancer prevention, the evidence is clear and convincing: alcohol in any form is a potent carcinogen. It’s linked to 6 different cancers. The best advice for those concerned about cancer is not to drink.

If you do choose to drink alcohol, however, limit your consumption to one drink for women and two for men per day.

Do not use supplements for cancer prevention

Aim to meet nutritional needs through diet alone

For most people, it is possible to obtain adequate nutrition from a healthy diet that includes the right foods and drinks.

The panel doesn’t discourage the use of multivitamins or specific supplements for those sub-sections of the population who stand to benefit from them, such as women of childbearing age and the elderly. They simply caution against expecting any dietary supplement to lower cancer risk as well as a healthy diet can.

High-dose beta-carotene supplements have been linked to an increased risk for lung cancer in current and former smokers. It’s always best to discuss any dietary supplement with your doctor or a registered dietitian.

For mothers: breastfeed your baby, if you can

Breastfeeding is good for both mother and baby

According to the expert report, breastfeeding benefits both mother and child.

There is strong evidence that breastfeeding helps protect against breast cancer in the mother. There are likely two reasons for this. First, breastfeeding lowers the levels of some cancer-related hormones in the mother’s body. Second, at the end of breastfeeding, the body gets rid of any cells in the breast that may have DNA damage.

In addition, babies who are breastfed are less likely to become overweight and obese. Overweight and obese children tend to remain overweight in adult life.

If you’re planning to breastfeed your baby, your doctor or certified lactation consultant will be able to provide more information and support.

After a cancer diagnosis: follow our recommendations, if you can

Check with your health professional about what is right for you.

Shyamali Singhal MD
moc.t1695643784sigol1695643784ocno-1695643784lacig1695643784rus@c1695643784od1695643784
650 641 7861

ADULT ACNE IN WOMEN

Lillian Soohoo, MD
Dermatology

Adult Acne in Women

Acne can be a problem not only for teens, but also for women well past their twenties, thirties, and even their forties. Many women continue to suffer from recurrent breakouts well into menopause and beyond, causing embarrassment, frustration, and stress in already busy lives.

Why?
Changes in women’s hormones, specifically a decline in estrogen levels, allow the other hormones commonly known as androgens (i.e., testosterone, progesterone) to have a greater effect on our skin. Androgens stimulate oil glands to produce sebum. This increase in sebum triggers bacterial overgrowth and inflammation in the skin which results in tender, nodular or cystic pimples on the lower part of the face particularly the chin, the lower cheeks and jawline, and the upper neck. Androgen levels normally peak during the week prior to menstruating and this is experienced by many women as increased oiliness and acne flares each month in the week prior to their period.

A normal decrease in estrogen production often begins during the late thirties (a decade or more prior to menopause) and can result in a gradual or sudden resurgence in acne for women. This acne is a result of the unopposed and increased effect of androgen during this time of life before other signs of menopause appear. Another important, often unrecognized source of adult acne is the use of androgen-containing hormonal contraceptives (e.g., Mirena IUD, LoEstrin pills). Even women in their teens and twenties may notice acne flaring with these types of hormonal contraceptives.

What signs to look for

Scarring from acne is best to avoid since total correction can be extremely difficult even with the latest technology. Acne scars commonly occur on the face, chest, and back and may appear as:
• Shallow depressions or divots
• Deep, icepick indentations
• Firm, rubbery bumps or nodules
• Dark brown spots and discoloration
• Persistent pink or red blotches

In general, the deeper and larger the pimples, the greater the risk is for residual scarring.

What you can do
If your acne is causing you discomfort, either physical or emotional stress, there are effective treatments to help. Acne is extremely common in women of all ages and is often a bewildering side effect of hormonal contraceptives, pregnancy, and postpartum changes, as well as approaching menopause. This can lead to unwanted imperfections in the skin, especially surface defects and discoloration. Therefore, early treatment of acne is ideal to prevent scarring.

State-of-the-art acne treatment includes topical medications (both prescription and non-prescription), oral antibiotics, Accutane, and blue light therapy. At The Menkes Clinic, we also offer aesthetic treatments to help control acne and reduce the appearance of acne scars. These include acne facials, chemical peels, micro needling, laser treatments, and Silk Peel infusion microdermabrasion.

My approach to the treatment of acne starts with recognizing that each patient requires an individualized treatment plan reflecting her unique needs. I evaluate each patient’s medical history, lifestyle, personal goals, and treatment preferences in order to formulate the most effective plan that will result in healthy, clear, and radiant skin. At The Menkes Clinic, together with my colleagues Dr. Andrew Menkes and Dr. Krystle Wang, we strive to answer questions clearly and to provide the latest, scientifically proven treatments for our patients.

Lillian Soohoo, MD
General, Cosmetic and Pediatric Dermatology
The Menkes Clinic
2490 Hospital Drive Suite 201
Melchor Pavilion, El Camino Hospital
Mountain View, CA
650.962.4600

THE MONALISA TOUCH AND THE FDA

In 2016, El Camino Women’s Medical Group purchased a CO2 laser device called the MonaLisa Touch. After months of research and collaborative discussion, we opted to add this procedure to our practice for the treatment of the Genitourinary Syndrome of Menopause (GSM). Only recently labeled GSM, there are a group of symptoms that are associated with the decline of estrogen after menopause, including vaginal and vulvar dryness and irritation, frequent vaginal infections, frequent urinary tract infections, pain with sex, mild urinary incontinence, and others. Unlike the hot flashes and mood swings that some women experience with menopause, GSM does not resolve but continues to worsen each year. Until the arrival of the MonaLisa Touch, the only effective treatments for GSM were hormonal.

Since adding the MonaLisa Touch to our practice, we’ve seen wonderful results for our patients including improved sexual function, decreased vaginal and vulvar discomfort, and improved bladder control. The side effects are minimal and there have been no adverse outcomes. In fact, there are no serious adverse outcomes documented in the scientific literature related to the MonaLisa Touch. There are dozens of published studies showing improvement in a variety of symptoms related to GSM.

In July of 2018, the FDA sent letters to multiple different companies offering products for “vaginal rejuvenation”. Hologic (the company that owns the MonaLisa Touch CO2 laser system) was among them. The MonaLisa Touch is the only device on the market for GSM that uses FDA approved technology for gynecologic purposes. The FDA concerns were related to a new device not part of the MonaLisa Touch treatment as well as marketing language around “vaginal rejuvenation” related to the MonaLisa Touch procedure itself. Our office has never used “vaginal rejuvenation” language around the MonaLisa Touch procedure, as that is not something we advocate for or treat.

In August of 2018, Dr. Azad sent a letter regarding the FDA letter to all our patients who have been treated with the MonaLisa Touch device. It’s also available on our blog.

If this is a treatment you have been considering, please come in for a free consultation to discuss. If the genitourinary syndrome of menopause is a new term to you, but you think it applies, please come in for an office visit for evaluation, as there are many options out there for treatment, some only recently available in the last few years.

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 we find important for all of you. The most popular article by far in the past few months has been on Marijuana and Breastfeeding. There was also a very important article on anxiety in pregnancy and how it can impact the outcomes of the baby if not properly addressed. We were also excited to see the release of a new, lower (and now lowest on the market) dose of vaginal estrogen available for the treatment of vaginal dryness and painful sex that occurs after menopause. Follow us on Facebook or Twitter to hear about new blog posts.

GENERAL OFFICE INFORMATION