Women’s Health Newsletter, Volume 4 Issue 3

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WOMEN’S HEALTH

Welcome Summer!

Wishing everyone a lot of family fun and quality time together during these wonderful days of summer. When you feel the heat is more “that it used to be” remember to take some time to brainstorm how your family can decrease its carbon footprint!

July is also Cord Blood Awareness Month. If you or someone you know is pregnant, we have some resources in this newsletter on where to get more information on the value of storing cord blood privately or publicly.

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

Sarah Azad, MD

In this issue:

Practice Updates

What’s New for Women’s Libido?

“This is Why I’m Here” Nurse Barb’s Recent Trip to Tanzania

Weight Loss from Dr. Yaskin, Board Certified in Obesity Medicine

Understanding Permanent Birth Control

Summertime=Pooltime……and Swimmer’s Ear?

Cord Blood Awareness Month

Highlights from our Women’s Health Blog

PRACTICE UPDATES

All of us, doctors and staff, have some vacation this summer, so please understand if your doctor is out of town for a week or two. Of course, there is always a physician in our group available for all our patients in urgent situations and to cover for a doctor who’s out of town. 

Barb Dehn, NP has taken some time to travel to Tanzania again and has written about it in this newsletter!

Your feedback on our office practices and our physician and staff communication are always welcome.

Don’t forget to follow us on social media to stay up to date on office information as well as women’s health topics. You can follow us on Facebook, Twitter, LinkedIn, or Instagram

We’re super excited about our new space in the IMOB across the street. If you’re interested in seeing the progress, you can follow here. There’s a good chance we’ll be moving in December of this year! This is our third home since we opened in July of 2009, we’re looking forward to finally settling down in this new, larger suite.

WHAT’S NEW FOR WOMEN’S LIBIDO?

Of the variety of problems that will affect a woman’s sex life, a decreased or absent libido (sex drive) is the most common problem. The medical term hypoactive sexual desire disorder (HSDD) is defined by both the decreased or absent desire for sexual activity and personal distress or interpersonal difficulties caused by the decreased desire.

Some studies show that nearly one out of every ten women in America suffers from HSDD.

So, what is there to do? A lot depends on the causes of HSDD. Historically, we’ve been limited to counseling for issues related to relationships and personal stress or history of trauma and some use of hormones in post-menopausal women with limited success. The last few years have seen the arrival of three new treatments for HSDD, which we’ll go through now.

Ristela

Launched by Hello Bonafide just this year, Ristela joins a successful line of supplements to address some of the most common women’s health issues. A plant-based product which primarily uses French Maritime Pine bark mixed with other naturally occurring ingredients, Ristela has been shown to increase sexual desire, orgasm, and sexual satisfaction. Improvement is seen in the first month and then continues to improve with ongoing use. Initial published studies show no difference in side effects between Ristela and placebo.

Pros: supplement, no prescription needed, affordable at $45-55/month, doesn’t interact with other medication

Cons: 2 pills to be taken every day, won’t be covered by insurance (but qualifies for HSA), published data does not include as many women as pharmaceutical options

Addyi

Addyi is the brand name for flibanserin, approved by the FDA in 2015, for the treatment of HSDD. Addyi works on a woman’s brain by altering levels of dopamine, norepinephrine, and serotonin. With ongoing use, women notice increased desire and report increased in desire and sexually satisfying events as well as a decrease in personal distress. It does take two months to start to see improvement. Due to limits on use with alcohol, it has not quite taken off as expected. This May, however, more data has come out showing the side effects from alcohol and flibanserin are relatively minimal, and the FDA has loosened its restriction.

Pros: with a coupon card: first two months free, then $24-99/month for most women, may be associated with weight loss, published data includes thousands of women 

 Cons: a pill taken every night, a concern with having alcohol while on it, cannot take with common yeast infection medications

Vyleesi

Just approved in June of this year, Vyleesi is the brand name for bremelanotide, a medication given via self-injection as needed, at least 45 minutes before anticipated sexual activity. Vyleesi is a synthetic hormone that activates receptors in the braininvolved in sexual responses by reducing the inhibition of some behaviors and increasing other behaviors. It’s still not completely clear exactly how Vyleesi works, but the studies so far have shown increased sexually satisfying events, improved perceptions of sexual function, and decreased distress related to sexual desire. Effects should be noticed within eight weeks, or it’s recommended to stop using it. It should be available by the end of September.

Pros: only taken when needed, with a coupon card: the first month free, then $99/month for most women 

Cons: maximum use eight times/month, data only shows small improvements compared to placebo, not advised for women with known heart disease

A VISIT TO FAME, MAY 2019: THIS IS WHY I’M HERE

Barb Dehn, NP

I was standing by the side of an old metal gurney covered in a thin blue pad, holding a small child’s hand. This little boy lived so far from any town or village that he had not had any health care or treatment for a common skin condition that had started four years earlier. His father had carefully explained how the rash started on the top of his head and was only the size of a small coin, but gradually over time had spread to cover his entire scalp, neck and the side of his face. 

What began as small and yet common fungal infection, tinea was now infected with another infection, oozing and painful, not to mention had completely changed his appearance. The other children in the village made fun of him, so he only went out wearing a borrowed hat, which had never been washed and caused the condition to worsen.

When we first met, his head was covered in a blood-soaked bandage, and he was using an old green cracked mirror to try to see how he looked. I wondered how I might help and later returned to visit him with a few gifts. For some reason, I had slipped a few small handheld folding mirrors in with all the medical supplies I was bringing to FAME, figuring some of the people out in the villages might find them useful. 

I also had with me a large bag filled with hundreds of colorful Coban self-adhering stretch gauze bandages. I had every color in the rainbow and every size with me when I went back to see him. 

He liked the green bandages best and so, through a translator, we decided that I should come with him when his bandages were changed. Because it would be a painful procedure, he would be receiving intravenous anesthesia and pain medication from one of FAME’s nurse anesthetists, Teddie. 

I was smiling as I watched the small group of Tanzanian nurses gather the anti-fungal cream, the special yellow gauze, and the other supplies. Dr. Badyana and Dr. Jackie, both Tanzanian physicians from FAME, discussed how they would carefully remove the infected skin so that new healthy skin would regrow.  

I was smiling because my job was not to do the procedure or to advise or to interfere. My job was to hold a little boy’s hand, and my privilege was to observe what a sustainable hospital and clinic really is. FAME’s highly capable staff of local doctors and nurses were doing what they do every day, day in and day out, 24 hours each day, seven days each week, providing excellent health care in a remote and rural part of Tanzania. As I watched the dressing change, it occurred to me that this was why I’m here. This is why I am so passionate about raising money and bringing supplies, working on projects, and recruiting people who can mentor and share knowledge with the providers at FAME.  

 The oxygen tubing he needed to breathe through, and the special yellow gauze came out of my suitcases just two days before, not to mention the bright green bandages. It was all necessary to support FAME’s mission – providing care to the community.

 If you’re inspired by the care FAME provides in rural Tanzania, near the Serengeti, I hope you’ll consider donating directly: FAME.org

 Barb Dehn, NP
Women’s Health Nurse Practitioner
NurseBarb.com

WEIGHT LOSS: UNDERSTANDING THE PROCESS AND DEVELOPING AN INDIVIDUALIZED PLAN

By Inna Yaskin, DO
Board certified Internal Medicine
Board Certified Obesity Medicine  

Today, people in the US struggle more with unintentional weight gain and obesity than ever before. There is, however, an abundance of weight loss information available to Americans based on various diets and exercise recommendations. A more comprehensive approach to sustainable weight loss often also requires nutritional education, behavioral counseling, anti-obesity medications, and surgical therapies. 

According to the Obesity Medicine Organization, diet and calorie restriction have a far more significant impact on successful weight loss than exercise. However, we cannot underestimate the importance of exercise for weight preservation and maintenance of muscle mass. In addition, people who experience gradual weight loss are more successful long term than those with rapid weight loss programs (US Centers for Disease Control). There are multiple genetic, biological, behavioral, and environmental factors contributing to abnormal weight and obesity. Possible obstacles to successful weight loss include a lack of sleep, FAD diets, consumption of alcohol, sweet beverages, stress, and an abnormal microbiome (flora in stool). Therefore, an individualized weight loss program in combination with behavioral change is considered to be the most successful and sustainable approach. 

Low carbohydrate diets have been most beneficial in improving metabolic risk factors and maintaining healthy weight long term. In addition, low carbohydrate diets will produce modestly higher weight loss results than fat restriction diets during the first six months. Hunger control will be a challenge in the first eight weeks and can be overcome with appetite suppressing medications. 

A very low-calorie regimen produces rapid weight loss, but it is difficult to follow long-term. Intermittent fasting diets (fasting for 8-24 hours between meals) are gaining popularity and are considered by some patients easier to follow. High-fat diets such as Atkins should be started with caution as saturated fats (margarine, shortening, processed red meat) are not required for nutritional balance and may contribute to worsening metabolic risk factors. 

In any diet that restricts calories, it is crucial that the essential ingredients are included to preserve metabolic balance. Omega 3 and Omega 6 polyunsaturated fatty acids are essential for heart health, mental health, and the weight loss process. The source of Omega 3 acids comes from fatty fish, algae, and several high-fat plant foods. Omega 6 fatty acids are obtained from poultry, eggs, nuts, vegetable oils, and grains. The recommended consumption ratio of Omega 3/6 is 4 to 1. The typical American diet, however, has the ratio of 20 to 1 with an insufficient Omega 3 consumption. It is also imperative to include the six essential amino acids in the diet since we cannot synthesize them: histidine, lysine, cysteine, tryptophan, isoleucine, valine, methionine, tryptophan. Lysine is often deficient in a vegetarian diet and should be substituted regularly in weight loss programs based on a vegetarian diet.  

We often recommend a multivitamin, vitamin D, and calcium supplementation along with an exercise regimen for muscle mass improvement and reduction of body fat percentage. 

Exercise recommendations by the Department of Health and Human Services are 150 minutes of moderate intensity exercise, split over three days a week. There should be no more than two consecutive days without exercise, and there should be resistance training two days a week. It is also essential to reduce a sedentary lifestyle by limiting sitting to no more than 90 minutes at a time. 

Other weight loss interventions include spending more time in nature, getting enough sleep, avoiding sweet beverages, and using sweeteners with caution as there is no clear data on their role in weight loss treatment. As more research is done on the topic of obesity and abnormal weight gain, new treatments and options are emerging. As we develop a deeper understanding of factors contributing to abnormal weight gain and obesity, we can provide better tools and strategies to educate and treat our patients. 

Inna Yaskin, DO
Board certified Internal Medicine
Board Certified Obesity Medicine  

UNDERSTANDING PERMANENT BIRTH CONTROL

When women, men, or families decide they have no desire to have another child, the discussion of permanent birth control comes up.  

For women, the types of permanent sterilization now available include tubal occlusion, partial removal of the tubes, and full removal of the tubes (bilateral salpingectomies). When discussing these options with our patients, a review of  Long Acting Reversible Contraception (LARC) is important. Many women are comfortable with the less invasive option of LARC methods due to their very high success rate. If after that discussion, women still prefer a permanent solution, we discuss the options. 

Permanent sterilization in women focuses on the fallopian tubes. These are the tubes that an ovum (egg) travels through to get from the ovary to the uterus, often encountering sperm along the way and becoming fertilized. While extremely effective, it’s important to understand that even surgical occlusion or removal of the fallopian tubes is  not 100% effective.  

Tubal occlusion can be done in a variety of different ways, but the essence is that the fallopian tubes are physically blocked. This means during surgery with anesthesia a clip, band, suture, or electric cauterization is used to create a permanent blockage which would prevent an egg from ever meeting sperm.  

Partial or full salpingectomies are the removal of either part or all the fallopian tubes under anesthesia during surgery. These are known to be more successful than occlusion alone, though the increased efficacy is small. With newer data on ovarian cancer often originating from the fallopian tubes, we do now recommend full bilateral salpingectomies in women choosing permanent sterilization. 

Sometimes these are done post-partum. After a vaginal delivery, women are taken to the operating room (on the same day or next day), an epidural is re-dosed, or placed if she never had one, and the procedure is performed. Through a small incision (2-3 cm) under the belly button, both tubes are visualized and occluded—either through a band, a clip, or cauterization. It is difficult during this procedure to fully remove both tubes due to limited visualization. Due to the unpredictability of most Labor & Delivery operating rooms, the increasing use of LARC and the newer recommendation for full salpingectomies, post-partum tubal ligations are becoming much less common. 

If a woman is having a cesarean section, this is the safest time to also remove her tubes. Since the major risks of surgery are already being undertaken for the purpose of the larger surgery, bilateral tubal ligation only adds a few more minutes to operating time without significant additional risk. This procedure is performed after the baby has been delivered and the uterus has been completely closed. 

For men, the only option for permanent birth control is a vasectomy. Though there are different ways to perform one; they are nearly all done in the office with local anesthesia. Most importantly, once performed, couples continue to use some type of contraception until follow up semen samples confirm sterilization. We have seen—in our own office—pregnancies post vasectomy when men fail to complete all recommended follow up. For more information on vasectomies, you’d have to speak with local urologist. 

Taking everything into consideration, when a woman decides she no longer desires her fertility, the safest of all available options is a bilateral salpingectomy at the time of a cesarean—if she’s already planning one. If not, then it’s a vasectomy for the partner—if she’s anticipating a long-term, monogamous relationship with her partner. Third, a tubal ligation done under epidural anesthesia after a vaginal delivery and finally a laparoscopic bilateral salpingectomy. Fortunately, all these options are considered very safe and effective. 

Scheduling a consultation with your OBGYN is the first step in deciding if permanent sterilization is the best decision for you and then to discuss what type of procedure will help you safely achieve your goal. 

*depends on the method of tubal ligation

**often included with tubal ligation when calculating efficacy. Maybe more effective.

SUMMERTIME=POOLTIME…..AND SWIMMER’S EAR?

By Katrina Chaung, M.D.
Board Certified ENT  

For many people, summer means pool days and water activities. During the summer months, the incidence of “swimmer’s ear” (or otitis externa) increases. “Swimmer’s ear” can occur in all age groups—not just in children and not just in swimmers. 

Otitis externa does not necessarily refer to only an infection caused by bacteria (although this is the most common type), but can also refer to a fungal infection, dermatitis of the ear canal, or any other cause of inflammation in the ear canal.

“Swimmer’s ear” can cause mild to severe ear pain, outer ear or ear canal redness and swelling, itching of the ear canal, drainage from the ear canal, or even hearing loss (usually temporary).  

www.mayoclinic.org

In extremely severe cases, usually in the elderly or patients with compromised immune systems, “swimmer’s ear” can progress into a very serious infection called malignant otitis externa. In these cases, the infection spreads into the bone of the skull and can cause very serious problems. 

How does “swimmer’s ear” develop? 

 Excess moisture or even scratching the ear canal can lead to breaks in the skin through which germs can enter and grow. Additionally, anything that occludes the ear canal such as hearing aids or earbuds can trap moisture or cause injury to the ear canal, increasing risk of developing an infection. People with skin conditions that affect the ear canal skin such as psoriasis or eczema can also be at risk of “swimmer’s ear.”

Swimming in dirty water or unsanitary conditions increases the risk of “swimmer’s ear,” but it is not contagious from one person to another. 

How is “swimmer’s ear” treated? 

Usually, treatment of swimmer’s ear includes an antibiotic ear drop. Oral antibiotics are usually not needed. If you have an infection, you also want to be careful to keep the ears dry because additional moisture can make the infection worse. Sometimes, the ear also needs to be cleaned by an Ear, Nose, & Throat doctor because drainage and debris can block the antibiotic ear drops from working.

 How can I prevent “swimmer’s ear”?

One important way to prevent infection is to remember, “Nothing smaller than an elbow in your ear.” Q-tips or other methods of cleaning or scratching the ear can cause small scrapes in the skin of the ear canal, allowing the entrance of germs.  

Take care to dry your ears after swimming or showering. You can do this safely by tilting your head with the ear down to allow water to trickle out; pulling gently on your earlobe with the ear down can also help the water drain out.

For people who do frequently suffer from “swimmer’s ear,” wearing earplugs when swimming may help. Also, after being in the water, use a hair dryer to help dry the ear; be sure to use the COOL setting to prevent burns while holding the dryer several inches from the ear. Applying drops with a mixture of alcohol and vinegar will help to not only dry the ear but also to reestablish an acidic and healthy environment in the ear canal. Please note, drops should only be used if you are sure you do NOT have a perforation or hole in your eardrum, ear tubes in place, or current infection. Lastly, avoid using earbuds or hearing aids when the ears are wet.  

If you are having ear issues, you may benefit from an Ear, Nose & Throat evaluation. 

Katrina Chaung, M.D.
Board certified, Otolaryngology – Head and Neck Surgery (Ear, Nose, & Throat)
2204 Grant Road, Suite 102
Mountain View, CA 94040
(650) 988-4161  

CORD BLOOD AWARENESS MONTH

July is Cord Blood Awareness Month! We want to celebrate by reviewing the basics of cord blood storage and donation and give you resources for more information. It’s very likely you, or a loved one are pregnant (or will soon be), and information is power.  

Cord blood refers to an infants blood that is in the umbilical cord and placenta after birth. Cord blood holds valuable newborn stem cells. Cord blood can be collected—even after delayed cord clamping—for private storage by the baby’s parents or for public donation for others to use for medical purposes. 

There are over 80 diseases that are currently using cord cells for treatment, and so many more that are in clinical trials. Fortunately, most of these diseases are rare in childhood, and the use of someone without a relevant family history of one of these diseases needing their own stem cells is low. Read more here about the likelihood of needing your own cord blood for treatment.  

There are many banks in the US that accept cord blood donations. You should ask the hospital you plan to deliver at if they have a formal affiliation with a public cord blood bank. El Camino Hospital does not currently have such a relationship, but through Cord for Life, we’ve had many patients donation cord blood. You do have to register and complete all paperwork with the bank before 32 weeks of pregnancy.  

We also keep a page on our website with detailed information on cord blood storage for ongoing reference.  

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.  Even though it’s been almost four months, our article on How can I have a Girl? (or a boy) remains the most read article on our blog for the year.  Seeking Help for Vaginal Dryness is our second most popular article.   And of course, for those working on weight loss, the 4th article in the series, on Intermittent Fasting has been popular.

Follow us on Facebook, Twitter, LinkedIn, or Instagram to be informed when we post new articles..

GENERAL OFFICE INFORMATION