Women’s Health Newsletter, Volume 5 Issue 3

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WOMEN’S HEALTH

Though it’s only been three months since our last newsletter, it feels like a lifetime!   The pandemic has changed the lives of all of us in ways we could not have predicted.   It’s added an entirely new health issue for women’s health, which we’ve been writing about and presenting in webinars, hoping to keep everyone up to date.  (The next one is July 7^th at 4:45 pm)  It’s changed workflows in our office.   And we want to thank all of you for your patience with scheduling changes and the generous donations of masks, 3D printed mask holders, and everyone’s kind wishes to our hardworking staff!

The biggest political issue of an election year is fortunately not about the election, but about institutional racism in America and how to bring about a truly just society for all people, living up to what should be a universal truth, that Black Lives Matter.  As the movement continues and grows, let us all hope for real, lasting change that we can be proud to tell our children we helped realize.

And after talking about it for well over a year, we really are finally moving.   If not in August, then in September, but definitely before the next newsletter!

Finally, as I mentioned in our last newsletter, we’ve started working with an anti-aging skincare company and a hair care company to offer their products to patients looking to maintain wellness, decrease the effects of aging and to treat thinning hair.  We’ve given out over $1000 in free giveaways since June and will continue every Wednesday through the end of summer. Make sure you follow us on social media (Facebook or Instagram) if you want a chance to win free products.

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

We wish all of you good health and encourage you to continue with social distancing, masking in public, and avoiding large gatherings for the foreseeable future.

Sarah Azad, MD

In this issue:

Practice Updates

Webinars, Online Prenatal Classes

Updates: COVID19 and Women’s Health

What is the Perimenopause

Dr. Soohoo’s Sunscreen Update (Dermatology)

Could Lockdown Lead to Higher Number of Cancer Diagnoses?

Ringing in your Ears?  Dr. Chaung (ENT) Explains Tinnitus

When Should My Teen See a GYN?

Highlights from our Women’s Health Blog

PRACTICE UPDATES

Having adjusted to our new workflows, we are back to our pre-pandemic capacity.  For the safety of all patients and staff:

• • • • • • • • • • We are scheduling televists when appropriate
                  • All physicians and staff are screened daily
                  • All patients are being screened the day before and the day of their visits
                  • Office entrance is limited to patients-only
                  • Face coverings are required by everyone in the office

If you have been putting off your care, please call to schedule.   As Dr. Singhal writes in her article below, delaying care to avoid COVID19 can result in other health complications.

Both Dr. Awaad (psychiatrist) and Zainab (therapist) are seeing patients via telemedicine, so if the pandemic (or just the stress of sheltering in place) is getting to you, reach out for an appointment.

Though we don’t have a date yet, we expect to be moving THIS AUGUST!  Even if there are delays, it’ll at least be before our December newsletter.  Our move is going to be about a year later than we were expecting, but we are very excited! Look out for announcements by email and on social media.  Anyone scheduled will be informed if there are any location changes.

With the move to our new suite, we will be closing the San Jose office and consolidating to one location.  Our San Jose location has been very convenient for so many of our patients; we are sorry to lose it.

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

WEBINARS, ONLINE PRENATAL CLASSES

Covid19

We had wonderful feedback on our webinars on COVID19 and Women’s Health.  We are going to continue every one to two months as more information is available.  We want all of you to have a trustworthy, informed source for the most recent information and how it’s affecting care in the Bay Area.

Our next webinar is scheduled for TODAY: Tuesday, July 7^th at 4:45 pm, hosted by Dr. Teng.  Email moc.n1695647708emowo1695647708nimac1695647708le@of1695647708ni1695647708 to register.

Prenatal Classes

El Camino Women’s Medical Group

We are now offering four virtual prenatal classes a month online.    These classes cover preparing for childbirth, breastfeeding, and newborn care.   These classes have been very popular and we will do our best to have them every month for the foreseeable future.

UPDATES: COVID 19 AND WOMEN’S HEALTH

First, The Local News

Our County continues to do very well in containing the spread of COVID19 in our area.   Even now, as CA overall seeing a huge surge in cases and hospitalizations, our county is seeing a much slower increase in cases and hospitalization.   The county put our indicators it’s following to measure our success.   The county has a lot of resources available on the COVID19 of their website:

• Free testing
• 211: a dedicated call center for questions about the coronavirus
• An up to date dashboard to keep track of cases/deaths in our county

COVID19 and Women

The severity of disease and mortality from COVID19 continues to be less severe in women.   Women with COVID19 have shown in studies across three continents and also here in the US to have less severe disease and almost 20% less mortality.   The reason why has not yet been isolated, but there is hope that by studying the difference in response to COVID19 in women vs men, there may be information on better treatments.

COVID19 and Pregnancy

Pregnancy has generally been found to make women high risk for more severe illness from viral infections like the flu.   All the early data suggested no increased risk for pregnant women diagnosed with COVID19.   Recent data from the CDC does suggest that pregnant women with COVID19 are more likely to be hospitalized than non-pregnant women, but overall mortality is the same.

The risk of transmission of COVID19 from an infected mother to her newborn also remains very low, despite a few case reports of infected infants.  Breastfeeding continues to be highly recommended, even when the mothers are affected by COVID19.   Good hygiene and safe cleaning practices are always important around newborns, more so in the current pandemic.

COVID19 and Young Children:

The data for young children is robust and reassuring.   Children are less likely to develop symptoms and for those symptoms to become severe.  Death is rare.  For the published data we have, the risk of death from COVID19 in children is lower than the general infant mortality rate in the US.   The American Academy of Pediatricians has also released recommendations for best practices to return to school in the fall.

El Camino Women’s Medical Group Policies:

• We continue to space out pregnancy appointments—when appropriate.
• We also continue to ask patients to come alone and for any visitors to wait in the car.
• Staff and physicians are screened daily at work
• Everyone is required to have a mask in the office
• We have always had detailed cleaning procedures for our exam rooms between patients. Those procedures have been intensified and include the entire office.

What El Camino Hospital is doing differently:

• Patients in the Women’s Hospital may only have one visitor and they do have to pass through screening.
• The main hospital is allowing only one visitor per patient, and only for a maximum of 2 hours a day
• The entire hospital system continues to use the most up to date cleaning protocols for every room and every shared space.

The Impact of Social Distancing

Social distancing is hard.   Please do your best to take care of yourself:

• Stay connected virtually with friends and family
• Take breaks from the news and social media
• Book a Televisit with us if you’re feeling sad or anxious
• Take on a new hobby or topic or language to learn
• Go outside for walks, hikes, bike rides
• Call to book a Televisit with our Psychiatrist or Therapist

Resources

Substance Abuse and Mental Health Services Administration:

1-800-985-5990 (TTY 1-800-846-8517)

Text TalkWithUs to 66746

National Domestic Violence Hotline:

800-799-SAFE (7233) and 800-787-3224 (TTY)

Live chat option at https://www.thehotline.org

If you feel like you want to harm yourself or others, call 911 right away

WHO Mythbusters

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters

WHAT IS THE PERIMENOPAUSE

Fortunately, we are seeing menopause a more common topic of discussion both privately and publicly.  What about the changes that happen in the 40s?  From 1-10 years before menopause itself starts?   This time is called the perimenopause or the menopause transition.

Generally starting in the mid-40s, but occasionally as early as mid-30s, a woman’s ovaries start to produce less estrogen.   The changes in hormones can result in changes to a woman’s menstrual bleeding patterns, irregular or heavy bleeding, and/or other symptoms like hot flashes and night sweats.

This time lasts up to menopause itself, defined as 12 sequential months without a period.  On average, women are in the perimenopause for four years before menopause, while some only have a few months and others over ten years.

What can perimenopausal women experience?

• Irregular periods
• Worsening PMS and/or mood swings
• Trouble with sleep
• Decreased libido
• Fatigue
• Urinary changes: leaking, urgency, frequency
• Hot flashes or night sweats
• Vaginal dryness or painful sex

Most of these changes are a natural result of the hormonal changes that occur before menopause, but some of these symptoms may be related to actual problems that are also more common in women aged 35 and older.   If you’re having any of the following symptoms, you should come in for evaluation:

• Periods that have become very heavy
• Periods that are becoming much longer
• Bleeding in between your periods

• Periods that start less than 21 days from the start of the previous period

A lot of these bleeding patterns are also just a result of the perimenopause but they may be caused by abnormal hormone changes (like thyroid), growths in the uterus (fibroids, polyps), pregnancy!, and rarely cancer.

What else to watch out for?

Pregnancy.   While we all are well aware of declining fertility with age, assuming you simply can’t get pregnant in your 40s or after premenopausal symptoms start is very untrue.   Unplanned pregnancies are common in this stage due to women becoming less careful about contraception.   If pregnancy in your 40s is not part of the plan, please continue to use contraception until you’ve completed 12 months without a period and have crossed over into “menopause.”

On the other hand, if you want to be pregnant and in the perimenopause, please seek evaluation by your gynecologist.   Most women who want pregnancy during this time of life would be best served with early evaluation and fertility assistance.

How to stay healthy during the perimenopause?

Most importantly, women should evaluate their lifestyles and make sure they are engaging in healthy activities:

• Regular exercise: aerobic and strengthening
• Healthy diet: low in added sugars and processed foods
• Adequate sleep with good sleep hygiene
• Sufficient daily calcium
• If you smoke: commit to quitting
• Decreasing alcohol consumption

For women with issues related to bleeding or night sweats or hot flashes, low dose birth control in the form of pills, patches, the hormonal ring can make the perimenopause and early menopause so much better.   This definitely needs a conversation with your physician.

Decreased libido is also something you should bring up with your doctors.  If it’s a result of less comfortable sex, vaginal lubricants, or low dose vaginal estrogen may help with the discomfort.   If it’s more than that there are many newer treatments that women can try, some have come out only in the last 1-2 years!

Decreased sleep quality is also a common problem.   There are a lot of factors that play into sleep quality.   For some women who chose to go on low dose hormonal birth control, their sleep issues also resolve.   Others need to be evaluated for sleep apnea.  Some still respond well to working on good sleep hygiene.  There is also an array of supplements that different women respond to and help improve a good night’s sleep.

Mood disturbances and concentration issues also come up during this time of transition.  It’s important to bring this up with your physician.   Some women respond well to low dose birth control; others do better with therapy, while others still find success with a class of drugs called SSRIs.   There are just so many options for achieving good health and personal wellness; discussing any symptoms with your physician is important.

Finally, as women enter the perimenopause, we encourage women to pay attention to their overall wellness.   Decreasing estrogen levels are also associated with changes in skin, bones, and heart health.  Learning about better ways to care for your skin, engaging in exercise that supports a healthy heart and stronger bones, and eating a diet that best serves your body should become a priority during these years.   The effects of a good lifestyle will help you be able to enjoy some of the best years of your life!

DR. SOOHOO’S SUNSCREEN UPDATE

Lillian Soohoo, MD

Board Certified Dermatologist

This summer, many patients have been asking me about the safety of daily sunscreen use. Why? A widely-publicized, preliminary FDA study published in the spring of 2019, in the Journal of the American Medical Association showed that chemical sunscreen ingredients are absorbed through the skin and found at higher levels in the blood than previously believed.

Chemical sunscreens (such as those in the FDA study) protect our skin by absorbing ultraviolet (UV) rays before they can harm skin cells. These chemicals work after penetrating the skin. This differs from physical sunscreens, namely zinc oxide and titanium dioxide, which work like a “blanket” or “shield” to actually reflect harmful UV rays from the skin’s surface. Zinc oxide and titanium dioxide are not absorbed into the skin because of their large particle size and are naturally broad-spectrum sunscreens, blocking both UVA and UVB rays.

In the study, researchers asked 24 volunteers to apply one of four sunscreens (two sprays and two lotions) to 75 percent of their bodies every 2 hours, 4 times a day for 4 days—the same amount recommended for proper use. The sunscreens used in the study contained four common chemical ingredients: Avobenzone, Oxybenzone, Octinoxate, and Ecamsule (Mexoryl).

What were the results?

Blood tests showed that after just one day of using these products, the volunteers’ blood levels of all four chemicals exceeded the FDA’s testing threshold; for Oxybenzone, that level was exceeded in just 2 hours. Spray-on sunscreens resulted in the highest blood levels. The concentration of these chemicals in the blood continued to rise over the four-day study period and the findings were published in the Journal of the American Medical Association in May 2019.

What does this mean?

Maybe nothing. We don’t know if long-term use of chemical sunscreens are in any way harmful to us since this is the first study to measure blood levels of these substances after applying them to the skin. These same chemicals have also been used in most available sunscreens for many years. They were previously even known to be found in breast milk and urine after normal application. The FDA’s call for further research in response to these recent findings will hopefully shed more light on the long term safety of these products.

What to do now?

Keep using sunscreen and protect your skin. Remember, we do know that skin cancer remains the most common type of human cancer and that sunscreen use has reduced the incidence of all types of skin cancer, including melanoma—the deadliest form of skin cancer and the most common cause of cancer-related death in a person between the age of 25 and 40.

So if you have a choice, use an all zinc oxide or titanium dioxide-containing sunscreen every day and read the label so you know which ingredients are in your sunscreen. Select cream or lotion formulations instead of sprays if possible, since the highest blood levels of chemical sunscreen ingredients were seen in those subjects who used spray sunscreens. The best sunscreens have “broad spectrum (UVA/UVB)” on the label and an SPF of at least SPF 30. Some reliable brands include ELTA MD, Skinceuticals and Colorescience, all available at The Menkes Clinic. Finally, remember that hats and long-sleeved clothing and pants will almost always provide superior sun protection and that you should never rely solely on your sunscreen (no matter how high the SPF) to avoid sunburn.

Have fun and keep safe in the sun this summer!

The Menkes Clinic is open to evaluate and treat new and established patients via teledermatology. If you

have more questions or would like to schedule an appointment with Dr. Soohoo, please call 650.962.4600 or

schedule appointments online at www.menkesclinic.com.

Lillian Soohoo, MD

Board Certified Dermatologist

The Menkes Clinic

2490 Hospital Drive Suite 201, MV

650-962-4600

COULD LOCKDOWN LEAD TO HIGHER NUMBER OF CANCER DIAGNOSES?

By Shyamali Singhal, MD

Surgical Oncologist

Founder of Hope & Beauty

Quarantine And Delayed Cancer Screening

Studies have shown, that with the largest portion of the world still in quarantine due to COVID-19, many people are missing their regular cancer screenings and appointments. Because of this, some people may be encountering early symptoms, but they postponing treatment.

As we see the number of COVID-19 cases starting to decrease worldwide, hospitals are preparing for the event of a new and different medical crisis. Medical experts fear that we’ll experience the rise of new cancer cases, advanced-stage diagnoses, and cancer deaths. Throughout the pandemic, while U.S. hospitals and the overall health care system was pushed to the limit, many procedures and appointments were postponed or canceled altogether—some because of federal guidelines, others by patients’ own choice, or other circumstances.  And while orders to stay at home and limited optional procedures have served us to flatten the curve of COVID-19 growth and spread in our population, experts now question if this could result in a new wave of cancer diagnoses in the following months or years.

One of the best ways to help flatten the curve of COVID19 infections and hospitalizations is to know when to self-isolate, when to stay home, and when to seek care.  Apricity Health has recently developed a app that allows people to input their symptoms, have them reviewed by a physician or trained nurse and get feedback of what’s best next step.   The initial registration includes a televisit.  Your daily symptoms will be monitored and if you need evaluation by a physician, a televisit will be available.

Postponed Screenings May Leads To A Backlog

As it becomes apparent that the coronavirus was making its way through the U.S., federal health officials and cancer organizations advised people to delay their routine mammograms and colonoscopies. The public has listened to those recommendations, and that, unfortunately, has helped lead to a serious decline in cancer screenings. Arrangements for screenings for cancers of the cervix, colon, and breast were down between 86% and 94% in March when compared to standard volumes in the three years before the first Covid-19 case was diagnosed in the U.S. Still, even as many health systems begin to open their services, delays could stay for couple more months as we see new cases and as hospitals begin to address the accumulation of patients whose plans were postponed.

Precautionary screenings for cervical, colon, and breast cancer plummeted in March, when we compare it with previous years, according to new reports. The numbers came from an electronic medical records company that analyzed 2.7 million patient records across 23 states.

Decreasing Of Cancer Referrals

“In some cancers, a three-month pause could make all the difference between a tumor being curable or incurable”, said Dr. Singhal. Some models suggest that delaying surgery can lead to a heightened risk of thousands of deaths that could have been prevented. By the end of April, cancer referrals had decreased by approximated 70%. Cancer doctors are having to make difficult decisions to delay some patients’ care throughout the coronavirus crisis.

“As normal service resumed, doctors should prioritize certain cancer types in particular”, Dr. Singhal said. Lung and colorectal cancers, for example, are especially fast-moving. But for others, such as prostate and certain breast cancers, treatment could more safely be delayed.

For every 10 Covid-19 patients whose lives were saved in hospital, four cancer patients could die, according to the studies, if all tumor-removal surgeries are delayed by six months. And more than 80,000 of these patients go on to survive for at least five years. But a three-month delay would lead to almost 5,000 excess deaths. A six-month delay could drive to almost 11,000.

Full Impact Of Delayed Screenings Is Still Unclear

“How delays in screenings actually impact ultimate outcomes is uncertain,” says Dr. Singhal. “However, in the presence of early symptoms, it is possible that a delay could lead to a worsening of the symptoms, negatively impact the quality of life, lead to the necessity of more aggressive surgery, and result in a higher stage of the disease.” A comprehensive new study of patients in dozens of hospitals nationwide shows notable drops in the quantities of screenings designed to discover early manifestations of cancer. According to studies, as the pandemic was taking hold nationwide, appointments dropped sharply for patients being screened for breast cancer, colon cancer, and cervical cancer. The study looked at 2.7 million patients from 190 hospitals in 23 states and compared the numbers of weekly screening appointments made from 2017 to 2019 to appointments made during March 2020.

Even After Reopening, The Issue Might Persist

The data implies there is reason to be concerned that cancer screenings may not rebound even as some states begin to reopen their economies. Researchers found an elevated rate of cancellations of cancer screening appointments in the days before mid-March when counties began issuing stay-at-home orders and the American Cancer Society and the Centers for Disease Control and Prevention recommended that people delay outpatient care. It’s also fairly reasonable to expect that even once the lockdowns are lifted, we’ll still see the concerned patients a little bit more reluctant to go in for a screening. Unfortunately,  it doesn’t take much to talk a person out of going in for a colonoscopy.

Shyamali Singhal MD
moc.t1695647708sigol1695647708ocno-1695647708lacig1695647708rus@c1695647708od1695647708
650 641 7861

RINGING IN YOUR EARS?  DR. CHAUNG EXPLAINS TINNITUS

By Katrina Chaung, M.D.

Board Certified ENT

While this Fourth of July may have been a bit different from the celebrations of years past, for some it may still have included loud fireworks or music that left their ears ringing.

Tinnitus, or ringing of the ears, is the perception of sounds where there is no actual external sound present.  This affects as many as 1 in 5 people.  It can range from an occasional nuisance to a disruptive obstacle that negatively impacts quality of life.  Some people hear ringing; others hear buzzing, chirping crickets, static, high pitched squeals, low pitched roars, or even ocean waves.  Tinnitus can be intermittent, continuous, or even pulse with your heartbeat.

Tinnitus is most commonly associated with problems of the hearing system, but it can also have other unrelated causes.

Most tinnitus is due to hearing loss.  This can include irreversible causes like age-related hearing loss or damage to the hearing nerve complex; or reversible causes such as earwax, a foreign body in the ear canal, infection, or fluid of the middle ear.  After exposure to loud noise, damage to the inner ear leading to hearing loss can occur; sometimes tinnitus can develop, temporarily or permanently, even before hearing loss is noticed.

Medications can also cause tinnitus by damaging cells in the inner ear.  These can include aspirin, antibiotics, diuretics, and chemotherapy agents.  Tinnitus that pulses with your heartbeat (pulsatile tinnitus) can be caused by normal variations in the anatomy of blood vessels, tumors that contain blood vessels, or even arteries narrowed by cholesterol plaques.  Rarely, benign tumors called acoustic neuromas can also be the culprit.

Tinnitus can also occur during pregnancy due to the increase of total blood volume, hormonal changes, or more serious issues like high blood pressure or preeclampsia.  Temporomandibular joint issues can also lead to tinnitus.  Lastly, stress, depression, anxiety, and lack of sleep can also contribute to tinnitus.

If you suffer from tinnitus, depending on your symptoms and exam findings, further tests like a hearing evaluation or imaging such as a CT or MRI may be ordered.  Some cases of tinnitus are treatable but, in many cases, there may be no “cure.”  Typically, the tinnitus does naturally improve over time to be less bothersome.  Options of hearing aids, masking techniques, diet modifications (like reducing caffeine intake) and even sound and behavioral therapy can also help.  Other therapies that you may encounter like acupuncture, dietary supplements, and transcranial magnetic stimulation have not been studied enough to be proven to be effective or safe to treat tinnitus.

If you are having issues with tinnitus, you may benefit from an Ear, Nose and Throat evaluation.

Katrina Chaung, M.D.

Board-certified, Otolaryngology – Head and Neck Surgery

2495 Hospital Dr.

Suite 450

Mountain View, CA 94040

(650) 988-4161

WHEN SHOULD MY TEEN SEE A GYN?

They may grow up too quickly, but they do grow up.   Talking with your teen about transitioning from their pediatrician to a gynecologist is not a parent’s favorite topic, but it’s an important one.   Pediatricians are well equipped to begin conversations about the changes that come with puberty, screening for sexual activity, and counseling on birth control and sexually transmitted infections.  But when these young women turn 18, they should be graduating on to physicians trained in caring for adults.

In our office, we offer a teen visit for young women and encourage parents to bring in their daughters between 16-18 years of age for an introduction.   It gives them a chance to meet a gynecologist, learn what we do, how we screen, examine and counsel young women, and ultimately leave them with one more adult in their life they can reach out to if they have a health concern.   For kids going off to college, it allows us to share advice on health and safety while entering that new phase of life.

As Pap tests are no longer routinely done before the age of 21, many young women don’t need a pelvic exam.  But Annual Well Women exams are still important as we counsel on a wide variety of health topics based on a young woman’s needs, including:

• Healthy eating habits
• Healthy exercise habits
• Self-esteem and mental health
• Periods and options for when they’re not normal
• Vaginal discharge and urinary infection and symptoms to look out for
• Healthy relationships and sexual behavior
• Discussion on pregnancy and prevention options
• Sexually transmitted infections, how to stay safe, and when to get tested

Teaching young women to take care of their health and continue to see their physician at least once a year is an important life lesson.   Having this conversation with your daughter in her mid-teens is important, and we’re to help you with her transition into adulthood.

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.  With everyone home with easy access to food, it’s no shock that our most popular article was Stop Eating all The Time: Snacking and Intermittent Fasting.  The next is from early in the pandemic: Information on the Coronavirus. The third is from over a year ago on The Lowest Effective Estrogen Dose for the Treatment of GSM. The treatment of the vaginal changes after menopause is always a popular subject.   We do our best to bring in the most effective treatments to the office. We update our blog at least a few times a month with information on all kinds of women’s health issues.

Follow us on Facebook, Twitter, LinkedIn, or Instagram to be informed when we post new articles and stay up to date on the latest in women’s health.

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