Areas of Expertise
Menopause
Live Well, Beyond "The Change"
Menopause
Live WELL, Beyond "The Change"
PMDD
More than just mood swings
Endometriosis
Endometriosis is a chronic condition that involves cells similar to those in the endometrium, the lining inside the uterus, implanting and causing fibrosis and scarring in various locations outside the uterus. Symptoms include severe pain with periods, abnormal bleeding, painful urination and bowel movements, pain with intercourse. Symptoms may start cyclic but then become constant- affecting day to day function, intercourse, bowel/bladder function and more.
Endometriosis affects an estimated 1 in 10 women during their reproductive years (ie. usually between the ages of 15 to 49), which is approximately 176 million women in the world.
I believe in a multimodal approach to the management of endometriosis. First and foremost is proper minimally invasive surgical technique- EXCISION surgery. I have been fortunate to have worked with some incredible endometriosis surgeons during my training. Their teachings have lead me to a greater knowledge and understanding of the disease.
Parallel to surgical interventions, I also believe there are various ways to keep the disease suppressed and under control. A combination of diet, exercise, pelvic floor physical therapy, hormonal suppression, neuropathic pain medications can help maintain long standing quality of life for patients suffering from this debilitating chronic disease.
Patients with endometriosis face an 8-10 year delay in diagnosis, seeing as many as 5-7 specialists before the diagnosis is made. Many have been told myths like, "you are too young to have endometriosis" or "you have a normal ultrasound so you can't have endometriosis." Too often these patients feel like they have not been heard, made to feel like they are exaggerating or faking it.
I believe in educating patients and taking a collaborative approach to management, with a common goal of living pain free and improving quality of life.
Fibroids
Fibroids are benign tumors of the uterus, however they can cause a long list of problems. They can lead to heavy bleeding, painful cramps, issues with urination/bowel movements, painful intercourse, and difficulty with pregnancy.
They form in the muscular portion of the uterus and can vary in size, shape and location. They can be as small as a seed or as large as – or even larger – than a grapefruit, and they can grow inside the uterus, on its outer surface or within the wall. Some fibroids are attached by a stem-like structure. Some fibroids may grow slowly and stay the same size for years, while others grow rapidly. Some may shrink on their own and others may disappear after pregnancy or menopause.
It’s unclear what causes uterine fibroids, but certain factors may increase the risk for their development, including:
Age. Most common in women in their 30s and 40s, though they can occur at any age.
Race. African American women are more likely to develop fibroids than white women.
Family history of fibroids
Early onset of menstruation.
Obesity.
A diet high in red meat and low in green vegetables.
Alcohol use.
Fibroid tumors DO NOT turn into cancer and the risk of developing cancer from these tumors is very rare. Also, having fibroids doesn’t increase a woman's chances of getting other forms of cancer in the uterus.
A woman who has a growth that pushes toward the outer part of the uterus may not even know it’s there – while a woman with a fibroid that pushes inward and disrupts the uterine lining will likely experience heavy bleeding and other symptoms. Symptoms can vary widely from person-to-person. A woman with multiple fibroids may not have any signs at all, while another with just one may experience debilitating symptoms.
Very often, women don’t connect their symptoms with fibroids, but assume that they’re just a normal part of being a woman. However, once properly diagnosed, fibroids can be easily and effectively treated.
Common symptoms of fibroids include:
Heavy menstrual bleeding
Irregular bleeding
Prolonged periods
Pain, feeling of fullness, or pressure in the pelvis
Low back or leg pain
Frequent urination and difficulty emptying your bladder
Constipation
When fibroids cause heavy bleeding, they can increase the risk for anemia. In rare instances fibroids may also cause infertility and interfere with a woman’s ability to achieve or maintain a pregnancy.
Any or all of the following methods may be used to diagnose and understand the location and size of fibroids:
Pelvic exam
Ultrasound
Saline Sonogram
Hysteroscopy
MRI
Treatment for fibroids largely depends on the severity of symptoms and the patient’s goals. Options range from doing nothing to medication management through birth control pills or other hormonal medications or opting for surgery.
Surveillance
Medical management: birth control pills or progesterone IUD
Myomectomy: Removal of the fibroids alone, often through minimally invasive hysteroscopic or robotic approach using the Da Vinci Robotic System; leaves the uterus in place to preserve the ability to have children. While fibroids do not regrow after being removed, new ones can develop, and more surgery may be necessary.
Hysterectomy: often through minimally invasive laparoscopic or robotic approach; does not require removing the ovaries too. Typically, the ovaries can remain in place, so early menopause can be avoided
Minimally invasive myomectomy or hysterectomy is a same day procedure, which means after a short period of recovery, you can go home and rest comfortably. Most patients have very little pain, which is easily managed with ibuprofen or Tylenol. After the procedure, your doctor will recommend that you rest for 2-4 weeks. The only longer term restriction is lifting – we ask that patients not lift heavy items for 6 weeks after surgery, to avoid the risk of hernia.
For women with a significant number of fibroids, open surgery may be necessary. You should discuss your plans for a future pregnancy with your doctor. If you do plan to have a child in the future, the fibroids can likely be removed in a way that preserves your uterus. Women who don’t want to carry a pregnancy may be better suited for a minimally invasive hysterectomy where the uterus is removed along with the fibroid.
I am a minimally invasive gynecologic surgeon. That means I am specially trained to approach challenging gyn surgeries using laparoscopy or robotic surgery. Many women with fibroids are told they are not candidates for minimally invasive surgery. This often leads to delaying treatment and unnecessarily prolonged suffering. In the hands of a fellowship trained surgeon, however, a minimally invasive approach may be possible! Not every woman is a candidate for laparoscopic/robotic management of their fibroids, this is true- but it also depends on her desires and goals. With a real discussion, with proper explanation and education, women realize there are more options available to them and they can understand why one may be better suited than others.
Laparoscopy and Robotic Surgery
Many women with fibroids, endometriosis, adenomyosis, cysts, abnormal uterine bleeding have been counseled they need surgery, however very little about what that surgery actually entails is explained. Hearing that you need surgery is not an easy bit of news to handle- your mind automatically thinks worst case scenarios and negative preconceived notions. “I can’t take that much time off of work. My family needs me, I can’t be out of commission. I won’t be able to afford the loss of pay/expense of surgery. What if something goes wrong? I can manage, surely I don’t really need surgery do I? I can make it to menopause. The surgery will make me go into menopause. My body will change. I won’t be able to enjoy sex anymore.” And on and on. It takes time to come to the conclusion that surgery is the correct next step, it takes education and patience.
I meet women at various points on that journey. Some women want to try all the conservative options available first, in efforts to avoid surgery- and some are successful! Others have exhausted their options and accept that this is the next best step. Still others want to take the most definitive step possible right away, willing to take some down time up front in order to get back to their lives asap. No matter what, a woman should be fully confident in her decision to proceed with surgery.
As a fellowship trained minimally invasive gyn surgeon, I have had the privilege of focused training in managing complex surgical scenarios with minimally invasive approaches. I am committed to these approaches because I see the difference in recovery time, return to daily activities, scar tissue formation and more, when compared to traditional open surgery.
Too often I meet women who never thought that her particular gyn concern could be managed laparoscopically or robotically, who had been told that they were simply not a candidate, and as a result put off their surgery, sometimes for years, and continued suffering to avoid an open surgery.
Laparoscopy is a minimally invasive surgical technique that involves one to four small incisions (0.5cm to 3cm), compared to laparotomy (open surgery) which involves one large incision (up and down in the middle or side to side at the “bikini line” like for C-sections).
In laparoscopic surgery, ports (small tubes) are placed through those small incisions and the abdomen is filled with air. Then a camera and instruments are placed through the tubes. The surgeon and her assistant stand on either side of the patient and manipulate the camera and instruments, performing the surgery inside the abdominal cavity, while watching their movements on a high definition screen. Many different procedures, of all levels of complexity, across various surgical specialities can now be performed laparoscopically!
The benefits:
Less postoperative pain
Short/no hospital stay (most are same day, outpatient surgery)
Lower infection rates
Faster recovery/return to work/return to activities
Robotic surgery is an advanced type of minimally invasive surgery. The term “robotic” often misleads people. Robots don’t perform surgery- your surgeon performs surgery by using instruments that he or she guides via a console. I use the da Vinci Robotic surgical system for many of my cases, particularly the more complex ones that require extensive dissection (scar tissue, severe endometriosis) or extensive suturing (myomectomies). The da Vinci system translates my hand movements at the console in real time, bending and rotating the tiny wristed instruments, while I see the surgical area with highly magnified, 3D high-definition views. It’s pretty cool! Though I was trained and am very comfortable with traditional laparoscopy, the advanced technology of the robotic system has allowed me to perform even more complex procedures, more efficiently.
Not every patient is a candidate for minimally invasive surgery. For those who are not, there is likely a real reason why an open surgery is a better choice for her. This deserves discussion and counseling- I believe in educating my patients about their treatment options.
Minimally invasive surgery is my passion. Helping patients who are suffering with their gynecologic issue, who have struggled with the decision to have surgery, get back to their day-to-day, faster and with less pain, truly brings me joy.
Polycystic Ovarian Syndrome
Polycystic ovarian syndrome is a metabolic disorder that includes a spectrum of clinical features caused by problems with hormonal regulations. It results in menstrual irregularities, high androgen levels, and poorly functioning insulin.
Signs and symptoms of high androgen (testosterone) levels include acne, unwanted hair, thinning hair, menstrual irregularities (irregular, infrequent, no period; heavy bleeding). The poor insulin function can lead to obesity and diabetes. Other symptoms include infertility, fatigue, mood swings, anxiety, depression, and poor sleep.
Diagnosis includes a detailed history and physical, lab tests, and ultrasound. The name PCOS suggests the cystic appearance of the ovaries is required for diagnosis- it is not, many patients will not have cysts. Those that do typically have a characteristic “string of pearls” appearance to their ovaries- with multiple small (<1cm) cysts along the edge of the ovary. Labs checked include total or free testosterone, DHEAS, prolactin, TSH, 17OHP, cortisol, cholesterol levels, fasting glucose and insulin.
According to the US department of Health and Human Services, there are several health risks associated with PCOS. More than 50 percent of those with PCOS will have diabetes or pre-diabetes (impaired glucose tolerance) before the age of 40. The risk of heart attack is 4 to 7 times higher in PCOS patients than those of the same age without PCOS. Patients with PCOS are at greater risk of having high blood pressure, have high levels of LDL (bad) cholesterol and low levels of HDL (good) cholesterol. This translates into a higher risk of cardiovascular disease at younger ages.
Some patients go months without periods. As nice as that sounds, it could be indicative of too much estrogen (with no progesterone for balance) and that can result in abnormal cells developing in the uterine lining. PCOS patients left untreated are therefore at higher risk for developing endometrial hyperplasia, and even uterine cancer, at much younger ages.
Patients with PCOS may also face infertility issues. Because of the irregular cycles, it may not be clear when one ovulates, making it difficult to conceive. Often close monitoring and even medication are needed to help with fertility.
Treatment involves achieving hormonal balance, improving metabolism with exercise & diet, and combating insulin resistance.
Medications often used include birth control pills, progesterone pills, spironolactone, clomid, metformin.
PCOS is a metabolic disorder that may be diagnosed early due to the GYN symptoms. Talk to your doctor if you have noticed any of the above and get properly diagnosed so you can better manage your health!
Chronic Pelvic Pain
Chronic pelvic pain is defined by persistent pain in the pelvic region lasting 6 months or more. The pain may be constant or it may be cyclic, such as with menstrual cycles. It may be worsened by walking or standing/sitting for long periods of time. Sex may be painful or even impossible. The pain may be just in the pelvis or it may shoot to the back or down the legs. Pain may worsen with bowel movements or urination.
Many medical conditions can present with or lead to chronic pelvic pain. The key to determining the root cause is a detailed history and physical. Often, by asking the right questions, we can determine which organ system is responsible (reproductive, urologic, gastrointestinal, musculoskeletal, vascular, neurologic etc.). Sometimes more than one system is to blame. Conditions like endometriosis, interstitial cystitis, irritable bowel syndrome, fibromyalgia, and vaginismus can all be inter-related at times.
It wasn't until my fellowship that I learned how to do a proper pelvic exam - to assess the muscles of the pelvic floor and look for signs of endometriosis, for example. I've found that this exam can reveal a wealth of information about a patient's pain condition. More importantly, detecting changes or abnormalities on the exam can help direct a patient to pelvic floor physical therapy and/or to surgery.
Few women have heard about pelvic floor physical therapy and most are shocked at the suggestion of such an "invasive" type of therapy. I am a true supporter of the benefits of pelvic floor physical therapy- IT WORKS! After obtaining a thorough history and doing a detailed general PT eval, an external and internal examination of the pelvic floor assesses muscle tone at rest and with strain, any areas of tenderness or pain, and for any defects or prolapse. Therapy involves pelvic floor exercises, soft tissue mobilization, and consideration of a variety of modalities including vaginal dilators, electrical stimulation, and ultrasound. Over the course of 6-12 weeks, women develop a deeper understanding of their pelvic floor and many notice real improvements in their pain.
Addressing the underlying condition is also incredibly important. Some conditions such as endometriosis may warrant a surgical intervention to excise disease and free up adhesions/scarring. Whether it is endometriosis, interstitial cystitis (an inflammatory/ painful bladder syndrome), or irritable bowel syndrome, there may be low inflammation dietary or nutrition changes that can help relieve symptoms.
Given the long standing nature of chronic pelvic pain, sometimes the brain starts perceiving non-painful touch or stimulation in the pelvic area as incredibly painful. In order to protect itself, the body starts firing pain signals too early. This is a central process that needs to be re-trained. Often, we can use centrally-acting pain medications to help turn down the intensity of those pain signals. These medications are often helpful in conjunction with the other treatment options, to help one get through PT for example.
In short, the diagnosis and treatment of chronic pelvic pain can take a lot of work and a lot of trust. The first step is finding a doctor who listens and building a team of practitioners who will work with you to get you to a better place.