Another month, another painful period. Or maybe that menstrual pain never goes away. For some women, it’s a painful life as usual. But what could be the cause of these painful cycles?

Endometriosis may be the culprit. And while the condition generally isn’t dangerous, it can be quite debilitating.

With endometriosis, the endometrial tissue that lines the inside of the uterus begins to grow outside of it in clumps called implants. The most common places for these implants are the ovaries, the fallopian tubes, the outer wall of the uterus and other pelvic areas. (It’s possible, though rare, for endometrial implants to spread beyond the pelvic area.)

Despite being relocated outside the uterus, the migrated endometrial tissue behaves as it should: thickening, breaking down and bleeding during each menstrual period. But if this tissue and associated bleeding have no manner in which to leave the body, pain and inflammation can result. Left untreated, endometriosis can have significant unwanted side effects — the most common being an increased risk of infertility, scarring of the fallopian tubes and severe pain with intercourse. But the good news is that women don’t have to suffer.

 

What Symptoms Am I Looking for?

Although many patients with endometriosis experience pain, the intensity of that pain isn’t a reliable indicator of just how severe or extensive the condition is. Some women have pain all the time; some experience only mild discomfort.

It’s not uncommon for symptoms to increase in severity just before and during your menstrual period. Some of the most common symptoms include:

  • Painful periods, including severe menstrual cramps and pelvic pain
  • Pain during or after intercourse
  • Pain during bowel movements, especially during your period
  • Abnormal bleeding, such as blood in the urine or stool

Another common symptom of endometriosis is infertility: Approximately 20%-40% of infertile women have endometriosis. In fact, many women are first diagnosed with endometriosis when they have trouble starting a family. Although it’s not known why endometriosis may cause infertility even in the absence of scar tissue involving the ovaries and/or fallopian tubes, there are several theories, including:

  • Scar tissue develops near the implants, changing the shape or function of the ovaries, fallopian tubes or uterus.
  • Implants alter the chemicals or hormones found in the fluid surrounding abdominal organs, preventing pregnancies or altering menstrual cycles.

Just as it’s impossible to predict who will have mild or severe symptoms, it’s also impossible to predict if an individual’s symptoms will increase or decrease in severity — or simply stay the same — over time.

 

How Do I Know if I Have Endometriosis?

Symptoms alone aren’t enough to formally diagnose endometriosis, and they’re occasionally mistaken for other conditions, like ovarian cysts and irritable bowel syndrome. If you suspect you have endometriosis, talk with your OB-GYN about having them perform a laparoscopy — it’s the only way for your doctor to diagnose the condition and know for sure.

You’ll be under general anesthesia during the laparoscopy procedure, while the doctor uses a long, thin, telescope device (a laparoscope) to look inside the abdomen for scarring on your uterus, ovaries, fallopian tubes and other organs. If the doctor does find signs of endometriosis, they may be able to remove scarring during the procedure. But it’s nearly impossible to get all the endometriosis, since many of the implants may be microscopic or buried from view.

 

What Causes Endometriosis (and Can I Prevent It)?

There’s currently no way to prevent endometriosis. And while doctors aren’t sure what causes endometriosis, they have some ideas:

  • Retrograde menstruation, in which menstrual blood flows back through the fallopian tubes and into the pelvic cavity. The endometrial cells in the blood may then stick in the pelvic area, grow, thicken and bleed during each cycle.
  • Embryonic cell transformation. Hormones may cause embryonic stem cells — which are capable of becoming almost any tissue in the body — to change into endometrial cell implants. This change occurs when a woman is actually in her mother’s womb, but it erupts into active disease during puberty.
  • Immune system disorder. A problem with the immune system may render the body unable to recognize and destroy endometrial tissue that’s growing outside the uterus.

 

Are There Any Complications of Endometriosis?

Unfortunately, endometriosis can cause more than just pain and discomfort. Endometriosis may also cause:

  • Fertility issues. Endometriosis may physically prevent the sperm from uniting with the egg.
  • Ovarian cancer. While the average risk of ovarian cancer is about 1 in 100, some studies suggest this risk increases in women with endometriosis — especially in women older than 60.
  • Ovarian cysts. Endometrial cysts of the ovary, also called ovarian endometriomas, can be a common complication of endometriosis. They can fill with a little more blood during each menstrual cycle and even burst with sudden movements or during sexual intercourse. Such ruptured cysts can cause severe pain and further spread the disease.

 

What Is the Standard Treatment for Endometriosis?

While there is no cure for endometriosis — symptoms can even remain even after menopause — there are endometriosis treatment options that can help with both pain and infertility.

  • Medication. Birth control hormones or pain medications might be enough to control pain, while birth control hormones may even prevent pain symptoms from intensifying. Nonsteroidal anti-inflammatory medications — like aspirin, ibuprofen and naproxen — can help with the associate pain and menstrual cramps.
  • Other treatments. Regular exercise and the application of heat to the area of discomfort might also alleviate pain.
  • Surgery. This may be a consideration if other treatments don’t work and implants begin to affect other organs. In the most severe cases, hysterectomies and oophorectomies are options. But these are considered the last course of treatment and can have long-term effects on a woman’s health.

 

You Do Have Treatment Options

If any of these symptoms sound familiar, we encourage you to get a formal diagnosis through your OB-GYN. And if you do receive a diagnosis of endometriosis, don’t feel like your treatment options are limited.

We’re here to help with both the pain and the fertility issues associated with endometriosis. Even better: You may be a candidate for nonsurgical treatment options that are available only at our practice.

If you’ve been diagnosed with endometriosis and want to learn more about the nonsurgical treatment options that may be available to you, contact our Washington, D.C. office at (202) 293-1000 to make an appointment.

Upon hearing a cancer diagnosis a person’s world changes immediately and forever. The person becomes a patient. The patient has to make myriad decisions about treatment plans, and the possibility of surgery, radiation, and chemotherapy. These treatments, while life-saving, are also life-altering. The side effects can modify body image, reduce or end fertility, change sexual identity and sexual function. Approximately 60 percent of cancer survivors have long-term sexual dysfunction. Oncology teams (who may focus more on the life-saving aspects of care) aren’t always taking the time to discuss fertility or sexual health matters as much as they should. But the good news is that our practice can help save a women’s eggs, or a man’s sperm for future use; mitigate and reverse most hormonal changes, and starting in September, we will also offer treatment for men with urological or sexual complaints in our practice. Our newest colleague, Rachel S. Rubin, MD, is specially trained to treat hormonal and sexual dysfunction in both men and women.

Talking about sexual health outside of the bedroom, in the office of a compassionate physician is key to holistic wellness. The emotions of being a cancer survivor can be overwhelming in and of themselves, but to add infertility or sexual dysfunction to the list of health issues can be daunting. We’re here to help you get back on track.

For Men
Following prostate cancer treatment, for example, the ability to have and maintain an erection becomes difficult and for some men, impossible, without help from a medical practice such as ours. Many men may not feel comfortable talking about these intimate issues, but there is help. Our compassionate and caring staff can help men who experiene treatable symptoms. It’s not just about physical symptoms, cancer affects sexual identity and when men are unable to perform as they could prior to cancer treatment, it can have a serious and detrimental effect on one’s psyche. Getting the courage to seek help is the first step to getting back to the “new normal.”

For Women
Breast cancer, when surgery is required, may alter a woman’s body and can hinder sexual identity and function. Breasts, once part of the sexual experience for both partners, are no longer the same. Even when reconstructed, the breasts may feel different, lack the pleasurable sensitivity they once had, or might even be painful and distracting. Sensation might even be completely gone. Partners may also feel hindered by the feeling of the new breasts. This can be uncomfortable for both partners. With any cancer treatment (i.e. chemotherapy, surgical removal of the ovaries or even hysterectomy) a patient may find herself in early/premature menopause with hot flashes, night sweats, disturbed sleep and weight gain. This is also accompanied by vaginal dryness, and pain with genital touching or intercourse. There are options to help enhance the sexual experience that we have available at the office, and that are not available anywhere else.

A wonderful Newsweek article about these issues does a deeper dive from both the patient and physician perspective that we welcome you to read for additional information.

If you are just starting cancer treatment, going through it, or are in the post-treatment phase and are facing future or current fertility concerns, hormonal deficiencies, or sexual dysfunction, we can help. Please call our office at (202) 293-1000 to make an appointment with one of our caring and compassionate members of Dr. James A Simon’s team.

If you’re in the New York City area on April 7-9, 2017 join me and colleagues at the The Westin NY at Times Square for our annual Survival Skills for Today’s Gynecologist program. It’s a great time to catch up with friends and hear discussions about the latest in gynecologic patient care. Each day starts with breakfast and includes time for Q&A to deepen the knowledge-share among us.

Along with Steven R. Goldstein, MD who serves with me as Program Co-Director, we have a terrific faculty who will present on leading-edge therapies and topical issues. You might be interested in the most recent recommendations about cervical cancer screening or are wanting more information about HPV education, VVA treatment, hysterectomy procedures, urogynecology, and much more.

On Friday, I will discuss the following topics:

  • Menopausal Hormone Therapy: Primary Prevention of Disease or Not?
  • Office Management of Female Sexual Dysfunction: You CAN do this.
  • Flashes, Flushes, and Night Sweats: New and Non-Hormonal Approaches

My topic for Saturday is Pelvic Floor Biofeedback/Physical Therapy: Should I Offer This in My Office?

The treatment of our patient population is ever-changing, as new treatments and options become available. The business of medicine is changing too. Don’t miss this great CME opportunity, learn some Survival Skills, and thrive in the years to come.

View the entire course or to Register at www.WorldClassCME.com or by phone at (888) 207-9105, M-F 8:30 am – 5 pm EST

Hope to see you there!

The encouraging news that teen pregnancy rates have been on the decline comes to us from the Journal of Adolescent Health. The amount of medically accurate information available for teens has increased. The conversation about what constitutes safe sex as well as the fact that some teens are simply waiting until later in life to engage in sexual activity also plays a role.  The teens who are sexually active are getting better about using safe and effective contraceptive methods such as “the pill” to avoid pregnancy, as well as condoms to avoid sexual transmitted infections. Additionally, the stigma around talking about sexual activity has diminished, and the discussion of sex of all kinds has empowered teens to have more open discussions with their educators and partners.

National Survey of Family Health
Laura Lindberg, PhD and colleagues reviewed data between 2007 and 2012 from the National Survey of Family Health to see substantial declines in adolescent pregnancy and birth rates in the United States occurred between 2007 and 2012. They wanted to find out if sexual activity, contraceptive use, and contraceptive efficacy correlated to the declines in the pregnancy and birth rates during this time. It did.

The researchers found that the contraceptive behaviors of sexually active adolescents have driven the recent shifts in fertility outcomes. The increases in overall contraceptive use during sexual intercourse between the years 2007 to 2012 are part of a longer trend. Between 1995 and 2012, any method use at last sex among adolescent women increased from 66% to 86%, while use of multiple methods increased from 11% to 37% during this time.

Public policy and programs can play a critical role in supporting adolescent contraceptive use. Since contraceptive use is the critical driver of adolescent fertility, it is important to ensure adolescents’ access to comprehensive sexuality education that provides medically accurate information about contraception.

Our practice offers a variety of solutions to pregnancy prevention, which can be stopped or removed at the time our patients are ready to start a family. We support the entire lifecycle of women, and it all starts with a healthy young adulthood.

To learn more please call the office at (202)293-1000 or email the practice at info@dev.loebigink.com

Participants in ob/gyn trials experience better health outcomes compared with non-participants, according to a new article in the British Journal of Obstetrics and Gynecology (BJOG). Scientists from England have found that women who join ob/gyn clinical trials had better health outcomes than the population of women who did not. The research team at Queen Mary University of London looked at 21 studies that focused on pregnancy and reproductive health. The review included 20,160 women and found that clinical trial participants had 25% better odds of improved health outcomes compared with non-participants.

I have been conducting clinical research for more than 35 years as a principal investigator for a variety of indications in women’s health including contraceptives, low libido/desire, uterine fibroids, endometriosis, menstrual migraines, symptoms of menopause (i.e., hot flashes and night sweats), vulvovaginal atrophy, osteoporosis, overactive bladder, and weight loss. Notable recent FDA approvals include Addyi® (flibanserin, Sprout Pharmaceuticals), Saxenda® (liraglutide, Novo Nordisk), and generic vaginal estrogen tablets, Yuvafem®.

Women’s participation in clinical trials has improved in many areas, but to continue this momentum, more women should speak up and find out if a trial of a medication can help them. There are a variety of opportunities to participate, and more to come every day.

Our practice is currently seeking patients in the following areas.

  • An oral medication for the treatment of heavy menstrual bleeding due to uterine fibroids.
  • An oral medication for the treatment of moderate to severe endometriosis related pain.

Why should you participate in a clinical trial?

It may help you better understand your medical condition.
You could be part of an ongoing process that may benefit others in the future. There can be great satisfaction from being a part of scientific research.

To learn more please call the office at (202)293-1000 or email the practice at info@dev.loebigink.com.

A tiny butterfly-shaped gland at the base of your neck has an important role in overall well-being; it helps regulate body temperature as well as metabolism (how fast you burn calories). When the thyroid is under-performing or over-performing, issues start to crop up and women, who this mostly affects, begin to feel off, gaining weight, feeling more tired or listless than usual.

An interesting study on subclinical hypothyroidism alerts us to issues such as weight gain and hair loss that may be symptoms of the thyroid being overactive or underactive. However, before jumping to a self-diagnosis, you should consider your family’s genes and inherited traits related to weight and hair, because these also show up at middle age, just simply as a factor of getting older. If you have eliminated those as family traits as possibilities, it may be time to consider some blood tests to see what is going on.

The confounding factor about the thyroid is that the range of normal levels of most hormones is very wide. Because of this, a person may have thyroid hormone levels on the threshold for needing treatment, but still in the “official” normal range. Getting too much thyroid medication to optimize one’s blood results, can lead to other serious medical complications such as heart attacks and cardia arrhythmias (irregular beats), as well as bone loss, osteoporosis, and fractures. So, it is imperative to get the dosage just right. An expert in medical endocrinology or reproductive endocrinology (like me), understands these issues and can make slight adjustments to optimize thyroid replacement or supplementation, which often results in the patient feeling much better, with less fatigue, while minimizing the risk of side effects such as cardiovascular and skeletal disorders.

I always try and look at the whole patient, not just their symptoms or their laboratory values. I take into account the other medications that patients may be taking, which could have an impact on well-being. For example, if a patient is taking an oral hormone therapy to mitigate menopause symptoms, this can upset the normal thyroid balance, so it is vital to find the right balance of both these hormones. Similarly, younger women on birth control pills may experience excessive weight gain because their contraception has thrown off their thyroid. Once the optimal thyroid treatment is determined, the patient can stay on that dosage for a long time. Like butterflies, each patient is unique and a personalized approach works best.


Key Points

  • There is no “one size fits all” thyroid treatment.
  • Most women should be screened around the onset of menopause, if there they are considering going on hormone treatment, to find the thyroid’s baseline levels.
  • Women with rapid and excessive weight gain should be tested.
  • If there is a family history, patients should be screened at age 35 or if other signs of hyper or hypothyroidism are present.
  • Heart attacks, cardiac arrhythmias, and bone loss – occur later in life and are asymptomatic until they occur. Over-treatment with thyroid medication can causes these disorders down the road.
  • To learn more please call the office at (202)293-1000 or email the practice at info@dev.loebigink.com.

As a reproductive specialist, board certified in reproductive endocrinology and infertility, this blog post has special significance for me. While you may not need the information provided here, you may know someone who does. Please “Pay It Forward”, “Pass It On”.

Women experiencing a cancer diagnosis is a life-altering experience; however, so is infertility. Breast cancer treatment is one cancer type that can have permanent effects on fertility because ovarian removal, injury (i.e., chemotherapy or radiation) and/or suppression is often part of the treatment strategy. Additionally, each year approximately 71,500 women in the United States are diagnosed with a gynecologic cancer, according to the Center for Disease Control (CDC). These cancers include cervical, gestational trophoblastic disease (GTD), primary peritoneal, ovarian, uterine/endometrial, vaginal and vulvar cancers. Because of the nature of cancer as it relates to fertility, I would like to provide more information about fertility options at the point of a cancer diagnosis so that patients can benefit from fertility preservation strategies before treatment begins because three out of four patients are interested in having a family one day.

How Treatment Affects Fertility
Treatment, including chemotherapy, radiation, and surgery can cause damage to organs involved in reproduction, such as the ovaries, fallopian tubes, uterus, and cervix. Ovarian suppression, used to slow or stop estrogen-receptor positive cancers, can be reversed following treatment. However, other treatments such as chemotherapy, radiation and some surgeries can cause women to experience early and permanent menopause.

Weighing the Options Before Treatment
There are several methods to preserve future fertility if patients are able to compete one of these prior to chemotherapy or radiation.

Embryo freezing is a primary method of fertility preservation for women, according to Cancer.Net a patient site from the American Society of Clinical Oncology (ASCO). After taking fertility drugs for two weeks a woman’s eggs are collected and fertilized by sperm though in vitro fertilization. The embryos are frozen until the woman is ready to become pregnant. Although fertility drugs increase estrogen during fertility treatment, aromatase inhibitors can keep the levels low for women with estrogen-sensitive cancers thereafter.

Oocyte (unfertilized egg) freezing is similar to embryo freezing, except that the eggs are frozen without being fertilized by sperm. This is a particularly important option for women who are not currently “partnered” or do not want to choose a sperm donor.
Fertility-preserving surgery is an option for cervical or ovarian cancer. Surgery can treat the cancer and help preserve a woman’s fertility. Surgery may also be used to “move the ovaries” out of harm’s way, should radiation be needed in an anatomically adjacent area. The ovaries can be “put back” in their normal location at a later time if needed for future fertility.

For girls who have not yet reached puberty, an experimental option is to try ovarian tissue cryopreservation, a process where an ovary or ovaries are actually removed from the body and frozen in pieces until needed following cancer treatment. At that time, the ovary or a part thereof can be re-implanted in the arm, abdomen or other easily accessible location for future egg retrieval. While this sounds like science fiction, some babies have already been born using this process.
During treatment, the oncology team may try ovarian shielding to ensure that the ovaries are not harmed during radiation therapy. In an effort to protect the ovary by reducing its exposure to chemotherapy an attempt can be made to “turn off/turn down” the ovary’s blood supply using other medications. This approach has had mixed results, but has few downsides. One cancer treatment has commenced and premature menopause results, patients may consider surrogacy or adoption in addition to the options listed above.

Guidelines Broaden the Discussion
In 2013 the American Society of Clinical Oncology (ASCO) updated its clinical practice guideline on fertility preservation. One of the pivotal updates to the guideline was the change from the word “oncologist” to “healthcare provider”, to broaden the responsibility to more members of the medical team who can help lead discussions with patients to help them better understand their fertility preservation options. While I applaud this approach, I prefer that these men and women be called “healthcare professionals”.

The Future of Oncofertility
Because patients with cancer are enjoying greater survival rates in large numbers, there is a need to address the whole person, not just the removal of the cancer, because survivorship, for many, also includes raising a family. Teresa K. Woodruff, PhD, of Northwestern University Feinberg School of Medicine in Chicago and Thomas J. Watkins, MD professor of obstetrics and gynecology at Northwestern, coined the term “oncofertility” to describe oncologists and reproductive specialists working together preserve patients’ fertility while treating their disease.

Medical professionals can ensure that patients and their families have all the decision-making tools available about fertility preservation. Members of the ob/gyn and also oncology teams should address the future fertility options with patients at the point of cancer diagnosis and prior to initiating treatment.

Top Tips for Discussing Fertility with Patients
1. Discuss fertility preservation with all patients prior to and of reproductive age if infertility is a potential risk of therapy.
2. Refer patients who express an interest in fertility preservation (and patients who are ambivalent) to reproductive specialists.
3. Address fertility preservation as early as possible, before treatment starts.
4. Document fertility preservation discussions in the medical record.
5. Answer basic questions about whether fertility preservation may have an impact on successful cancer treatment.
6. Refer patients to psychosocial providers if they experience distress about potential infertility.
7. Encourage patients to participate in registries and clinical studies.
Reference: Key Recommendations: Fertility Preservation for Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update

Top 10 Questions to Ask your Doctor about Fertility and Cancer Care
1. How does cancer affect my fertility?
2. Which cancer treatments can affect my fertility?
3. Which fertility preservation methods should I consider before cancer treatment begins?
4. How does the process of egg preservation work?
5. How long does this procedure take?
6. How soon after cancer treatment can I plan for a pregnancy?
7. My cancer type requires ovarian suppression. When can I become pregnant after ovarian suppression is reversed?
8. What are the side effects of these procedures?
9. I’m already pregnant and diagnosed with cancer. Will I be able to have children in the future?
10. Will my insurance cover these procedures?

To learn more please call the office at (202)293-1000 or email the practice at info@dev.loebigink.com.

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