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My uterus has been invaded by fibroid tumors! What am I to do?

January 22, 2012 by Dr. Tamar K. Gottfried Leave a Comment

Uterine fibroid tumors are a very common finding on pelvic ultrasound or pelvic exam and tend to cause women to worry unnecessarily. As many as one in 5 women have fibroids, and most will never cause any disruption in a woman’s health. Most commonly, a woman will have an annual exam and an ultrasound will be ordered because her uterus is felt to be enlarged or for another reason such as abnormal bleeding or pelvic pain, and fibroids will be one of the findings on the ultrasound. Fibroids can range in size from very small (grape sized) to very large (grapefruit sized) and can be solitary or numerous. Whether or not something needs to be done about them depends on factors such as size, number, location and symptoms.

What are the symptoms of fibroids? They can vary immensely. Most women with small or few fibroids may have no symptoms at all. These fibroids can be monitored periodically with ultrasound to check for growth. Fibroids that are asymptomatic and not growing rapidly can be left alone because they will shrink after menopause. Other fibroids can cause symptoms such as heavy bleeding, pain, pressure on the bladder or rectum, increased abdominal size, and difficulty becoming pregnant or carrying a pregnancy.

Treatments for fibroids vary based on symptoms. Some menstrual bleeding abnormalities can be managed with medications, even when fibroids are involved. There are nonsurgical solutions for fibroids such as uterine artery embolization or MRI guided ultrasound treatment- these procedures block the blood supply to the uterus or fibroids and shrink the tumors. They should not be used if future childbearing is desired.

Fibroids in the uterine lining can be removed with outpatient hysteroscopic surgery or can be treated during a uterine ablation procedure. Larger fibroids in the muscle of the uterus can be removed with a surgery called a myomectomy, if a woman desires future childbearing. Alternatively, a hysterectomy can be done if a woman is done having children. Either of these surgeries can be done open or laparoscopically. While there is no medicine available that can eliminate fibroids, a drug called Lupron is often used prior to fibroid surgeries to shrink the tumors.

In conclusion, a diagnosis of fibroid tumors usually does not mean disruption to a woman’s life or health. Many fibroids live quietly in the uterus and never cause symptoms. Luckily, if and when fibroids become symptomatic, there are a number of nonsurgical and surgical treatments to treat them. Further information about fibroid tumors can be found at my Mesa Ob/gyn office.

Tamar Gottfried is a Board Certified Obstetrician/ gynecologist practicing general Ob/gyn in Mesa Arizona and affiliated with Banner Desert and Banner Gateway Medical Centers. She can be contacted at 480-545-0059. This is a general interest article only and is not intended to be medical advice. See a medical professional before making medical decisions

My doctor just told me I have HPV! I have been monogamous for years- What do I do with my husband?

December 14, 2011 by Dr. Tamar K. Gottfried Leave a Comment

This statement above is not an unusual one when a woman is diagnosed with a Human Papilloma Virus (HPV) infection for the first time. The easy answer to the question is to relax and stop considering harm to a spouse: HPV does not mean that a partner has been unfaithful. It can live in a person harmlessly for years, even decades in some cases.

HPV is a virus that is responsible for abnormal paps and precancers of the cervix, as well as cervical, vaginal, vulvar, and even anal cancers. There are many forms of HPV- low risk strains may cause warts, but don’t cause the more dangerous lesions. High risk strains can cause precancerous cells to develop and grow, but can also live silently in a person for years. In past years, HPV was only found when someone had an abnormal Pap smear. Recently, due to advances in the technology used to detect HPV, high risk HPV screening is done at the time of Pap smear in most women over 30 years of age. Because of this, and to the surprise of many women, asymptomatic infections are found at the time of routine annual exams.

HPV infection is very common in both men and women- perhaps one out of every four women has been infected with a high risk HPV strain. This is why there is such a push to vaccinate teenagers before the onset of sexual activity. While teenagers and women in their 20s are more likely to come into contact with HPV, become infected, and then clear the virus through the work of their immune systems, older women are less likely to clear the virus. For this reason, it can live in someone, but go to hibernation, only to emerge at a later time. While women may not be able to permanently get rid of HPV (there is no treatment for the HPV itself, only its effects when they occur), HPV can go silent again once it has emerged. Most people do not stay HPV+ for extended periods of time.

So what does being positive for high risk HPV mean? It means that a woman has come into contact with HPV through sexual activity at some point in her life, perhaps years prior, and is now showing up on a Pap. Having HPV does not equal having cancer or even precancer, it just means that a woman needs to be monitored more closely by her gynecologist until the HPV clears. Any woman who has more questions about HPV should contact our Mesa Ob Gyn office.

Do I get an ultrasound in my third trimester? The function of ultrasound in late pregnancy.

December 13, 2011 by Dr. Tamar K. Gottfried Leave a Comment

For many expectant parents, the first comment after seeing their baby onscreen in a detailed ultrasound for the first time is, “when do I get to SEE my baby again?”. This is a natural question- after all, ultrasound is a wonderful way for parents and family to get to know and bond with a baby before the Birth day. However, ultrasound is a medical procedure and has limited use in the last few weeks of pregnancy.

Most women who have gotten prenatal care from an early stage of pregnancy get to see their babies at least once in the first trimester for a dating ultrasound and again for a genetic screening for down’s syndrome, if needed. In the second trimester of pregnancy, ultrasound is used to look at at the anatomy of the baby, make sure all the parts are there and functioning, and to look at the placenta, umbilical cord, and blood flow to the uterus. From a medical perspective, it is this ultrasound that really determines if the fetus is developing normally.

In the third trimester, ultrasound can be used to look at the health and functioning of the placenta and umbilical cord and to evaluate the baby’s growth. Unfortunately, the accuracy of ultrasound at predicting a baby’s weight diminishes later in the pregnancy so that an ultrasound can over or underestimate the weight by a pound. Late pregnancy ultrasound is essential for high risk pregnancies with conditions such as diabetes, high blood pressure, high or low amniotic fluid, and some twins. For most low risk pregnancies, ultrasound is mostly needed at the end if a baby is suspected of growing too much or not enough or if the baby isn’t moving as much as usual.

In conclusion, ultrasound is a vital and exciting tool during pregnancy. While it is most helpful at providing information about a fetus early in pregnancy, it can also be useful in selected pregnancies during the third trimester. Because there is no guarantee that ultrasound will be needed later in pregnancy, it is best to really enjoy and savor the second trimester ultrasound and to make sure and grab some good shots to start the baby album. We offer both early and late ultrasound in our Mesa ob gyn office.

I watch what I eat and exercise regularly- why am I not losing weight?

November 23, 2011 by Dr. Tamar K. Gottfried Leave a Comment

Chandler Obgyn Tamar Gottfried discusses weight management over the holidays:

As we prepare to enter the holiday season, many people are focusing on simple weight managment- i.e. not gaining weight between November and January. However, there are those already on weight loss journeys, wondering how to achieve their goals. As I speak to patients in my office about nutrition and exercise a common question arises: Why am I not losing weight?

Although there a million different diet and exercise plans out there, the simple fact remains that in order to lose weight, a person has to burn more calories than she ingests. The most effective nutrition plans advise food journaling ( which means writing down every morsel eaten and weighing and measuring ingredients and portions for accuracy) and calorie restriction. Some people eat the right kinds of food, but eat too much of them due to misjudging portion sizes. While calories, as well as proportions of fat, carbs and protein, do have to be watched in order to have weight loss success, the total number of calories cannot be too high or too low. Many people who are trying to lose weight eat too little or too infrequently during the day. Then their bodies think they are in a starvation mode and hold on to every calorie. That is how someone can eat very little and still not drop weight.

There are many people who exercise daily and become frustrated when the scale doesn’t budge. Again, it is the calories in, calories out idea that can affect weight loss. It has been found that people who exercise regularly may also burn less total calories in the rest of their day, being more sedentary as a reward for having “worked out”. If a person works out and then sits at a desk all day and comes home to sit in front of a computer or a TV, the total calories burned for the day may be low. Additionally, if a person is ravenously hungry after a workout and ends up eating more than usual at the next meal or snack, this will affect the total calories in for the day.

Unfortunately, there is no easy weight loss solution- magic pills aren’t so magic, the success of the HCG diet involves continuing to follow a low calorie diet, and exercise requires a daily commitment to personal challenge. However, in the simplest terms, burning more calories a day through exercise and incorporating calorie burning activities throughout the day, than calories taken in through eating, will eventually result in weight loss success. Luckily there are many more specific tools and plans like Weight Watchers, and the Body Bugg to help people achieve their goals.

As an Chandler Ob gyn physician who has personal experience with weight issues and lifestyle changes, I have a particular interest in helping women address their diet and exercise challenges. Contact my Mesa office for more information.

Do I really need to have a menstrual period? Info on the art of menstrual manipulation.

November 14, 2011 by Dr. Tamar K. Gottfried Leave a Comment

Gilbert Obgyn Tamar Gottfried discusses menstrual manipulation;

Although the monthly menstrual period is essential to the reproductive process, it can easily become a burden for women not interested in becoming pregnant. Many women ages 12-55 experience problems with their periods ranging from too far apart to too often to too heavy to too long. This raises a common question: If I’m not trying to become pregnant or if I’m done having babies, do I really need to have a period?

From puberty to menopause, the monthly period bleed is a means to shed the lining of uterus that builds up each month and, in the absence of a pregnancy, is not needed. While an average cycle is every 4 weeks, the range can be from every 3 weeks to every 8. Some women have very infrequent periods and wonder if this is healthy. In women that are not on some kind of hormonal manipulation (the pill, the shot, the IUD), it is important to bleed at least every 3 months. Without some kind of shedding of the uterine lining, the lining can build up and cause pre-cancerous changes. Some women don’t have periods because they are very skinny or are athletes with low body fat percentages. They are at risk from having low estrogen levels and can develop problems such as weak bones. Therefore, in women who are naturally not having regular periods (especially those with polycystic ovaries or are over or underweight), it is best to start some kind of hormonal medication to bring on a regular or more frequent period.

For women who have medical problems associated with their periods (menstrual migraines, irritable bowel syndrome, anemia, horrible cramps, etc) or for women that would prefer not to menstruate, there are ways to safely minimize or skip the period. The birth control pill was originally designed with a placebo or sugar-pill week so that women on the pill would have a monthly bleed and know that they weren’t pregnant. However, there is no medical need for this monthly bleed on the pill or on other methods of hormonal therapy. Therefore, women who want to skip a period can skip the sugar pills in their pill pack each month. Alternatively, they can use a medication like Depo Provera or the Mirena IUD to minimize monthly bleeding.

Women who have seen or heard ads in the media for “stop the flow” often inquire about surgical means for avoiding periods. While a hysterectomy will definitely stop bleeding, it is not necessary for most women. Endometrial ablation, such as the Thermachoice procedure, is an in-office surgical procedure that can minimize and sometimes eliminate monthly bleeding. However, it is designed to lighten bleeding and cramps for women with extremely heavy and/or painful periods, not to eliminate them for women with normal flow. Complete absence of periods after this procedure can never be promised. It is a wonderful, minimally invasive option for improving periods in women who suffer with their cycles each month.

In conclusion, periods are a necessary event for women not on medication, but can definitely be controlled or eliminated temporarily by medical or surgical means. To further discuss menstrual control or the in office Thermachoice procedure, contact my Mesa Ob Gyn office for a consult.

I’m not sick, I’m pregnant! Why should I deliver in a hospital?

November 13, 2011 by Dr. Tamar K. Gottfried Leave a Comment

Chandler Obgyn Tamar Gottfried discusses why you should deliver your baby in a hospital;

In past centuries, most of the babies in this country were born at home with midwives. Infant and maternal deaths were not an uncommon occurrence. Over the years, more and more births were done in hospitals by physicians, and labor and delivery became a medical event. The availability of safe cesarean delivery, antibiotics, epidurals and advanced neonatal care improved the safety of the labor and delivery process for moms and babies.

In more recent decades, there has been another shift in opinion to a care model that allows moms to have the safety of hospital delivery with some of the comforts of home. Long gone are the routine shaving and enemas and episiotomies of the past. Now, hospital based labor and delivery units can offer bedroom-like rooms, wireless fetal monitors, birthing balls and squat bars and nursing support and encouragement for a natural delivery with the safety of operating rooms and neonatal teams minutes away for the rare emergencies that happen.

While the majority of labors are uneventful and proceed without incident, emergencies can occur without warning. A perfectly normal labor and delivery for an experienced mom can turn scary in minutes if the placenta stops working suddenly, a baby’s shoulder gets stuck, a baby doesn’t breathe at delivery or if bleeding doesn’t stop after the baby is born. While some women are classified as “high risk” during the pregnancies and these types of problems are anticipated, obstetric emergencies can happen to anyone. For this reason, hospital delivery brings a level of comfort and security for expectant parents.

Home birth has been around since the dawn of humanity and, under the care of experienced midwives, continues to be an option for low risk women. As my colleague puts it- if you ride on the freeway at 100 mph on a motorcycle without a helmet, you may make it to your destination, but you are taking a risk. It is the same with home birth- it can be safe, but when unexpected events occur, transfer to a hospital is a necessity and the time it takes to get there can critical for mom and baby.

In the instances when emergencies develop, I am always happy to be practicing in the safety of a hospital like Banner Desert Medical Center, with a a level 3 Neonatal ICU, a full children’s hospital, and 24 hour neonatologist on site , with advanced techniques to stop maternal bleeding available, with 3 operating rooms staffed and ready to go, with high risk pregnancy consultants and ultrasound right there, and with anesthesiologists assigned 24/7 to the maternity ward. My patients who choose to have a more natural, unmedicated delivery can do so in a safe and supportive environment. That is why, as an Ob Gyn in Mesa, I recommend hospital delivery for my patients.

When do I need to take my teenage daughter to see a gynecologist?

November 3, 2011 by Dr. Tamar K. Gottfried Leave a Comment

Many concerned parents have questions about if and when their adolescent daughters need to visit a gynecologist. While there is no official subspecialty in pediatric and adolescent gynecology, there are many Ob/gyns that have an interest in taking care of younger patients and their obstetric and gynecologic needs. That said, most teenage girls do not need to have a gyn visit once they begin developing and having periods. Gyn visits are reserved for those girls that are having problems with their periods, having undiagnosed abdominal pain, problems with discharge or itching, or need counselling for birth control or sexually transmitted disease prevention.

Perhaps the most important gyn issue for the teenage patient is vaccination for the Human Papilloma Virus (HPV). HPV is the virus that causes abnormal paps, genital warts and cervical cancer. There are 2 vaccines on the market available for women and girls ages 11- 26. In order to prevent abnormal paps caused by HPV, it is important to vaccinate women before they are exposed to the HPV virus through sexual contact. That is why the vaccine is given to teenagers. It involves 3 injections over 6 months and can be given in a pediatric or gynecology office. While teenagers do not have to have actual Pap smears until age 21, HPV prevention is an issue even in the teenage years.

Other reasons to see the gynecologist as a teen are menstrual problems such as late onset of periods, irregular bleeding or heavy, long or painful periods. A young woman doesn’t have to suffer and miss school and activities because of bad periods. There are treatments that can help lighten periods.

Of course, some teenagers are thinking about becoming sexually active or already are. For these young women, it is extremely important to visit a gynecologist to learn about protecting themselves from pregnancy and from sexually transmitted diseases. These are real risks, even for teenagers, and are preventable with proper education.

In conclusion, even though routine gyn exam or Pap smears are not needed for teenage girls, there are many others reasons for a teenager to visit a gynecologist. We are happy to see teenage girls in a comfortable and confidential manner for their ob/gyn needs at our Mesa office.

My family is complete and my husband won’t get a vasectomy. What is my permanent birth control solution?

October 23, 2011 by Dr. Tamar K. Gottfried Leave a Comment

There have been various options for female sterilization offered throughout the years for women desiring permanent birth control. Previously, women could only get their fallopian tubes tied, cut, burned or clipped through a procedure requiring anesthesia, abdominal incisions, and surgery in the abdominal cavity. This required time off from work and involved the risk of major surgery.

Now there is the option of a sterilization procedure that is easier for women than a vasectomy is for a man. For a vasectomy, an incision is made under local anesthesia into the scrotum and the vas deferens, the tube that transports sperm is cut. With the Essure procedure, women can have permanent sterilization in their Ob/Gyn office under a light anesthesia and without any “cutting’. Using a camera to look into the uterus, small metal devices are placed in the opening of each Fallopian tube. These will cause a natural scarring which will eventually block the tube and prevent pregnancy,. With this procedure, women avoid the hospital or surgicenter copayment, and can walk out of office, relatively pain free, minutes after the procedure.

Essure, like the older female sterilization procedures, is permanent and for women who are sure that they never ever want to get pregnant again. It doesn’t affect their periods or their hormones either. However, some women who use hormonal methods for birth control prior to sterilization notice that their “natural” periods are heavier when they go off of the pill, IUD or shot and lose that benefit. For women that don’t ever want to worry about birth control again, Essure is a wonderful option. A 10 minute office procedure provides permanent contraception and is incision- free.

Is there a down side to Essure? It does require being on a back up method of birth control for 3 months after the procedure, while the device is scarring into the Fallopian tubes and causing the permanent blockage that will prevent pregnancy. This is still less than the waiting period after a vasectomy.

If you are considering a permanent birth control solution to prevent pregnancy and tired of waiting for your husband to do the task, please contact my Mesa Ob/Gyn practice to schedule an appointment.

If a pregnancy is full term at 37 weeks, why can’t I be induced?

October 21, 2011 by Dr. Tamar K. Gottfried Leave a Comment

Although pregnancies are considered to be full term after 37 weeks, there are advantages to waiting until 39 weeks to deliver. Pregnancies are dated from the mom’s last menstrual period, not from the date of conception. Full term pregnancy is a range rather than a date, with 37-41 weeks considered to be full term.

There has been a lot of press lately about the ideal time to electively deliver a baby. Recent recommendations from the March of Dimes and the American College of Obstetrics and Gynecology take into account the fact that babies are healthier if they are born after 39 weeks. Babies born from 35-38 weeks, considered near- term, have more problems with feeding, maintaining their temperature and other factors than babies born after 39 weeks. They are also more likely to spend time in the Neonatal Intensive Care Unit and not go home from the hospital with their mothers.

Banner Health Care, based in Arizona and including Banner Desert Medical Center in Mesa Arizona, has been leading the way in the movement to only electively deliver babies after 39 weeks. This new policy only applies to elective (non medical) deliveries- not to medically indicated ones. For example, if a mother has high blood pressure, or if the fluid around the baby is low, or if her water breaks and her labor needs to be induced or if she’s in labor, she will be delivered even if she is not 39 weeks along. On the other hand, if a mom is planning a repeat cesarean delivery, or wants to deliver on a specific day, or is simply tired of being pregnant, that will have to wait until she is 39 weeks. This policy ensures that that babies are born at the safest time for them and their mothers.

Tamar Gottfried is a Board Certified Obstetrician/ gynecologist practicing general Ob/gyn in Mesa Arizona and affiliated with Banner Desert and Banner Gateway Medical Centers. She can be contacted at 480-545-0059 . This is a general interest article only and is not intended to be medical advice. See a medical professional before making medical decisions

When is vaginal discharge abnormal?

October 20, 2011 by Dr. Tamar K. Gottfried Leave a Comment

For many women, vaginal discharge is a common occurrence. It can be difficult to know which discharge is normal and which needs medical attention. Many women try to diagnose themselves, based either on their prior experience or on over the counter tests. However, more than half of women who self diagnose a yeast infection are incorrect in their diagnosis. Additionally, the otc tests, which rely on the pH or acid/base balance of the vagina can be difficult to read and interpret. Results can be confused by other factors as well.

A general rule with vaginal discharge is that it should not be smelly or cause itching or irritation. A discharge that has an unpleasant or fishy odor, and/or is bubbly or frothy could be Bacterial Vaginosis, an upset in the chemical balance of the vagina, which requires prescription antibiotics to treat. An extremely bad smelling discharge can also be a sexually transmitted infection such as Trichomonas, Chlamydia or Gonorrhea. If a discharge causes itching or burning, it could be any of the above. It could also be yeast or even an allergic reaction. While many yeast infections have the typical curdy white thick discharge, some present with other symptoms and can be more challenging to diagnose.

In an Ob Gyn office, the diagnosis of vaginal infection is made not only by examining the discharge, but usually by doing a confirmatory lab test that can detect even low levels of bacteria or fungus. These tests take at least 24 hours for the result to come in and then, if positive for infection, a prescription can be called in to the pharmacy if needed.

Sometimes a vaginal discharge is examined and the tests do not confirm an infection. A mucousy/ slimy clear discharge can actually be normal since the vagina cleanses itself by producing discharge. Some people produce more discharge than others do due to factors such as medications, the use of an IUD (intrauterine device) or changes in the menstrual cycle.

In conclusion, there are a wide variety of vaginal discharges, some normal and some not. The best way to distinguish which is which is a trip to the Gynecologist for an exam and testing. While over the counter tests and creams can seem to be time savers, their use sometimes delays making the correct diagnosis and getting the correct treatment for a vaginal infection.

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