Pap Smear

Many women go to their physician yearly for their annual exam but may be unclear exactly what is getting tested or screened during their exam.  Most annual exams include a pap smear.  A pap smear is a scraping of the cervix (the lowermost portion of the uterus).  The pap smear is screening for cervical cancer.  A pathologist looks at the cells obtained from the scraping of the cervix and determines if the cells look normal, look atypical or look dysplastic.  Atypical cells are abnormal but not necessarily considered pre-cancerous.  Dysplastic cells are considered pre-cancerous lesions.  A pap test does not screen for uterine or ovarian cancer.  Unfortunately, there are not any screening tests currently available for these types of cancers.  A physician usually feels the uterus and ovaries during the annual exam to see if there are any masses that would be concerning for cancer. 
Current recommendations for pap smear screening are beginning screening at the age of 21, screening every 2 years between the age of 21 and 30, and every 3 years after the age of 30 if the patient's last 3 pap tests have been negative.  A patient may need more frequent testing if she has a history of HIV, or immunocomprised.   If the pap smear shows atypical cells, a test for the presence of the human papilloma virus will be performed. The human papilloma virus is the main cause of cervical cancer.  If the virus is present, further testing for cancerous cells will need to be performed which is called a colposcopy.  This test involves looking closely at the cervix with a microscope during a pelvic exam.  If abnormal cells appear under the microscope, a biopsy of the cells will be taken to evaluate for pre-cancerous or cancerous lesions.  If the pap smear shows dysplastic cells, a colposcopy is needed as well.
Please look at the following link for more detailed information:

http://www.acog.org/Resources_And_Publications/Practice_Bulletins/Committee_on_Practice_Bulletins_--_Gynecology/Cervical_Cytology_Screening

Breast pain

Breast pain is a common and concerning symptom in women.  Breast pain can either be cyclical and associated with hormonal changes or noncyclical and constant.  Cylical breast pain associated with hormonal changes tends to be bilaterally (both breasts) and tends to feel heavy, achy, and full.  Noncyclical breast pain tends to be one sided and can be more sharp or stinging.  Causes of noncyclical, one sided breast pain can be a cyst, infection, trauma, pain in the underlying ribs, or nerve disease.  In women being evaluated for breast pain, cancer is the cause in only 1-6% of the patients. 
If a women has breast pain that is cyclical or noncylical, clinical evaluation by her physician is recommended.  The physician will determine if the pain is associated with hormonal changes.  The physician will determine if the pain is one sided or not, is associated with a specific mass, and if there is any associated causes of the pain.  After determing the answers to these question, the physician will perform a careful exam to evaluate for any nodule or cyst in the breast that could be the cause of breast pain. 
If a woman has a normal breast exam and pain that is cyclical in nature, a physician can reassure the patient that the pain is most likely hormonal in nature.  However, if the pain persists for longer than 3-6 months or if the patient notices any masses, it is important to follow up with one's physician for an additional examination.
If a woman has noncyclical breast pain, an examination by one's physician and an imaging study is recommended.  If a woman is under the age of 35, an ultrasound may be the best choice because the density of women's breasts under the age of  35 which make mammograms less useful.  If she is over 35, a mammogram would be recommend.  If there are any abnormalities found on the imaging studies, biopsy is recommend either by a breast surgeon or radiologist. 
If the imaging studies or breast biopsies turn out normal, treatment for breast pain include wearing a well supported and fitted bra, and pain reliever medication such as ibuprofen or acetominophen.  Some studies suggest that caffeine avoidance and use of vitamin E or evening primrose oil is helpful.  Other studies suggest these things do not help.
It is important to discuss any breast pain or concerns with your physician.
Please look at the following link for more info:
http://www.uptodate.com/contents/patient-information-common-breast-problems?source=see_link

Placenta previa

Abnormal placenta locations during pregnancy can be a serious complication during pregnancy.  Placenta previa is associated with bleeding during pregnancy and can cause significant and life threatening bleeding.  There are three types of placenta previa-total, partial, or marginal.  In total placenta previa, the placenta completely covers the cervical os (opening),  whereas in partial placenta previa, only a portion of the cervix is covered.  In a marginal placenta, the placenta does not cover the cervix but is nearby the opening and may cause bleeding during contractions.
Placenta previa occurs in about 1 in 200 pregnancies and occurrs more often in women greater than 35 years, African American women, women who have been previously pregnant, women who smoke, women who live at higher altitude, or in women with a previous cesarean section. 
Approximately 5-15% of women will be diagnosed with a placenta previa at their 20 week anatomy scan.  90% of these women will have a normal placental location at term.  This is due to the lower aspect of the uterus growing during pregnancy which will then cause the edge of the placenta to move farther away from the cervix.
The clinical symptoms of placenta previa are painless bleeding.  This bleeding can range from spotting to hemorrhage requiring emergent surgery and delivery, although this is rare.  One third of women with a previa experience bleeding before 30 weeks gestation, 1/3 experience bleeding between 30-35 weeks gestation, and 1/3 experience bleeding after 35 weeks gestation.  If a women does experience bleeding, it is imperative for them to contact their physician for examination.  If a women is remote from term (37 weeks), their bleeding is stabilized and they may receive a blood transfusion.  If a women is at term, delivery is recommended.
Conditions associated with placenta previa that adversely affect the pregnancy include poor fetal growth, preterm contraction or rupture of membranes, abnormal presentation of the fetus (ie breech), and placenta accreta.  Placenta accreta is a serious complication of pregnancy in which the placenta invades the uterus.  Approximately 2/3 of women with a placenta accreta will need a hysterectomy at the time of delivery secondary to the significant bleeding associated with an accreta. 
Depending on a woman's amount of bleeding due to the previa, she may be placed on activity restrictions including no heavy lifting, no intercourse, or even modified bed rest. 
Placenta previa is a serious complication in pregnancy but most women can be safely managed by their obstetrician to result in a term or near term delivery.

Breech presentation in pregnancy

Breech presentation at term (fetus is bottom first or feet first) occurs in less than 5% of pregnancies.  There are numerous causes of breech presention such as an abnormally shaped uterus (ie heart shaped), low amniotic fluid, high amniotic fluid, abnormal placenta placement, uterine fibroids, uterine scarring, fetal malformations, and decreased fetal mobility.  Random chance plays a signficant factor as well.
Most fetuses settle into their final position in the uterus around 34 weeks although certainly fetuses may switch positions even at 40 weeks or beyond.  If one is diagnosed with a breech fetus after 34 weeks,  management options include trying to turn the fetus to cephalic or head down position, scheduling a planned cesarean section, or attempting a vaginal breech delivery. 
External cephalic version is a procedure that an obstetrician will perform in the labor suite to attempt a change in the fetus's position.  A fetus is monitored via fetal heart rate monitoring usually for one half hour.  An ultrasound is performed to verify that adequate amniotic fluid is present.  An obstetrician will then push on the fetus through the maternal abdominal wall to attempt the fetus to "somersault" into position.  The success rate is variable and depends again on the factors that caused the breech position in the first place.  Risks associated with the procedure are infrequent (less than 5% of the time) but including fetal heart rate deceleration, placental abruption, rupture of amniotic membranes and stillbirth.  A fetus is monitored via fetal heart rate monitoring after the procedure as well.
Recent clinical trials have shown that fetuses born via cesarean delivery due to breech presentation instead of vaginal delivery tend to have decreased morbidity (illness or injury) or mortality (death).  This is because when a fetus is born via vaginal delivery in the breech presentation, the umbilical cord is more likely to get compressed, thereby decreasing the blood flow to the fetus.  The fetal head is also more likely to become stuck in the birth canal.  Most fetuses in breech presentation that do not convert to cephalic presentation after an attempted external cephalic version are born via cesarean section.
Some women choose to have a vaginal breech delivery which may be acceptable as long as they understand the above risks and are at a hospital where obstetricians are skilled in breech deliveries. For more information, please look at the following links:
http://www.ncbi.nlm.nih.gov/pubmed?term=11052579
http://www.acog.org/~/media/F65E95C3644349F1AEFABBB8B560CBE5.ashx

Twin pregnancies

Twin pregnancies are becoming increasingly more common in Amercia secondary to women choosing to have children at a later age and the increased use of assisted reproductive technology to aid in achieving pregnancy.  Twins are either monozygotic (one egg fertilized by one sperm splitting into two eggs) or dizygotic (two eggs fertililzed by two different sperm).  Monozygotic twins are identical genetically where dizygotic are different genetically.  The frequency of dizygotic twins increase as a woman ages and has more children.
Twin pregnancies have more risks associated with them and require increased monitoring.  Twins have an increased risk for intrauterine growth restricion(small baby), premature delivery, congenital birth defects, abnormal placental development and stillbirth.  Because of these risks, a woman who has a twin pregnancy will need frequent doctor visits, ultrasounds and prenatal testing.
When a woman is diagnosed with a twin pregnancy, it is important to determine by ultrasound whether the twins have two placentas and two sacs, one placenta and two sacs, or one placenta and one sac.  The risks of the above mentioned complications are more common in pregnancies with one placenta and one sac.
It is also important to consider genetic testing for chromosomal abnormalities in twin pregnancies.  A woman has a double risk of chromosomal abnormalities with twins secondary to having two fetuses instead of one.  Screening tests include a first trimester ultrasound and blood test. Invasive diagnositic testing is also available in the first trimester by chorionic villus sampling.  (Please see my previous post on genetic screening in pregnancy for more detail regarding these tests and procedures). 
It is important for a woman with twins to obtain a detailed anatomy ultrasound of the fetuses between 18-22 weeks.  As twins have an increased risk of congential birth defects, it is important to try to detect these during this ultrasound.
As a woman progresses further in pregnancy it is important to monitor the fetal growth by ultrasound.  Twins tend to grow at the same rate of single pregnancies until 32 weeks and then have slower growth.  Twins can also have vascular connections in their placenta which enable one twin to grow larger than another.  It is important to monitor this because if one twin is larger than another by greater than 10 % weight, the smaller twin has an increased risk of stillbirth. 
It is also important to monitor the fetal well being during pregnancy by antepartum testing.  This involves monitoring the fetuses heart rate for approximately 30 minutes twice per week and checking the amniotic fluid once per week.  This testing reveals whether the uterus is still a good environment for the fetuses allowing them to grow and obtain adequate blood flow.  This testing will usually begin at 32 weeks and continue until delivery.
A woman has increased risk of medical complications associated with twin gestation as well.  She is more likely to develop gestational diabetes or pre-eclampsia (elevated blood pressure in pregnancy).  It is important to have regular doctor visits to monitor for these symptoms.
The average age for twin delivery is 35 weeks.  This delivery age would change depending on what type of twin gestation a woman has.  The route of delivery (vaginal versus cesarean) depends on a number of factors.  For a twin pregnancy consisting of one sac and one placenta, the optimal route of delivery will always be cesarean delivery usually around 32 weeks.  For twins with two sacs and one placenta, optimal delivery is usually between 36-37 weeks gestation.  The route of delivery depends on the presentation of the fetuses.  If both fetusus are vertex (head down), vaginal delivery is recommended.  If the first fetus is breech (bottom or feet down) cesarean delivery is recommended.  If the first fetus is vertex and the second fetus is breech, vaginal delivery is possible as long as the second fetus is not greater than 20 % of the first fetus's weight.  For twins with two sacs and two placentas, delivery is usually recommended at 38 weeks.  The route of delivery depends on the same factors listed above.
It is important to be under an obstetrician's care during pregnancy to facilitate the best pregnancy outcome possible.  Please read further for more info:
http://www.acog.org/~/media/For%20Patients/faq092.ashx

Body changes in the first trimester of pregnancy

A woman's body goes under significant changes during pregnancy due to hormonal changes and the growth of the fetus.  These changes can cause concern if it is your first pregnancy.  This post will discuss normal changes in the first trimester of pregnancy.
A woman's threshold signal for thirst is altered causing a woman to drink more often which in turn causes a woman to need to urinate more often.  The change in thirst occurs to increase a woman's total volume of water in her body.  This increase allows a woman to increase her blood volume as well as contribute to the fluid content in the placenta and the amniotic fluid. 
A woman's appetite will increase during the first trimester in general, depending on how nauseated they feel.  A recommended amount of increased calories per day is 300 calories per day throughout the pregnancy.
Nausea and vomiting affect approximately 70 % of pregnancies.  It usually begins during the 4-8th week of pregnancy and usually stops by the 14-16th week.  Eating small meals frequently, ginger supplements, vitamin B6 or accupuncture wrist bands may be helpful.  There are also anti-nausea medication for women with more severe symptoms.
Constipation or diarrhea are also common in the first trimester which likely due to changes in the motility of the small intestines and large intestines. 
Breast changes associated with early pregnancy include tenderness and tingling sensations.  This occurs beginning the 4th week throught the 8th week.  The breasts continue to enlarge throughout pregnancy to prepare for lactation.  The nipples and the areola also enlarge.
Skin changes also occur during pregnancy.  Women may notice increaed acne which is due to the changes in hormones.  A woman may also noticed increased pigmentation (or darkening of the skin) during pregnancy.  This will usually resolve after delivery but may persist for some women.
A woman will also notice fatigue during pregnancy, especially the first trimester.  This usually improves during the second trimester but may redevelop during the third trimester.
Changes or symptoms that may occur during the first trimester that should prompt contact with your physician include vaginal bleeding, cramping, or severe nausea with an inability to maintain food intake.
I try to encourage my patients to hang in there through the first trimester.  Most patients will feel much better during the second trimester!

Infertily Evaluation

Infertily can be a frustrating and nerve wracking experience for couples.  Most couple will conceive within one year of attempting pregnancy.  Approximately 70% of couples conceive within the first 6 months and 85-90% by 12 months.  However, 10-15% of couples have not conceived after one year of unprotected intercourse.  A couple may choose to pursue evaluation at any point in their attempts at conception.  Most physicians recommend evaluation after one year of trying; however, a couple may want to present for earlier evaluation depending on their age. 
The three main causes of infertility include ovulation dysfunction or anovulation(no ovulation occurring), fallopian tube scarring or disease, and sperm abnormalities.  An evaluation by a physician for infertility will focus on a careful history and physical examination.  A physician will want to know if a patient is having regular menstrual cycles which indicate regular ovulation.  For a patient with irregular menstrual cycles, it is possibile that a low frequency of ovulation is occurring which would contribute to infertility.  A physician will also want to know if a patient has a history of sexually transmitted diseases such as chlamydia.  A history of chlamydia can cause fallopian tube scarring which makes it difficult or impossible for the egg to enter the uterine cavity.  A physician will also want to know if a couple has had a previous pregnancy together or if the partner has fathered any other pregnancies.  It is also important to know if a patient has had any previous surgeries on her cervix or in her uterus that could be affecting the sperm's ability to enter the uterus or a fertilized egg's ability to implant in the uterus. 
Initial diagnostic testing for infertility include male partner semen analysis.  Sperm abnormalities account for 35 % of infertility cases.  A semen anlaysis is simple to perform.  A man provides an ejaculate sample to the lab within 30 minutes of ejaculation.  A man should refrain from intercourse or ejaculation for 48 hours prior to the test.  The semen analysis will evaluate for total sperm count, sperm motility (number of sperm moving), sperm morphology (number of sperm shaped normally), and progressive motility (sperm moving in the forward direction). Abnormalities in these areas can contribute to infertility.  If abnormalities are found, a second semen analysis is usually performed to verify the test.  If the abnormalities persist, a man is usually referred to a urologist for evaluation of the cause of sperm abnormalities.
Other diagnostic testing for infertility include testing for ovulatory function.  This can be done by evaluating a patient's menstrual calendar, testing a woman's basal body temperature and tracking it throughout her cycle, testing progesterone levels in the blood, or testing a woman't urine for luteinizing hormone(the hormone which signals the ovary to release an egg).  For women who are menstruating at regular intervals, having cycles in similar length and experiencing premenstrual and menstrual symptoms usually confirms ovulation.  A woman whose basal body temperature rises consistently is also likely ovulating.  A blood progesterone level can be checked usually one week after ovulation, and if elevated, indicates ovulation has occurred.  The "ovulation indicator kit" will generally become positive one day before ovulation occurs.  This kit is testing a woman's urine for luteinizing hormone. A woman should use this kit daily approximately 2-3 days prior to the expected day of ovulation.  Ovulation dysfunction affects approximately 15 % of couples experiencing infertility.
Fallopian tube abnormalities are a common cause of infertility and occur in 30-35% of infertile couples.  Abnormalities may be due to previous infection, ectopic pregnancies, or surgeries on the fallopian tube.  Endometriosis can also cause fallopian tube scarring.  To evaluate for fallopian tube abnormalities a physician may choose a radiologic test called a hysterosalpingram.  This test involves injecting fluorescent dye into the uterine cavity and evaluating the dye as it moves through the fallopian tubes.  The test is usually performed 2-5 days after the last day of menses.  Another testing option would be laparoscopy (minimally invasive surgery) to directly evaluate the fallopian tubes as dye is injected into the uterus.  This allows a thorough evaluation of the pelvic organs.
Further resources regarding infertility evaluation include:
http://www.uptodate.com/contents/patient-information-evaluation-of-the-infertile-couple?source=see_link
http://www.acog.org/~/media/For%20Patients/faq136.ashx
http://www.reproductivefacts.org/