When it comes to female infertility, one of the most common causes is polycystic ovary syndrome (PCOS), which can prevent women from ovulating. The good news is that there are ways to spur ovulation in women with PCOS, and achieve a healthy pregnancy and baby.

Dr. Jackie Gutmann, a reproductive endocrinologist at Reproductive Medicine Associates of Philadelphia and Central Pennsylvania, see patients with PCOS and helps them start their families. She answered some of our questions about PCOS.

What is PCOS?
Reproductive hormones are abnormally regulated in women with PCOS. In a perfect world, the hypothalamus, pituitary gland and ovaries all work together each month to grow follicles, stimulate one of them and release one egg from that stimulated follicle. In women with PCOS, several follicles are stimulated but none mature enough to ovulate, so there is no release of an egg and no chance to get pregnant.

Why do some women get PCOS and others don’t?
We know genetics play a large role in who develops PCOS – first degree relatives of women with PCOS (mothers and sisters) have up to a 30-50 percent chance of developing the condition. There are also others theories about the cause of PCOS, such as the effect of the in-utero environment on the risk of developing PCOS later in life.

What are the symptoms of PCOS?

• Irregular periods or a loss of menstruation entirely
• Acne and abnormal hair growth (on the face, chest, or abdomen)
• Obesity, difficulty losing or maintaining weight, and type 2 diabetes
• Infertility
• Anxiety, depression and eating disorders

How is PCOS diagnosed?

Because irregular cycles are a common symptom of PCOS, a doctor will ask about a woman’s menstrual cycle history and look for symptoms like acne, hair growth or difficulty losing weight. During a physical exam, the woman’s vital signs, including height, weight and a calculation of Body Mass Index (BMI) are important to determine. A transvaginal ultrasound will help doctors see whether the patient has ovarian features of PCOS. Then, the doctor will take blood tests to examine her levels of FSH, LH, estrogen, testosterone, AMH and to screen for insulin resistance.

How is PCOS treated in women who want to conceive?

The first line of treatment for women with PCOS is lifestyle modification. Modest weight loss and increase in lean muscle mass can have huge impacts on the abnormal hormone regulation seen in women with PCOS. For many women trying to conceive, medications are needed. The goal of treatment is to correct ovulation. A woman may be prescribed Clomid, an ovulation inducing medication that indirectly promotes the production of FSH and the growth and release of a mature egg. Another medication commonly used to induce ovulation in women with PCOS is Letrozole. After ovulation is induced with Clomid or Letrozole, the doctor may recommend timed intercourse or intrauterine insemination (IUI). In vitro fertilization (IVF) is another excellent treatment for women with PCOS and has superior success rates.

Breastfeeding has many benefits to both mother and child, benefits that have been well studied and consistently shown for decades. Babies who are breastfed have lower rates of respiratory illnesses, gastrointestinal and ear infections, as well as lower rates of allergies, SIDS, diabetes and many other illnesses that can impact their life-long health. Breastfeeding mothers also experience health benefits, from decreased postpartum bleeding and depression to long term decreases in diabetes and breast cancer.

While infant formula has been improved over the years and offers an alternative for women who are unable or choose not to breastfeed, even in the best circumstances it has disadvantages. Formula is expensive and can cost families several thousand dollars a year in direct costs. Increased illnesses in formula fed babies also result in higher healthcare costs and loss of wages for parents who have to miss work to take care of their child. By increasing breastfeeding to optimal rates in the US, up to $13 billion a year could be saved on these indirect costs, according to analyses by the U.S. Department of Agriculture, Food Assistance and Nutrition Research. As a result of the importance of health and economic benefits, the American Academy of Pediatrics urges that breastfeeding be viewed as “a public health issue and not only a lifestyle choice”.

The impact of formula feeding on poor and developing countries can be even more profound than what is seen in the United States. Many women in these countries are malnourished and falsely believe they would be unable to produce milk with adequate nutrition for their children. Aggressive marketing by the formula industry, a multi-billion dollar industry, often focuses on poor areas and promotes this and other inaccurate information about the benefits of formula. This misinformation can be particularly dangerous as many of these women do not have access to clean water to mix with the formula, resulting in higher rates of water-borne illnesses in these areas. Due to the high cost, many women end up diluting the formula to extend its use, which also results in higher rates of illness and even death. A 2016 series in The Lancet journal estimated that worldwide 800,000 formula-fed infants a year could be saved by breastfeeding, mostly due to reducing rates of diarrhea, respiratory infections and malnutrition from formula dilution.

In 1981, the World Health Organization voted 118 to 1 adopt a non-binding resolution promoting the dissemination of accurate information on breastfeeding worldwide, as well as restrictions on inaccurate formula advertising and direct marketing and kickbacks to health providers. 130 countries have adopted the ban on the promotion of formula, and in countries where these laws are enforced, such as Brazil, the rates of breastfeeding are typically higher than those that do not. During the World Health Assembly (WHA) each year, this resolution has been reaffirmed and in 2016, the United States, under Obama, supported strengthening the resolution. Despite these efforts, in the past year alone, more than 800 violations of these practices have been noted by formula companies around the world. Funding for formula industry lobbyists has also remained high, with one company, Abbott Pharmaceuticals (makers of Similac and other formulas), spending more than $790,000 on lobbying efforts, including contributions to President Trump’s inauguration ceremonies. In the most recent WHA, our president sided with the formula industry in trying to oppose the existing regulations that would limit the negative effects of inaccurate formula advertising and direct marketing to healthcare providers. The US administration went as far as threatening the US contribution to funding for WHO to oppose this resolution.

Whether or not to breastfeed is a decision that each woman needs to make for herself and her family. Providing accurate information on options, as well as support for the challenges that new mothers will experience is the best way to optimize the health of future generations.

What is the ThermiVa®?

ThermiVa® is a non-surgical, safe and effective procedure that uses radiofrequency heat to tighten loose, sagging skin and increase blood flow and nerve sensitivity in the vaginal area.

What are the benefits of the ThermiVa®?

• Vaginal and labial laxity
• Vaginal dryness
• Urinary incontinence and overactive bladder
• Painful sex 

How is it performed?

During the procedure, a small wand is slowly moved over the areas of concern, gradually heating the tissue.  The procedure takes less than an hour, during which most women report feeling only a warm sensation and no pain.  There is no down time once completed, women can return to exercise and sexual activity immediately.

What is the O-Shot®?

The O-Shot® is a non-surgical, minimally invasive procedure that can help improve a woman’s sexual desire and orgasm, decrease urinary incontinence and treat a chronic skin condition called lichen sclerosus.   Up to half of women experience low sexual desire and many others experience issues with arousal, lubrication and orgasm.  The O-Shot® uses platelet-rich plasma (PRP) that contains growth factors from the woman’s own blood, and is injected into the clitoris and vaginal wall.  This increases the blood flow, nerve sensitivity and collagen formation in the area, leading to improved sexual function.

What are the benefits of the O-Shot®?

This injection can increase a woman’s sexual desire and arousal, as well as improve the number or quality of her orgasms.  In addition, this procedure can help with

• Leaking urine
• Painful sex
• Vaginal dryness
• Decrease symptoms and long-term consequences of lichen sclerosus

How is it performed?

Blood is drawn from the patient and then using a special double-spin process the red blood cells are removed, leaving the plasma which is full of growth factors.  Numbing cream is then placed onto the areas that will be injected, and a lidocaine injection is performed to ensure there is minimal to no discomfort during the procedure.  The PRP is then injected into the clitoris and vaginal wall.  The procedure takes less than an hour.

If you would like to learn more about these procedures, schedule a consultation with one of our Women’s Health providers.

June is post-traumatic stress disorder (PTSD) awareness month.

PTSD is a severe, potentially chronic and disabling disorder that develops in some persons following exposure to a traumatic event involving actual or threatened death, serious injury, or sexual assault. Some common symptoms include intrusive thoughts, nightmares and flashbacks of traumatic events, avoidance of trauma reminders, hypervigilance, and sleep disturbance. These symptoms can be highly distressing and substantially impair social, occupational, and interpersonal functioning. The intensely distressing and impairing symptoms of traumatic stress are highly prevalent immediately following traumatic exposure and dissipate over the following days and weeks in most people. Persistence beyond one-month post-trauma suggests PTSD [1].

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition stipulates that for an individual to be diagnosed with posttraumatic stress disorder, he or she must have experienced or witnessed a life-threatening event and reacted with intense fear, helplessness, or horror. The traumatic event is persistently reexperienced (e.g., distressing recollections), there is persistent avoidance of stimuli associated with the trauma, and the victim experiences some form of hyperarousal (e.g., exaggerated startle response). These symptoms persist for more than one month and cause clinically significant impairment in daily functioning. When the disturbance lasts a minimum of two days and as long as four weeks from the traumatic event, Acute Stress Disorder may be a more accurate diagnosis.

The prevalence of PTSD in the U.S. population is approximately 8%, with incidence as high as 17% in primary care patients. PTSD can become chronic in as many as 40% of cases [2]. 50% of women in the United States have experienced a traumatic event, with the majority reporting trauma exposure also reporting two or more traumatic events. The National Comorbidity Survey Replication estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%. Current past year PTSD prevalence was estimated at 3.5%. The lifetime prevalence of PTSD among men was 3.6% and among women was 9.7%. The twelve-month prevalence was 1.8% among men and 5.2% among women. However, PTSD only develops in 10% of those exposed to trauma, a finding that has prompted intense research efforts in identifying risk factors and early intervention to prevent or reduce the development of PTSD [2]. Populations at risk for PTSD include refugee victims of torture, combat veterans, persons released from incarceration, victims of sexual assault, and adults who endured repeated sexual or physical abuse as children http://phoenixaustralia.org/wp-content/uploads/2015/03/Phoenix-ASD-PTSD”>[4].

Explanatory models of PTSD have been proposed to better understand psychotraumatization processes and PTSD. [5] These perspective models include:

1. Disease/Illness Perspective [6-11]-

2. Dimensional Perspective

3. Cognitive-Axiologic Perspective [12,13][6]

4. Behavioral Perspective [6]

5. Spiritual/Transcendental Perspective [14]

6. The Narrative Perspective [15]

PTSD is viewed as a maladaptive response to a traumatic stressor, characterized by altered fear-related learning (fear conditioning) and extinction, behavioral sensitization and kindling, and alterations in brain regions and neurotransmitter systems closely linked to these processes. The hypothalamic-pituitary-adrenal (HPA) axis is the primary system activated as a stress response and a potential source of vulnerability to trauma-related psychopathology such as PTSD. Normal response to stress exposure initiates a neuroendocrine cascade in the HPA axis, leading to adrenal gland hypersecretion of the glucocorticoid cortisol. HPA axis activity is tightly controlled through complex regulatory mechanisms of glucocorticoid negative feedback. Glucocorticoids regulate the secretion of hypothalamic corticotropin-releasing factor (CRF) and pituitary adrenocorticotropic hormone. HPA axis activity is also regulated by glucocorticoid receptors (GRs) in the hippocampus and prefrontal cortex [[16,17] HPA stress response pathways are intimately linked with neurotransmitter systems and key brain regions in PTSD. The neural circuitry that mediates fear memory involves complex interactions among three brain centers: the hippocampus, involved in short-term memory and contextual fear; the amygdala, involved in conditioned fear response; and the medial prefrontal cortex, which mediates suppression of subcortical (e.g., amygdala, hippocampus) responses. Several neurotransmitter systems serve as chemical messengers in this neurocircuit. Alterations in these transmitter systems reflect a dysregulated stress response and substantially impact conditioned fear response and the consolidation and retrieval of traumatic memories [18,19].

Treatment of PTSD is aimed at interfering with this persistence of traumatic memories. The treatments of PTSD are varied and diverse including:

1 Psychosocial

2 Rehabilitation

3 Somatic and Alternative Therapy

4 Pharmacotherapy

In 2002 Marsicano found that the CB1 receptors in the amygdala are required for the extinction of fear memories [20]. A further study by Hillard in 2015 showed that following chronic stress signaling in the endocannabinoid system (ECS) is downregulated [21]. This downregulation impaired reversal learning (the ability to be trained differently to two stimuli based on reward or punishment response) in mice and as anticipated induced perservatory behaviors. The study also found that the effects of chronic stress were reversed when an exogenous CB1 agonist was applied. Hill found Reductions in circulating endocannabinoid levels in individuals with post-traumatic stress disorder following exposure to the World Trade Center attacks [22]. These studies showed that there may be a scientific rational behind the use of marijuana by veterans to reduce PTSD. Medical marijuana has been shown to be an effective adjuvant in the treatment of PTSD. It may even be possible to treat PTSD without the side effects caused by THC.

If you think that you might have PTSD or would like to discuss the possibility of Cannabinoid therapy, please speak with me or your primary care physician.

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association Press; 2013.Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey.Arch Gen Psychiatry. 1995;52(12):1048-1060.

2. National Center for PTSD. How Common is PTSD? Available at https://www.ptsd.va.gov/public/PTSD-overview/basics/how-common-is-ptsd.asp. Last accessed February 16, 2018.

3. Phoenix Australian Centre for Posttraumatic Mental Health. Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder. Available at http://phoenixaustralia.org/wp-content/uploads/2015/03/Phoenix-ASD-PTSD-Guidelines.pdf. Last accessed February 16, 2018.

4. Jakovljević M, Brajković L, Jakšić N, Lončar M, Aukst-Margetić B, Lasić D. Posttraumatic stress disorders (PTSD) from different perspectives: a transdisciplinary integrative approach. Psychiatria Danub. 2012;24(3):246-255.21. McHugh PR, Slavney PR. The Perspectives of Psychiatry. 2nd ed. Baltimore, MD: John Hopkins University Press; 1998.

5. 22. Tyrer P, Steinberg D. Models for Mental Disorders: Conceptual Models in Psychiatry. 3rd ed. Chichester: John Wiley & Sons; 1998.

6. 23. Summerfield D. Cross-cultural perspective on the medicalization of human suffering. In: Rosen GM (ed). Posttraumatic Stress Disorder: Issues and Controversies. Chichester: John Wiley & Sons; 2005: 233-245.

7. 24. Frueh BC, Elhai JD, Kaloupek DG. Unresolved issues in the assessment of trauma exposure and posttraumatic reactions. In: Rosen GM (ed). Posttraumatic Stress Disorder: Issues and Controversies. Chichester: John Wiley & Sons; 2005: 63-84.

8. 25. Herbert JD, Sageman M. First do no harm: emerging guidelines for the treatment of posttraumatic reactions. In: Rosen GM (ed). Posttraumatic Stress Disorder: Issues and Controversies. Chichester: John Wiley & Sons; 2005: 213-232.

9. 26. Friedman MJ. PTSD and related disorders. In: Stein D, Friedman M, Blanco C (eds). Post-Traumatic Stress Disorder. 1st ed. Chichester: John Wiley & Sons; 2011.

10. 27. McNally RJ, Frueh BC. Why we should worry about malingering in the VA system: comment on Jackson et al. (2011). J Trauma Stress. 2012;25(4):454-456.

11. 28. McNally RJ. Conceptual problems with the DSM-IV criteria for posttraumatic stress disorder. In: Rosen GM (ed). Posttraumatic Stress Disorder: Issues and Controversies. Chichester: John Wiley & Sons; 2005.

12. 29. Reivich KJ, Seligman MEP, McBride S. Master resilience training in the U.S. Army. Am Psychol. 2011;66(1):25-34.

13. 30. Maguen S, Litz B. Moral injury in veterans of war. PTSD Res Q. 2012;23(1):1-6.

14. 31. Amendolia RA. A Narrative Constructivist Perspective of Treatment of PTSD with Ericksonian Hypnosis and EMDR. Available at http://www.aaets.org/article32.htm. Last accessed February 16, 2018.

15. Morris MC, Compas BE, Garber J. Relations among posttraumatic stress disorder, comorbid major depression, and HPA function: a systematic review and meta-analysis. Clin Psychol Rev. 2012;32(4):301-315.

16. George SA, Stout SA, Tan M, Knox D, Liberzon I. Early handling attenuates enhancement of glucocorticoid receptors in the prefrontal cortex in an animal model of post-traumatic stress disorder. Biol Mood Anxiety Disord. 2013;3(1):22.

17. Ressler KJ, Mayberg HS. Targeting abnormal neural circuits in mood and anxiety disorders: from the laboratory to the clinic.Nat Neurosci. 2007;10(9):1116-1124.

18. Rauch SL, Shin LM, Phelps EA. Neurocircuitry models of posttraumatic stress disorder and extinction: human neuroimaging research—past, present, and future. Biol Psychiatry. 2006;60:376-382.

19. Neumeister A, Corsi-Travali S, Green CR. The role of BDNF-TrkB signaling in the pathogenesis of PTSD. J Depress Anxiety. 2013;S4:006

20. G Marsicano, CT Wotjak, SC Azad, T Bisogno. The endogenous cannabinoid system controls extinction of aversive memories. -Nature volume 418, pages 530–534

21. Maria Morena, Sachin Patel, Jaideep S Bains & Matthew N Hill. Neurobiological Interactions Between Stress and the Endocannabinoid System. Neuropsychopharmacology volume41, pages80–102 (2016)

22. Hill MN1, Bierer LM, Makotkine I, Golier JA, Galea S, McEwen BS, Hillard CJ, Yehuda R. Reductions in circulating endocannabinoid levels in individuals with post-traumatic stress disorder following exposure to the World Trade Center attacks. Psychoneuroendocrinology. 2013 Dec;38(12):2952-61

23. George Fraser, M.D., F.R.C.P.C., The Use of a Synthetic Cannabinoid in the Management of Treatment‐Resistant Nightmares in Posttraumatic Stress Disorder (PTSD). CNS Neuroscience and Therapeutics. 2009 February 13; Volume15, Issue1 Pages 84-88

The sun is shining, the birds are chirping and spring has (finally!) arrived. This is the season of renewal, so what better time to clean up and refresh your health. Here are 5 easy ways to get started today!

1) Get outside!

These warmer temperatures are just calling for a walk at lunchtime, a run down the Schuylkill River Trail, or a picnic in Rittenhouse Square. Though being active is important, just getting out into the fresh air can lead to greater happiness. Maybe give gardening a try. Even small city balconies can grow veggies in pots and containers and people who garden have reduced stress, get increased amounts of vitamin D and can have improved mental clarity. Plus, they tend to eat more fruits and veggies, which leads us to our next tip.

2) Clean up your diet

With fresh fruits and veggies more readily available this time of year, it is a great time to embrace “clean eating”. This means incorporating fresh, real, whole foods into the diet and limiting overly processed foods with long, indecipherable ingredient lists. Ways to achieve clean eating include: increasing your intake of fresh fruits and veggies, eating the least processed grains (such as quinoa, wild rice, steel cut oats), avoiding added/refined sugar and going light on meat products. Choosing grass-fed/pasture raised options when you do eat meat is overall better for your health and the health of the environment.

3) Clean out your medicine cabinet

You likely have medicines stored from old prescriptions that might be handy “someday”. This is a good time to get to work clearing out all of those medications that have outlived their use. Be sure to check expiration dates. Many meds lose efficacy after this date and some can become toxic. A good rule of thumb is to toss any prescription medicine that is over a year old. For safety and environmental reasons, it is best not to toss medications directly into the trash or down the toilet. Your local pharmacy, police station or DEA may provide opportunities to safely dispose of medications. If not readily available, you can place meds in a sealable bag (add water if pills or solid medications are present to dissolve them fully). Then add kitty litter, coffee grounds or saw dust to the bag. This makes the package less appealing to children and animals. Finally seal the bag and place in the trash. Be sure to remove all labels of medication bottles that are thrown away.

4) Clean out your makeup bag

I know you might be very attached to that perfect shade of lipstick you have had for years, but old makeup can carry bacteria that can lead to infection. Here are some guidelines on when to toss those products: eyeshadow:3-6 months, Blush/bronzer: up to 2 years, Lipstick: up to 1 year, Mascara: 3 months. Be sure to also clean your brushes and make up bag regularly.

5) Finally, if you have not done so already, make an appointment for your annual physical. At this appointment we can guide you with recommendations on diet and exercise and be sure you are up to date on all of your recommended screenings.

Happy spring, everyone!

Intrauterine devices (IUDs) have become an increasingly popular form of contraception in the US due to their convenience and effectiveness. However, the cost of these devices has been a barrier to some women. The Liletta is the first IUD created by a non-profit organization to provide a more affordable option that still has all the benefits of the more costly IUDs.

At Rittenhouse Women’s, we have decided to offer this IUD not only for the benefit to our patients, but also to the community. Liletta provides devices to the local health centers at almost no cost to help protect underprivileged and at-risk women from unintended pregnancy. We believe that better access to this device can improve lives and should be an option for all women.

Why choose the Liletta?

The Liletta is more than 99% effective at preventing pregnancy and can decrease the amount of bleeding and cramping you have with your periods. It is placed in the office in only a few minutes and can be removed at any time. Once removed, your ability to get pregnant returns right away. There is a low risk of complications during placement or significant side effects from the device. While newer than most other IUDS, Liletta has been evaluated in the largest IUD trial that has ever been conducted in the US. This study showed Liletta was also safe and effective for women who have never been pregnant before.

How does it work?

Liletta releases a small amount of progestin hormone in the uterus. This small amount of hormone thickens the mucus inside the cervix, which creates a barrier that sperm cannot penetrate. The progestin also may thin the uterine lining and slow movement of sperm through the fallopian tubes. Very little hormone gets into the blood stream, so most women continue to ovulate.

How long does it last?

Currently, Liletta is approved for 4 years of use, but can be removed any time sooner if desired. The device is currently being studied for longer use, and likely will get the 5 year approval in the near future. Ongoing studies are being performed and the device may be approved for up to 7 years in the future.

What are the risks and side effects?

The most common risk is expulsion, or the IUD falling out on its own and the Liletta has similar rates to other IUDs for this issue. Also similarly to other IUDs, there is a small risk of uterine perforation (making a hole in the uterus) during insertion. This risk is extremely low and is unlikely to cause long-term damage if it occurs. If you have an STI, such as gonorrhea or Chlamydia, during placement, there may be an increased risk of the infection going into the pelvis. However, once the IUD has been in for more than a month, it is likely the risk of pelvic inflammatory disease may actually decrease.

Most women will experience some spotting after placement, which can last up to 6 months or occasionally longer for some women. Some women will no longer have periods, which is a desired effect for some. Hormonal side effects are uncommon, but can occur.

There are many forms of contraception, including several options for long-acting reversible contraception we offer, so there is a good chance there will be an option that will work for you. It is important to discuss your medical history, periods, and experience with other forms of contraception in the past with your provider to find the right fit.

At Rittenhouse Internal Medicine, we recognize that the health care and medical insurance industries can be confusing to navigate for many of our patients. Our goal is to make the process of seeing a provider as smooth and as simple as possible. Part of that process is ensuring that you, our patients, are aware of the different appointment types that we offer so that the proper appointment is scheduled to fit your needs at a given time. We also recommend reviewing your insurance policy, so that you can be aware of how/if the different appointment types are covered ahead of time to avoid surprises (and large bills!).

“Annual Physicals”, also called “Routine Medical Exams”, “Health Maintenance Exams” or “General Checkups”, are preventive health exams that are typically covered by an insurance provider no more than once a year. The purpose of the annual physical is to is to review a patient’s health history, family history, and social habits, to make sure she is caught up on routine vaccinations and recommended age-appropriate health screenings such as colon cancer screening, cholesterol testing, mammograms, etc. It is also an opportunity for the provider to make specific recommendations that would reduce a patient’s risk of poor health outcomes down the road–such as advising an increase in certain types of exercise, or cutting back on the amount of alcohol a patient is drinking. The goal of this appointment type is to prevent disease by identifying factors in a patient’s history/lifestyle that could put their health in jeopardy if not addressed and modified.

The “Annual Gynecological Exam”, also called a “GYN Exam” or “Women’s Health Exam”, is another type of preventive visit. This type of appointment is also typically covered by insurance providers no more than once annually. It differs from the Annual Physical in its more narrow focus; the exam exclusively focuses on preventing adverse gynecological health outcomes. Items addressed in an annual gyn exam may include cervical cancer screening (the Pap smear), breast cancer screening, birth control/family planning, or preventing/screening for low bone mass.

All visits that do not fit into the above categories are classified as “Problem” visits. Most insurance companies do not put a limit on the number of problem visits that can be scheduled in a calendar year; but they typically will require you to pay a copay for each of these visits (even if the problems are addressed during a preventive visit–which we discourage, due to time constraints). Problem visits (which may be referred to as “Follow up visits”, “Sick visits” or “Annual medication checks”, depending on the reason for the appointment) are made to address one or more specific health issues or symptoms. Problem visits are not preventive health exams, and they are scheduled separately from preventive visits to allow adequate time for evaluation and management of the symptoms prompting the appointment. These may be new, acute symptoms–such as a sore throat, a new rash, or a vaginal discharge–or chronic issues, such as high blood pressure, depression, or managing thyroid medication. Additional testing or medication may be advised; these may or may not be covered by your insurance company (again, reviewing/knowing the details of your insurance plan coverage ahead of time is advised, as we are not privy to these details).

Hopefully this is a helpful guide to scheduling your next appointment with us; our call center staff is always available to help you schedule the correct appointment type if you have any questions or need further clarification.

As March is patient safety month we wanted to share a few ways we work to ensure patient safety in our practice!
Although we are just a little internal medicine office and not a huge hospital, there are still plenty of steps we take to try and keep our patients safe.

1) Employee Training: All of our employees receive various trainings on an annual basis. We provide our staff with training on HIPAA so that they become highly familiar with how to treat private health information. We also host a CPR training for our staff so that we always have employees who are able to provide emergency care. On an as needed basis, our MAs also receive refresher courses on best practice for venipuncture and any other procedures.

2) Processes: As a medical practice we have a few processes in place to ensure patient safety. All of our MA stations have label machines connected to our EMRs that allow our medical assistants to print legible labels for any laboratory samples collected at our practice. This is the best way to reduce any possibility of mislabeled specimens and potentially giving patients incorrect lab results. We also have specific sterilization processes for our different instruments – weather they need to be packaged or cleaned at a different temperature – these processes ensure that instruments we use in the office are not a source of infection for our patients.

3) Equipment: You may have noticed that we have gloves available in all of our exam rooms – gloves are an important barrier to keep our patients safe as well as keep our staff safe! We also have hand sanitizer available all over the building which is our go-to, especially during flu season!

4) Building Safety: There are a few safety measures we have taken to make our facility safer for patients also. Our entryway steps now have treads which makes them much easier to walk on in wet weather; the same goes for our carpeted staircase. During snowstorms, our staff regularly shovels and salts the sidewalk in front of our building and we try to mop our waiting room regularly also to get up any water that had been trekked in so that there are no slips in our waiting room.

Although a lot of these items may seem obvious, they all go a long way in ensuring the safety and well-being of our patients. We review these processes regularly and consider employee and patient input to find any problems or improvements that can be made. Please know that we are always doing our best not only to treat you but also to keep you safe physically and psychologically whenever you visit our practice. Thank you for being our patient and have a safe and happy March!

ThermiVa® is a non-surgical, safe and effective procedure that uses radiofrequency heat to tighten loose, sagging skin and increase blood flow and nerve sensitivity in the vaginal area. This procedure is used to treat many common vaginal complaints, including:

1· Vaginal and labial laxity

Stretching of the vaginal tissues and muscles is common after childbirth and can occur with normal aging. This can cause decreased sexual satisfaction, discomfort with exercise and bothersome urinary symptoms. The labia (external lips around vagina) also experience sagging over time, which can cause rubbing and irritation and cause many women to feel self-conscious. ThermiVa® can be used both internally and externally for these concerns. The heat applied during the procedure causes the tissues to contract and increases the amount of collagen in the area.

2· Vaginal dryness

Many medications, as well as the normal aging process can cause vaginal dryness for many women. This dryness often becomes severe after menopause or cancer treatments, causing daily discomfort and making sex painful. Without exposure to hormones, the ThermiVa® procedure increases blood flow in the area which increases vaginal moisture and lubrication during sexual activity.

3· Urinary incontinence and overactive bladder

Urinary complaints are common in women of all ages, most commonly incontinence (leaking urine) and overactive bladder. The radiofrequency applied to the vaginal tissues during the ThermiVa procedure can help tighten the tissue under the urethra, which decreases the rate of leaking with cough, sneeze or exercise. The procedure also increases nerve growth around the bladder, which can decrease bladder irritation that causes the urgency experienced in overactive bladder.

4· Painful sex

ThermiVa® helps reduce muscle spasms in the pelvic floor that are commonly a cause of pain with sex. Many women also report an improvement in their desire, arousal and ability to orgasm after the treatment. Due to the small probe size, most women report little to no discomfort during the procedure even if they are unable to tolerate penetration during sex due to pain.

How is it performed?

During the procedure, a small wand is slowly moved over the areas of concern, gradually heating the tissue. The procedure takes less than an hour, during which most women report feeling only a warm sensation and no pain. There is no down time once completed, women can return to exercise and sexual activity immediately. A total of three treatments, scheduled a month apart, are recommended for optimal results.

When will I see results?

While each woman’s experience may differ, many women notice a difference within hours to days after their first treatment. For some women it takes longer or multiple treatments. The effects of the treatments continue to improve for several weeks and lasts up to one year on average. A touchup session is often needed after a year to maintain the effect.

Is it safe?

Over 50,000 procedures have been performed with this technology worldwide, and no burns or significant adverse outcomes have been reported.

If you are dealing with any of these issues, you do not have to live with the discomfort any longer. Schedule a consultation with one of our Women’s Health providers to review your concerns, discuss alternative treatment options and determine if you may benefit from this procedure.

The start of the new year heralds the American Red Cross’s annual effort to raise awareness of the critical need for blood and blood products through the winter months. Blood donations typically go down during this period, due to illness of potential donors, cancellations of blood drives due to inclement weather, and other reasons. It is estimated that 38% of the US population is eligible to donate blood, but less than 10% of that eligible population donates, according to the Red Cross. National Blood Donor Awareness month aims to remind the public that the need for blood is real, and to motivate first-time and previous donors to give blood or support blood donation efforts in other ways.

Over 20 million blood products are transfused in the US annually; 40% of these products come from volunteer donors to the American Red Cross. Every 2 seconds, someone in the US needs blood, and an average transfusion requires 3 pints of blood. A victim of a car accident may need as many as 100 pints of blood! A typical blood donation takes about a pint of blood out of the approximately 10 pints in the average adult body–plenty for a healthy adult to spare. Each donation can help multiple people, as components of whole blood can be separated out for different uses. Red blood cells carry oxygen to tissues in the body, and are used in trauma, surgery, and in the treatment of severe blood loss. Platelets are cell fragments that help with clotting–these are used in surgeries and cancer treatments. Plasma is a clear liquid that contains proteins and clotting factors; it is commonly used in burn patients and bleeding disorders. Although donors of all blood types are needed, certain blood types are usually in shorter supply because their blood products can be used for patients of any blood type (critical in emergency situations, when a patient may need blood before his/her blood type is known); these are Type O negative, the “universal donor” for red blood cells, and type AB positive, the “universal donor” for plasma. Only 7% and 3% of the US population, respectively, has these blood types.

Giving blood is safe for most healthy adults, and a single donor can give blood multiple times annually. General eligibility requirements are that donors must be at least 17 years of age, and weigh at least 100 pounds. Additional eligibility/exclusion criteria can be found on the American Red Cross website. To donate blood, you can download the ARC blood donor app, visit www.redcrossblood.org, or call 1-800-RED-CROSS (733-2767). If you do not meet current eligibility criteria, you can still support blood donation efforts by spreading the word about Blood Donor Awareness month, by donating to the Red Cross, or by hosting a blood drive through your workplace or community group (such community efforts provide about 80% of Red Cross blood donations!). Giving blood is giving the gift of life to someone in need–please consider donating this winter.