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.

At Rittenhouse, we believe that medical marijuana may be useful in the treatment of the following conditions and you should be discussing these conditions at your visit:

• Amyotrophic lateral sclerosis.
• Autism.
• Cancer, including remission therapy.
• Crohn’s disease.
• Damage to the nervous tissue of the central nervous system (brain-spinal cord) with objective neurological indication of intractable spasticity, and other associated neuropathies.
• Dyskinetic and spastic movement disorders.
• Epilepsy.
• Glaucoma.
• HIV / AIDS.
• Huntington’s disease.
• Inflammatory bowel disease.
• Intractable seizures.
• Multiple sclerosis.
• Neurodegenerative diseases.
• Neuropathies.
• Opioid use disorder for which conventional therapeutic interventions are contraindicated or ineffective, or for which adjunctive therapy is indicated in combination with primary therapeutic interventions.
• Parkinson’s disease.
• Post-traumatic stress disorder.
• Severe chronic or intractable pain of neuropathic origin or severe chronic or intractable pain.
• Sickle cell anemia.
• Terminal illness.

The State of Pennsylvania has legalized the use of medical marijuana.  Starting sometime next year, dispensaries will be opening and patients with the following serious medical conditions will be able to get medical marijuana. To purchase medical marijuana, a patient will need to be under the continuing care of a physician who is registered with the Department of Health. The physician may then provide a signed certification to the patient stating that the patient has a serious medical condition. The patient must then apply to the department for an identification card. Once the patient receives an identification card, he or she can purchase medical marijuana at an authorized dispensary.  In the upcoming months we will be discussing many of the below conditions and how medical marijuana may be useful in their treatment, and how to obtain the patient certification from our practice.

Cannabis, also known as marijuana is a psychoactive drug from the Cannabis plant used medically and recreationally.  The main psychoactive chemical of cannabis is tetrahydrocannabinol (THC) (THC); one of 483 known compounds in the plant, including at least 65 other cannabinoids.   Cannabis can be used by smoking, vaporizing, within food, or as an extract.    As early as 2737 B.C., the mystical Emperor Shen Neng of China was prescribing marijuana tea for the treatment of gout, rheumatism, malaria and poor memory.   The criminalization of Marijuana by the Harrison act inhibited medical research on the plant.  The new research on marijuana in the 21^st Century has led to the characterization of two receptors for cannabis in humans, CB1 and CB2. These receptors work through a unique feedback  mechanism on G protein–coupled receptors(GPCRs), again too complex for this setting.  GPCRs, which transduce extracellular signals into intracellular effector pathways, include about 900 members and represent the most prominent family of validated pharmacological targets in biomedicine.  Advair and Abilify are among the drugs that work with this receptor.  ~4% of the protein coding genome is devoted to these receptors.

Dr. Saltzman’s background in Pharmacokinetics and the dynamics of medications has led to him researching the significant benefits of medical marijuana and he has received his certification from the state of Pennsylvania and will be seeing patients at our office for medical marijuana evaluations.