University of Pennsylvania Health System

Penn Health for Women Newsletter

Thursday, July 30, 2015

When Should Pelvic Floor Issues Send You to the Doctor?

Some women deal with their pelvic organ prolapse or urinary incontinence on their own and don’t let their symptoms interfere with their lives. Others are mortified by them.

Dr. Uduak Andy
“What I always tell my patients with prolapse and incontinence is that none of those things will kill you, but they can significantly impact your quality of life,” says Uduak Andy, MD, a urogynecologist at Penn Medicine.

The decision to seek treatment is up to the patient, Dr. Andy explains. “It depends on how much it bothers the woman.”

That said, some women live in a state of denial about how much their pelvic floor disorders change their lives.

There comes a time when seeking treatment is in your best interest. Here are five clues it’s time to see a doctor for your pelvic floor issues.

1. When you start to experience depression and self confidence issues

“Incontinence is associated with depression, isolation, and a worsened quality of life,” says Dr. Andy.

Depression caused by pelvic floor disorders can create a self-perpetuating cycle: You avoid social situations and other activities because you’re depressed, but that avoidance only worsens the depression.

2. When you stop doing activities you used to enjoy

“If a woman has to worry about something in between her legs, she’s probably not going out as much or doing as many things as she wants to,” Dr. Andy explains.

“If she has to wear a diaper every time she leaves the house, she may not engage in things like sports.”

Many women don’t realize just how much they miss these activities until they start doing them again after treatment. Dr. Andy has seen firsthand how treatment for pelvic floor disorders helped women return to their normal routines.

3. When you start avoiding sex

“Both incontinence and prolapse can interfere with people’s sex lives,” says Dr. Andy.

“A lot of women who have prolapse are very apprehensive about sex. They don’t feel sexy. They wonder, ‘Is he going to notice? What’s going to happen?’” These are common insecurities expressed by women with this condition.

But, as Dr. Andy explains, “If prolapse is getting in the way of your having sex, then we absolutely need to take care of it.”

The same goes for incontinence, she says. “Some women with incontinence are leaking urine while they’re having sex and they’re absolutely petrified. That’s not what we want.”

4. When you need to wear a pad

“If you’re spending money on pads for your incontinence, you really should be seeing somebody for it,” Dr. Andy says.

This can be a bit subjective, however. “You’ll have a woman who’s changing her pad four times a day who’s not bothered, and a woman who has a panty liner and is losing her mind about it,” she explains.

The decision to seek treatment goes back to the quality of life issue.

5. When you start changing your social life

According to Dr. Andy, “A women who leaks anytime she coughs or laughs is probably not laughing. She’s probably not going out with her friends.”

“One thing that decreases quality of life is that as we get older, we isolate ourselves,” she explains. “The last thing we want is for an older woman not to engage in things because she’s worried about prolapse or incontinence. This should not be a reason for a woman to stay at home.”

This is why treatment is so important.

“If we can treat her condition and she can feel more confident and comfortable when she goes out, then I think that’s a huge success.”

Thursday, July 23, 2015

Hair Loss – Not Just a Problem for Men

Women can experience significant hair loss and baldness.

“Hair loss in women may be caused by either over or under production of androgen (male) hormones in the body,” says George Cotsarelis, MD, chair of the department of dermatology at Penn Medicine. “So as women age and produce less estrogen, they may notice that their hair is getting thinner.”

A change in hormone levels at the time of menopause is just one of the causes of hair loss in women. For women not approaching menopause, there could be multiple reasons that need to be considered.

Dr. George Cotsarelis
“If you’re concerned about hair loss, it’s important to work with a physician who will complete a thorough exam and tests to identify possible causes,” says Dr. Cotsarelis. “Thyroid disorders, medications, stress, illness, diet or even anesthesia can trigger hair loss.”

Dr. Cotsarelis also says an iron deficiency can affect a woman’s hair.

“Women who have had a dramatic weight loss, or aren’t getting enough iron through their diet may experience hair loss.”

Hair loss is also not uncommon in women with Polycystic Ovary Syndrome (PCOS). PCOS is a complex condition in which women experience infrequent menstruation, weight gain, acne, hair loss or excess hair growth. On ultrasound examination the ovaries have multiple small cysts. Most women complain of excess hair growth on the face, arms, chest and back, but a subset of women will experience hair loss. It's associated with high levels of testosterone.

“Women with PCOS are at risk for other related life-long conditions including diabetes, high cholesterol, hypertension and, in some cases, fertility problems,” says Anuja Dokras, MD, PhD, director of the Penn Polycystic Ovary Syndrome Center. “Hair loss or excess hair growth may be one of the first signs in a young woman.”

What Can You Do?

Dr. Anuja Dokras
“The first step is identifying the underlying reason a woman is losing her hair,” says Dr. Cotsarelis. “For women who have normal iron and hormone levels, but are still experiencing female pattern baldness, a product that contains minoxidil can help regrow hair.”

When treated by a team of physicians and specialists trained in PCOS management, women can regain control of their hair growth and loss.

“Treatment for PCOS-related symptoms includes hormonal and non-hormonal medications, nutritional counseling and weight loss,” says Dr. Dokras.

The Penn PCOS Center assists women in managing their PCOS symptoms and related health conditions. Penn physicians take an individualized approach to care. They understand that no two cases of PCOS are exactly alike, and work closely with each patient to determine the best treatment plan.

Led by Dr. Dokras, the Penn PCOS Center works with Penn dermatologists to offer patients a multidisciplinary approach to treatment. Patients have access to a variety of services including hormonal treatment, fertility treatment, weight management, nutrition services and laser hair removal to manage the excessive hair growth associated with PCOS.

Thursday, July 16, 2015

Top Five Myths About Urinary Incontinence in Women

Dr. Uduak Andy
Urinary incontinence—the fancy clinical term for those inconvenient leaks that women sometimes experience—is far more common than most people would expect.

Even though there are plenty of treatment options available for this condition, a lot of people buy into widespread myths about urinary incontinence in women.

Uduak Andy, MD, a urogynecologist at Penn Medicine, is all too familiar with these myths. She’s also ready to help spread the truth.

So here are the top five myths about urinary incontinence in women—busted.

1. Incontinence Is a Normal Part of Aging

Perhaps the most popular myth about urinary incontinence is that it’s inevitable—that as women age, their bodies are bound to lose the ability to hold their urine.

“One of the big risk factors for incontinence is advancing age, but it’s not normal,” Dr. Andy says.

Unfortunately, she adds, “Incontinence is one of the leading reasons why women will get put in nursing homes.”

2. There’s Nothing You Can Do About Incontinence, So Just Wear a Pad

Too often, women assume that aren’t any treatment options available for urinary incontinence. And they’re very, very wrong.

“Not knowing that there are options for treating it is probably one of the big misconceptions and reasons why women don’t go to their doctors,” says Dr. Andy. Aside from the embarrassment, that is.

But wearing a pad is not a solution. It’s a bandaid that doesn’t address the underlying condition.

3. You’ll Have to Have Surgery to Fix Your Incontinence

On the other end of the spectrum, some women assume that a super invasive surgery is the only way to deal with the problem.

Many women don’t know that there are non-surgical treatment options for urinary incontinence. These treatments tend to fall under the umbrella of behavioral therapy. They include:
  • Pelvic muscle training: Kegel exercises can help build muscle control and prevent leakage.
  • Bladder training: Gradually expand the length of time between bathroom trips.
  • Relaxation exercises: Taking slow, deep breaths can help calm the urge to urinate until you can get to a bathroom.
  • Dietary modifications: Decreasing caffeine intake, for instance, can reduce the risk of leakage.
  • Medication: Some medications can help with bladder muscle control.

4. Your Doctor Can’t Help You with Incontinence

Some women may want to seek treatment for their urinary incontinence, but don’t know where to turn.

“They’re not clear on who to see—should they see their primary care physician? A gynecologist? Women sometimes don’t know that there’s a specialist called a urogynecologist,” Dr. Andy says.

A urogynecologist is a doctor who specializes in both urology and gynecology.

“I like being a urogynecologist because it’s really a field where you help women live better. You get to improve their quality of life,” explains Dr. Andy.

The reason many women don’t know about this unique specialty could be because urogynecology is a relatively new field. Doctors only began receiving board certification in this specialty in 2013, according to the American Urogynecologic Society.

5. Running for the Bathroom Is a Good Idea

“A lot of women with urge incontinence will just beeline for the bathroom,” Dr. Andy says. “You’re not going to make it. You’re not going to be able to run your way to the bathroom.”

Instead, she says, “When you have that really bad urge, stop, take a deep breath, do a really strong Kegel to contract your pelvic floor muscles. The contraction will break a bladder spasm. Then, you can walk to the bathroom.”

Thursday, July 9, 2015

No Periods – Should You Be Alarmed?

Menstrual bleeding is a normal monthly event for most women, so should you be concerned if you or your daughter stops bleeding or has not started having regular periods?

Athletic Amenorrhea

Kate Temme, MD, specializes in sports medicine and women’s health, including treatment of the female athlete triad. According to her, the female athlete triad is composed of three interrelated conditions that include:
  • Energy availability (nutritional intake)
  • Menstrual function
  • Bone mineral density
The triad occurs along a spectrum from optimal health to disease. At the extreme, the triad is defined by low energy availability (with or without an eating disorder), amenorrhea and osteoporosis. Girls and women can have one, two or all three components. Low energy availability is the core component of the triad, and affects bone health by decreasing new bone formation, and increasing bone resorption due to a lack of estrogen. Without adequate nutrition, adolescent girls miss out on critical bone health – a price they may pay throughout their whole life.

Dr. Kate Temme
“The vast majority of bone density is built in the years surrounding the onset of menstruation,” says Dr. Temme. “Without estrogen, a girl cannot build the critical bone mass she needs throughout her lifetime. This can result in low bone density, fractures and osteoporosis.”

Dr. Temme sees girls who have multiple stress fractures due to repetitive movements. While training errors may be at fault, frequent stress fractures are often associated with poor bone health.

“Gymnasts, ballet dancers and runners – any athlete who participates in a ‘lean physique’ sport - can be at greater risk, but the triad can affect girls and women across a wide range of sports and activity levels” she says. 

According to the American Society for Reproductive Medicine and the American College of Sports Medicine, girls who have not yet menstruated by the time they are 15 have a condition called primary amenorrhea. Women who have previously had a period and stop menstruating for three or more consecutive months have secondary amenorrhea. 

Primary Amenorrhea

“Primary amenorrhea can result from genetic, anatomic or endocrine causes. In young athletes, primary amenorrhea may occur when a girl does not eat enough to support the amount of energy she is expending in her sport,” says Dr. Temme. “In extreme cases, this may be a result of an eating disorder, but often times, it is inadvertent – she is simply not getting enough nutrition to sustain the exercise her body is performing as well as her body’s other physiologic functions.”

This imbalance of energy intake versus energy expenditure affects the body’s endocrine system, including reproductive function and estrogen production.

“It’s the body’s way of saving energy for all the exercise a girl is doing,” she says. “Certain biologic systems shut down, affecting metabolism, skeletal and reproductive health.”

Secondary Amenorrhea

Dr. Monica Mainigi
In some cases, secondary amenorrhea can be associated with low estrogen levels and can lead to osteopenia, which is the precursor for osteoporosis, osteoporosis and bone fractures. It also decreases a woman’s chance of becoming pregnant.

“When a woman’s body doesn’t have enough estrogen, she does not ovulate.” says Monica Mainigi, MD, assistant professor of obstetrics and gynecology at the Hospital of the University of Pennsylvania, “This is the body’s way of saying there is not enough energy to support a pregnancy.”

Dr. Mainigi specializes in infertility and reproductive endocrinology. She explains that some women who exercise excessively or restrict their caloric intake can experience secondary amenorrhea and infertility. One of the first steps is a comprehensive evaluation by a gynecologist to identify the cause of amenorrhea so that a personalized treatment strategy can be developed.

Treating the Female Athlete Triad

“Treating girls and women who have the Female Athlete Triad is complex and requires women to be plugged in to the right resources,” says Dr. Mainigi. At Penn, nutritionists, counselors, orthopaedic specialists and endocrinologists work together to provide coordinated care for these athletes.

“Simply telling a woman to eat more or train less is not the answer,” says Dr. Mainigi. “Her personal identity may be wrapped up in appearance, athletics and performance, and she can lose sight of what is healthy and what is not.”

Dr. Temme adds that there are positives when it comes to treatment. 

"The good news is that when discovered early, and treated comprehensively, a lot of the damage can be prevented.”

Friday, June 26, 2015

What on Earth Is Urogynecology?

Picture this: You’re out with your friends and someone says something so hilarious that you all burst out laughing. But your good mood plummets to embarrassment: You’ve started to leak urine. You dash to the nearest restroom, hoping you’ll make it in time.

Over the next few months, you’re plagued by more embarrassing leaks and close calls. Finally, you mention it to your primary care physician. She recommends you see a urogynecologist.

A what...? You heard right—urogynecologist.

No, it’s not a European gynecologist. Urogynecology is a hybrid specialty: Urology plus gynecology.

“I see a lot of women who are postpartum—just had babies. I see women who are in or approaching menopause. I see women who are postmenopausal.  I also see women at other times in their life who are simply bothered by their symptoms,” explains Pamela Levin, MD, assistant professor of Clinical Obstetrics and Gynecology.

Here's what you should know about the specialty.

What exactly does a urogynecologist do?

Urogynecologists help women who have pelvic floor conditions. They handle everything from evaluation and diagnosis to treatment and management.

“The beauty of urogynecology is that it is a collaboration between you and your doctor. It’s all aimed at meeting your goals,” says Dr. Levin. “The primary focus is on quality of life.”

Treatment for pelvic floor conditions include:
  • Behavioral therapy—relaxation techniques, muscle training, dietary changes can help manage symptoms
  • Pessaries—after receiving doctor instruction on proper use, this device that fits into the vagina to support the bladder, uterus, etc. can be removed for cleaning and reinserted
  • Medications—depending on the condition, this may be an option for treatment  
  • Surgery—options vary from minimally invasive and laparoscopic procedures to reconstructive surgery, depending on the condition

What are some common pelvic floor conditions that urogynecologists treat?

Urinary Incontinence

Urinary incontinence is the clinical term for urine leakage. The American Urogynecologic Society (AUGS) found that it's twice as common in women than in men. Risk factors include:
  • Vaginal childbirth
  • Genetics
  • Diuretic medications
  • Chronic constipation
  • Obesity
  • Smoking

Overactive Bladder

People with overactive bladder have urine leakage as well as a frequent, intense urges to urinate.

Some women have an obvious underlying medical condition—usually a neurological or inflammatory illness—that causes overactive bladder. But for most women, the cause is unknown.

Pelvic Organ Prolapse

Pelvic organ prolapse occurs when the pelvic organs—like the uterus or bladder—drop because of weakened vaginal muscles, says the AUGS.

Risk factors for pelvic organ prolapse include:
  • Vaginal childbirth
  • Genetics
  • Smoking
  • Pelvic floor injuries
  • Chronic constipation
  • Chronic coughing
  • Obesity
Obese women are 40 to 75 percent more likely to have pelvic organ prolapse.

Is urogynecology a new field of medicine?

Yes and no. The health issues that urogynecologists deal with are not new.

But the American Board of Medical Specialties (ABMS)—the organization that oversees certification standards—added urogynecology as a subspecialty in 2011, according to AUGS.

Urogynecology is also known as Female Pelvic Medicine and Reconstructive Surgery. Doctors began receiving board certification for it in 2013.

What should you look for in a urogynecologist?

Your primary care physician or gynecologist can refer you to a urogynecologist if you're dealing with pelvic floor issues.

If you’re looking at prospective doctors on your own, keep in mind a few key factors: Experience and certification are important. But, so is the doctor’s personality and how comfortable you feel with him or her.

“You have to make sure you feel like this person is someone you can share intimate details of your life with," says Dr. Levin "Someone that you feel comfortable with, that you trust and that you know is listening to you."

Do you want to learn more about urogynecology services? Ready to see a specialist about your pelvic floor issues? Sign up for an appointment with a Penn urogynecologist.

Friday, June 12, 2015

Improving Health for the LGBT Community

Lesbian, gay, bisexual and transgender (LGBT) people experience multiple health disparities due to harassment, discrimination and stigma. Because of these disparities, and the barriers to high quality patient-centered care members of the LGBT community face, the Penn Medicine Program for LGBT Health was created.

Dr. Baligh Yehia
“Barriers such as decreased access to healthcare, lack of awareness and/or insensitivity to their unique health needs, and inequitable health system policies and practices put members of the LGBT community at greater risk for diseases and conditions that affect their physical and mental health,” says Baligh Yehia, MD, MPP, MSHP, director of Penn Medicine’s Program for LGBT Health. “Greater public awareness of these health issues allow us to address these health disparities and advance the health and well-being of all lesbian and bisexual women.”

Recent studies by the National Institute of Health, Gay and Lesbian Medical Association, the Institute of Medicine, and the Center for American Progress have identified numerous health disparities and issues that need to be addressed including higher rates of smoking, obesity, psychological distress, partner violence, cancer risks as well as reduced access to care.

“We are working to improve the health of lesbian women, bisexual women and all individuals within the LGBT community,” says Dr. Yehia. “Our program is unique because we are interdisciplinary, and have access to resources through Penn Medicine, the University of Pennsylvania and affiliated health systems such as the Children's Hospital of Philadelphia and the Philadelphia Veteran's Affairs Medical Center. As a local and national leader in LGBT patient care, education, research and advocacy, we can advance the well-being of the LGBT community.”

The program’s focus areas include:
  • Institutional Climate and Visibility: Nurture and support LGBT diversity and inclusion in the workplace, classroom, and healthcare settings
  • Health Education: Enhance education of faculty, students, and staff in LGBT health and health disparities.
  • Research: Foster research on the optimal ways to improve the care for LGBT patients and their families.
  • Patient Care: Provide patient and family-centered care to the LGBT community.
  • Outreach: Increase collaboration between Penn, affiliated health systems, and the Philadelphia LGBT community.

Tuesday, May 26, 2015

How to Do Kegel Exercises Correctly

Kegel exercises: If you’re a woman, chances are just hearing someone mention those two words causes you to involuntarily start doing them yourself.

But are you doing them correctly?

If you are, your pelvic floor muscles all relax and contract together, not separately. So when you do a kegel exercise, you’re contracting a whole group of muscles.

Pamela Levin, MD, assistant professor of Clinical Obstetrics and Gynecology, knows firsthand that a lot of women think they’re doing kegel exercises correctly. But they’re not.

Here are some of the most common mistakes her patients have made and some tips on how to do them correctly.

Three Common Kegel Mistakes

1. You’re squeezing the wrong muscles.

“It’s not your abdomen, and it’s not your butt cheeks,” explains Dr. Levin. “If you put your hand on your abdomen and you feel your belly muscles clenching, you’re not squeezing the right place. If you feel your butt cheeks tightening and coming up off the chair, then you’re not squeezing the right place.”

2. You’re not contracting your muscles. 

Dr. Levin says, “Some people who think they’re doing kegels correctly are actually pushing, not squeezing.”

3. You’re trying to practice at the wrong time. 

One of the main misconceptions about kegel exercises is that you should try to stop your urine mid-stream when you’re on the toilet.

“I think at some point we’ve all heard that advice,” says Dr. Levin. But, she warns, “Practicing that way sets you up for trouble.” That trouble may include difficulty urinating in the future.

Instead, practice them when you have a spare moment, like when you’re sitting in traffic waiting for a red light to change. Here’s how:

Doing Your Kegels the Right Way

“Envision you have a straw in your vagina, and you’re trying to pull fluid up through the straw,” suggests Dr. Levin.

It may help to insert a finger into your vagina and tighten the muscles like you’re trying to hold your urine in, says the NIH. If you’re doing your kegel exercises correctly, you should feel your muscles tighten as you do this.

As with all muscle training exercises, practice makes perfect.

“Often you can squeeze the muscles for a quick second but then the muscles fatigue really fast,” explains Dr. Levin. “With practice, focus, and training you can actually learn to do kegels that you can sustain for a few seconds before releasing. Being able to do both the quick squeezes and the longer, stronger Kegel exercises is the best-case."

As for how often you should practice, Dr. Levin says, “I suggest you do them a couple of times a day.”

You’re doing them right now, aren’t you?

Monday, May 18, 2015

Menopause, Hormones and Heart Disease: The Battle to Find the Lesser of Three Evils

Hot flashes. Night sweats. Sleep disturbances. Mood swings. Irregular and racing hearts. These are all signs of menopause setting in, the time in a woman's life when her ovaries cease to function. It signals the end her fertility years, her menstrual cycle and a drop in naturally produced hormones.

As if the possibility of menopausal symptoms setting in as early as age 40 isn't unsettling enough, check out these disturbing facts:
  • A woman's risk for heart disease automatically increases at age 40
  • Heart disease is the leading cause of death in women over 40, particularly those in the midst of menopause.
If menopause doesn't cause heart disease, then why is this such a significant time? Estrogen is a hormone that has a positive effect on the cardiovascular system by keeping the blood vessel walls flexible. The decrease in estrogen as menopause sets in causes negative changes to occur to the blood vessels, no longer protecting them in the same way and through the changes in the walls of these vessels, clots are more apt to form. In addition to these changes, in post-menopausal women, blood pressure begins to go up and LDL cholesterol ("bad") levels rise while HDL ("good") stay the same.

So what's a woman to do? It was once thought that hormone replacement therapy (HRT) not only helped stave off these unwanted symptoms of menopause but also helped to keep more serious health threats, such as heart disease, cancer and osteoporosis, at bay. In 2002, however, HRT studies involving these hormones were halted secondary to evidence that women in them showed an increase in risk of heart attack, stroke, breast cancer and even dementia.

The known increase in heart disease in this subset of women has led to increased screening and a more personalized approach when it comes to treating menopause. According to Kelly Anne Spratt, DO, Penn cardiologist, "Treating a woman for menopause depends on many factors, including how severe and life-altering her symptoms are, her current health status, medical and family history and treatment preferences. Many symptoms can be effectively managed through lifestyle changes and other types of therapies."

One thing is clear, however. HRT should not be used to prevent heart disease. Nor should women with heart disease take it. And, women need to enlist the help of a physician. They can start with their primary care doctor or their gynecologist and discuss with him other ways to decrease blood pressure and LDL cholesterol and prevent heart attack and stroke, such as lifestyle modifications (i.e., switching to a heart-healthy diet and quitting smoking) and keeping blood pressure and cholesterol levels under control with the proper medications.

"I would also strongly suggest that menopausal women who have a family history of heart disease or are showing symptoms of heart disease of or have multiple risk factors for cardiovascular disease should seek the professional medical advice of a cardiologist in addition to their primary care physician," adds Dr. Spratt "A woman's risk for cardiovascular disease – including heart attack and stroke – bone loss and cancer is subject to change as she gets older. That's why it's so important for her see a physician regularly to review her health status."

Want to know more about menopause and your risk for heart disease? Sign up for an appointment with a women's health specialist today.
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