University of Pennsylvania Health System

Penn Health for Women Newsletter

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.

Friday, May 8, 2015

Feeling Well, Healing Well After Pregnancy

The bra that fit perfectly before the baby might not be as flattering now. And your bathroom habits? Well, they may be different, too.

“Urinary incontinence during pregnancy is not uncommon. and makes sense given the changes that take place during pregnancy,” says Uduak Andy, MD. Dr. Andy is a urogynecologist at Penn Medicine, an ob/gyn that specializes in treating women with pelvic floor disorders.

“You have this baby growing in your uterus pushing down on your bladder and urethra. For some women, incontinence will increase as the pregnancy progresses.”

Childbirth can lead to urinary incontinence, too. As your baby makes its way down the birth canal, your pelvic floor muscles may be stretched and, in some cases, even damaged. Even women who have a C-section are not without risk.

Dr. Andy says that because of all the changes a woman may experience throughout her pregnancy and childbirth, it may take anywhere from six weeks to a year to fully recover.

“If a woman is still experiencing pain, painful sex, or urinary incontinence six months after she’s given birth, she may want to see a urogynecologist, who can offer her treatment options and exercises to improve the pelvic floor,” says Dr. Andy. 

Bladder and Pelvic Floor Issues

Women with stress urinary incontinence may leak urine while coughing, sneezing, laughing or exercising.

According to urogynecologist Pam Levin, MD, stress incontinence occurs when the urethra and surrounding muscles of the bladder lose their strength and support.

“Urinary incontinence and pelvic floor disorders don’t have to be a rite of passage for women, or something we just have to deal with as we age," she says.

That's why she created the Feeling Well, Healing Well Program.

Treatments for Urinary Incontinence

Penn's Feeling Well, Healing Well Program focuses on pelvic floor disorders women may experience as a result of pregnancy and childbirth.

“The post-partum time period can be challenging for new moms,” says Dr. Levin. “They might not feel comfortable talking about the issues they are experiencing. We want them to know that we specialize in these disorders and are here to help.”

It’s estimated that nearly 50 percent of women suffer from bladder and pelvic floor disorders at some point in their lifetime; however, there are options so that women don't have to live with their symptoms.

Stress incontinence can be treated with physical therapy, including Kegel exercises, physical therapy, or the use of a pessary, a removable appliance similar to a diaphragm that is inserted into the vagina or rectum to strengthen the pelvic muscles. Collagen injections may also be used to help minimize urine leakage from the bladder.

“In some cases, we recommend surgery to place a hammock or sling under the urethra to provide more permanent support,” says Dr. Levin. During the operation, a sling created from FDA-approved mesh is inserted behind the urethra to support the weakened pelvic muscles.

Women who have vaginal pain after delivery or pain with intercourse may experience muscle spasms or have painful scar tissue that narrows the opening of the vagina.

“Once we learn what is causing the pain, we can determine if a woman needs surgery, physical therapy or both to address the issue,” says Dr. Andy.

Depending on the issue, surgery may be deferred until a woman decides not to have any more children. This decision would be made in collaboration with the patient after a full consultation and discussion about the risks and benefits.

Tuesday, May 5, 2015

Marisa's Story: Defying the Odds in the Intensive Care Nursery

Marisa Mackintosh and her husband were ecstatic to learn they were expecting twins. But when Marisa was three months along, an ultrasound revealed that the babies were having growth problems. Here, she shares the story of her family's difficult journey and the neonatal intensive care team that saved her babies' lives.

When my husband and I learned I was pregnant with twins, we were overwhelmed with surprise, immense joy and anticipation. We dreamt of welcoming them home and introducing them to our beautiful daughter, who was 16 months old at the time. The twins were due August 28, 2013, and we believed we would soon have three healthy and happy children nestled safely under our roof.

Our vision quickly came to a halt at 15 weeks after an emergency ultrasound revealed that one of our babies wasn’t growing well. We were asked to prepare for the unimaginable possibility of losing one or even both babies.

The following weeks were dark and uncertain. Regular ultrasounds were both reassuring and terrifying. 17 weeks became 20 weeks, which became 24 weeks. Of course, we did not want to deliver then, but reaching 24 weeks, we learned, was a milestone. Another ultrasound at 27 weeks showed two babies, growing and defying the odds, though dangerously imbalanced in size and health.

My doctor offered us the opportunity to tour the Intensive Care Nursery (ICN) at Pennsylvania Hospital to get acquainted in the event that we would spend time there. We walked through a door labeled “CHOP Newborn Care at Pennsylvania Hospital” and were greeted warmly by a neonatologist who, with kindness and patience, gave us insight into the world of prematurity. Then a nurse manager gave us a tour, which provided a glimpse of life in the ICN.

One week later, at 28 weeks gestation, the babies decided it was time. On June 7, 2013, we welcomed our miracles William and Daniel (Will and Danny), weighing 2 lbs 12 oz and 1 lb 13 oz, respectively. At this moment, Will and Danny began the fight of their lives. But they – and we – were not alone.

Over the next four months, we witnessed neonatal intensive care at Pennsylvania Hospital's ICN and the Children's Hospital of Philadelphia at its absolute finest. The doctors made decisions that were simultaneously life-saving and delicately mindful of long-term health. The nurses were by our boys’ sides, 24 hours a day, 7 days a week, providing expert care and love when we – with terrible pain – had to leave at night.

It is immensely difficult to think about those days. It conjures up images of our tiny sons connected to devices, separated from us – and each other – by technology. But when reflecting on that time, it is impossible to forget that we were part of something truly incredible. The team at Pennsylvania Hospital became our family, who hugged us, cried with us, answered our endless questions, loved our children – and who celebrated with us when we finally brought our two babies home after 81 and 116 days.

In honor of Neonatal Intensive Care Awareness Month, we want to thank the very special people at Penn Medicine’s ICNs. They give themselves to our babies, and they provide hope to parents. For that we are truly grateful, this month and forever.

Friday, April 24, 2015

When Should You See a Doctor for Irregular Periods?

Maybe you’re in your mid-to-late 20s and and suddenly—after having regular periods for more than a decade—your cycle suddenly stops behaving like clockwork. You’re not pregnant, and you’re nowhere near menopause, so what’s the deal?

Here’s what you should know about how to identify irregular periods, what causes them and when to see a doctor.

What Are Irregular Periods, Anyway?

During a normal menstrual cycle, an egg is released from one of your ovaries during ovulation. If the egg is not fertilized by a sperm, then changing hormone levels signal for your body to shed the blood and tissues that line your uterus, says the Office on Women’s Health (OWH).

This bleeding typically lasts about five days. Then, the monthly cycle repeats itself.

But some women have what is called abnormal uterine bleeding—another term for irregular periods, the OWH explains.

What is abnormal uterine bleeding?
  • Bleeding or spotting between periods
  • Bleeding after sexual intercourse
  • Heavy bleeding during your period
  • Menstrual bleeding that lasts longer than normal
  • Bleeding after you’ve reached menopause
According to the American Academy of Family Physicians (AAFP), between nine and 14 percent of women who have already gotten their first period but haven’t yet reached menopause have irregular periods.

What Causes Irregular Periods?

There are a number of reasons why a woman has irregular periods, says the National Institute of Child Health and Human Development (NICHD). 

When a girl first starts menstruating, it may take some time time before her periods become regular. And periods may stop becoming regular up to eight years before menopause.

Common causes of irregular periods include:

Uncontrolled diabetes—Women with unmanaged diabetes may have irregular periods because the interaction between blood sugar levels and hormones can disrupt a woman’s menstrual cycle, says the American Diabetes Association.

Eating disorders—Women with conditions like anorexia or bulimia may have irregular or missed periods because their bodies are not producing and circulating enough hormones to control the menstrual cycle, according to the Hormone Health Network.

Hyperprolactinemia—Women who have too much of a protein hormone called prolactin in their blood can have irregular periods.

Certain medications, including anti-epileptics and antipsychotics—can cause irregular periods.

Polycystic ovary syndrome—PCOS is caused by imbalanced sex hormones, which can disrupt regular menstruation.

Premature ovarian failure—The ovaries of women with POF stop working before the age of 40, says the National Institutes of Health. Some women with this condition continue to have periods occasionally, however.

When Should You See A Doctor For Irregular Periods?

It may be time to talk to your doctor if:
  • You haven’t had a period for 90 days
  • Your period suddenly becomes irregular
  • You have a period more often than every 21 days
  • You have a period less often than every 35 days
  • Your period lasts for more than a week
  • Your period becomes unusually heavy
  • You bleed between periods
  • Your periods are extremely painful
Source: Office on Women’s Health

A gynecologist will be able to determine the cause of your irregular periods and help you figure out a treatment course. This may include oral contraceptives to regulate your cycle.

Friday, April 10, 2015

Join Penn at the Race for the Cure 5/10

The 25th Annual Komen Philadelphia Race for the Cure® is a Mother’s Day tradition benefiting breast cancer research, education, screening and treatment.

The Penn Medicine Breast Health Initiative (PMBHI) was recently awarded $100,000 from the Susan G. Komen Philadelphia Community Grants Program to provide screening and diagnostic services to an additional 600 women this year.

25 percent of the funds raised by Komen Philadelphia supports the Komen national research program – a peer reviewed cancer research program offering grants in areas such as diagnosis, treatment, public health, survivorship and prevention. The remainder of the funds raised are invested locally in programs like the PMBHI, which help provide access to care and education in our community – both enriching and saving lives.

These are just a few good reasons to come out and join the Penn Medicine team.

25th Annual Komen Philadelphia Race for the Cure®
Mother’s Day: May 10, 2015
Eakins Oval/Philadelphia Museum of Art
5K Run/Walk & 1-Mile Fun Walk
Join us and help make a difference.

Interested in Joining Our Team?

To join the official Penn Medicine Team, patients, friends and family are welcome to visit the official registration page online and follow the instructions.

Race for the Cure Schedule:
7:00 am: Opening Ceremony: 25th Celebration Extravaganza
8:15 am: 5K Run Start
8:25 am: 5K Walk / 1-Mile Fun Walk Start

Other Ways to Show Your Support

Can’t make it on Mothers' Day? You can still support Penn Medicine’s team by making a donation to the team.

If you have questions about joining or would like to tell us why you walk in the Susan G. Komen Race for the Cure, please email Amy Kleger or visit
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