Gynecology

Urinary incontinence (involuntary loss of urine) is experienced by millions of women and may vary from a few drops while coughing, lifting, walking or running to large amounts following a strong and sudden urge. It may also occur during sex, which can be emotionally devastating.

The causes are generally from problems with either the nerves or muscles involved in holding or releasing urine. The types of incontinence include stress (leakage during movement), urge (sudden leakage at unexpected times such as during sleep), overactive bladder (increased frequency or urgency), functional (physical or mental disability), overflow (retention of more urine than the bladder can hold) or transient (temporary causes such as infections). Diagnostics may involve many types of tests.

We offer a full range of diagnostics and treatment options including many non-surgical methods and medication. If you believe you may be suffering from urinary incontinence, we encourage you to make an appointment to discuss diagnosis and treatment.

There are many factors that can cause a couple's infertility, including problems with the reproductive system of either partner. See our "Gynecology FAQs" about causes of infertility. At A New Beginning OBGYN, we are able to help you with many causes directly, and can refer you to excellent specialists if your specific cause needs more specialized treatment.

Our Nurse Practitioner is highly skilled in diagnosing and treating many of the causes, while Dr. Bullaro-Anderer provides expertise in others. Infertility can be devastating to a couple planning to start or add to a family. While the most common causes are a sperm disorder in men or an ovulation disorder in women, there are many others. This is why a detailed infertility workup is required to isolate the cause and start the most effective treatment.

If you have regularly tried to become pregnant for a full year and are unsuccessful, we encourage you to make an appointment to discuss a detailed workup and treatment.

Decreased bone density resulting in fragile bones is a skeletal disorder than can lead to frequent fractures. Often the first symptoms are a painful fracture. Nearly half of Caucasian women will experience a fracture due to osteoporosis at some time during her life. It is less common in men.

Osteoporosis, or a propensity to develop it, can be detected by checking bone density. All postmenopausal women below 65 should be tested if they have risk factors* for osteoporosis. All women over 65 should be tested regardless of risk factors. If you have a fracture that is determined to be from osteoporosis, a density check may be unnecessary because you should begin treatment anyway.

Diet, resistance exercise and medication can all reduce your risk of developing osteoporosis. We offer a variety of treatment options and can help you choose those that are best for your age, condition and current bone density.

* Risk factors include being female, Asian or Caucasian, being thin or having a small body frame, a family history of osteoporosis, a history of fractures as an adult, cigarette smoking, lack of exercise, excessive alcohol consumption, poor nutrition (low calcium in diet), poor general health, low estrogen levels, loss of menustrual period due to extreme training and/or very low body fat, vitamin D deficiency. Long term use of medicatins such as heparin (blood thinner), Dilantin, oral corticosteroids such as prednisone may also increase the risk of osteoporosis.

If you have an abnormal Pap smear, there may be many causes and the majority of these are not cervical cancer. To make sure of the cause, we want to take a closer look at your cervix. This is done with a colposcope. This instrument allows Dr. Bullaro to examine the cervix in detail. The test itself is painless. However, during this evaluation it may be advisable to do additional procedures to take samples of abnormal-looking tissue (see also LEEP).

An abnormal Pap smear may indicate extraction of cells from your cervix. The presence of abnormal cervical cells is called cervical dysplasia, and warrants further examination of these cells. To extract these cells for laboratory analysis, Dr. Bullaro-Anderer places a thin wire loop near the cells. A carefully controlled electrical current passes through the wire that rapidly heats the abnormal cells and allows them to be separated and removed from the cervix. The placement of the LEEP device is guided by a colposcope.

We perform this well-tolerated procedure in the office and it takes about 30 minutes.

 

Dr. Bullaro-Anderer recommends (per the American College of Obstetrics & Gynecology) that Pap smears commence no later than 3 years after becoming sexually active, or at the age of 21, whichever comes first. This test will allow detection of abnormal cells on the cervix. An abnormal Pap can be caused by many things, most of which are not cervical cancer. However, further examination is warranted when a Pap result is abnormal, so we will request that you make an appointment for further evaluation.

We want you to be as informed as possible about your risk of developing breast or ovarian cancer. We have a close cooperative relationship with Myriad Genetics and provide links to some of their excellent resources here.

The health risk questionnaire we use in the office is available here as a PDF file, and also under the "Forms" tab above.

An online hereditary risk questionnaire is available from Myriad that may provide you with some additional information. You will find this questionnaire here. It is only for your information. We need for you to complete the Brodsky questionnaire and bring it to the office for our use.

If you are looking for more helpful information about cancer, please also refer to the Myriad Genetics patient resources here.

We offer detailed consultation on hormone replacement therapy, including bioidentical hormone replacement therapy (bHRT). This approach has been successfully used by many women with less undesireable side effects than are experienced with traditional hormone replacement therapy. See this topic under the Gynecology FAQs tab on this page for more details.

 

While a diagnosis of menopause may be supported by laboratory tests of hormone levels, they are not usually required. If you are over 40, still have your uterus, and have ceased having periods for more than 12 consecutive months, you are very likely in menopause.

The symptoms include:

• hot flashes
• vaginal dryness
• possible mood swings
• possible hair and skin changes
• vaginal dryness
• painful sexual intercourse

The cause is an imbalance in estrogen and/or progesterones and the most common treatment is hormone replacement therapy (HRT). We can advise you on the options that may be best for you. Please refer to the FAQ on menopause for more details.

We offer a variety of treatments for menorrhagia, including endometrial ablation. Please refer to this topic under the Frequently Asked Questions (FAQ) tab, or see the "Essure/Ablation" menu for more details.

Other than mild menstrual-related cramps, chronic pelvic (abdominal) pain is not normal and requires investigation. Pelvic pain can occur in relation to reproductive events, bladder or bowel function, or it can occur during or after sex. Pelvic pain negatively impacts a woman's quality of life, including her social life. There are hidden costs of pelvic pain as well. These can be financial or professional, such as time missed from work or school. Click here for more information on female pelvic pain.

 

While many gynecologic disorders can cause great distress, few are as damaging to a woman's long-term wellness and self-esteem as Polycystic Ovarian Syndrom or PCOS. Symptoms of PCOS can include weight gain or the inability to lose weight, facial hair, acne, scalp hair loss, irregular or absent menstrual cycles, and infertility. Undiagnosed, untreated or undertreated, PCOS results in heightened insulin resistance which can ultimately lead to Type 2 diabetes. Early identification and aggressive treatment can reverse some symtoms and minimize the devastating effects of others. We offer detailed diagnosis and treatment for PCOS. Click here for more information.

 

A woman's sexual health impacts the health of her intimate relationships as well as her sense of herself as a woman. It is imperative that time and attention be devoted to answering sexual questions and discussing symptoms such as decreased sexual desire or sexual pain. Our knowledge of these matters and comfort in discussing them make our office the ideal venue for starting to find solutions.

 

Birth control pills can provide several health benefits in addition to preventing unwanted pregnancy. A brief summary of the benefits include:

• Prevention of unwanted pregnancy
• Control of menstrual cycle timing and mood swings
• Control of flow, clotting and cramps during periods
• Decreased risk of uterine and ovarian cancer (up to 75% decrease for ovarian cancer)
• Decrease of both facial and body acne

There are several types of pills and all do essentially the same thing—preventing ovulation. They do not cause abortion, but rather prevent conception. Your body will require a period of time (3 to 6 months is common) to adapt to the pill. During this time you may feel some nausea and you may have abnormal bleeding. If these do not disappear with time you may need a different pill. Some women have no periods while taking the pill. This is safe provided that you did not suddenly stop having periods while on the pill. If your periods suddenly stop it may indicate pregnancy.

The main risk with birth control pills is the potential for blood clots. Birth control pills do not increase your risk of breast cancer, nor do they cause weight gain. They do not cause abortion of an existing pregnancy, they simply prevent it by preventing ovulation. The birth control pill does not encourage sexual activity.

There are several options for heavy bleeding, with varying benefits and risk. Heavy bleeding is indicated if you need to change your tampon or pad more often than about every 2 hours. The options, in order of increasing severity, are explained below:

Hormones	If your body is tolerant of hormonal use you may take them in the form of birth control pills or progesterone pills. We also encourage considering bio-identical hormones. Women who are unable to use hormone treatment, or those whose symptoms do not respond to hormone treatment may consider the IUD.
Intra-uterine Device (IUD)	See the FAQ "How does an IUD work?" For control of bleeding, the IUD's release of a hormone is better controlled than with the pill and has a similar effect.
Endometrial Ablation	Endometrial ablation is a process that destroys the uterine lining (endometrium). It stops or reduces menstrual flow, but should not be considered if you wish to become pregnant. See the tab "Endometrial Ablation" on this page for a detailed discussion.
Hysterectomy	A hysterectomy is the removal of the uterus and cervix, either with or without the ovaries. Dr. Bullaro-Anderer can advise you of the benefits and risks of leaving the ovaries intact in your particular case. The general benefits include hormonal production that helps prevent osteoporosis, menopausal symptoms and some heart disease. However, there may be increased risk for ovarian cancer or other ovarian disease. Removal of the ovaries may be beneficial in women who have endometriosis, ovarian cysts, or a family history of ovarian cancer. Further benefits include freedom from hormone-related problems such as specific types of migraine headaches.

 

The Mirena Intrauterine Device (IUD) is inserted during an in-office procedure. It delivers a small amount of the hormone levonorgestrel directly to the uterus. This hormone circulates within your body and is kept at a steadier and lower level than with birth control pills. There are several factors that may be responsible for the IUD's remarkable effectiveness at preventing pregnancy. More than likely, it is these factors working together that allows the IUD to provide better results than the birth control pill.

The IUD may inhibit sperm, near the Fallopian tube, from reaching and fertilizing the egg. It may also thin the lining of the uterus (reducing bleeding or stopping periods), and thicken the cervical mucus plug (stopping sperm from entering the uterus). It may also prevent the release of eggs from the ovaries.

You can get more information about Mirena from the manufacturer's web site.

There are several causes of infertility, which is why a complete infertility workup is required to help resolve it. The general definition of infertility is the inability to conceive after one year of regularly attempting to become pregnant. Couples may worry about infertility long before a year, and this worrying can adversely affect ovulation. Until you have tried for a year, the best practice is to optimize your chances by understanding the process fully. Women who are able to get pregnant but then experience repeated miscarriages are also considered to be infertile.

The best practice is to have intercourse daily or every other day starting 4 to 5 days prior to ovulation, which is usually 14 days prior to the start of your period. If you have regular periods this is fairly easy to determine. Note the date that your period starts. Add the number of days in your period (say, 28) to that date on the calendar. Now back up 14 days. Your most fertile time is from that date until 5 days from that date.

If your periods are irregular, it may be beneficial to use an ovulation kit or to keep temperature charts. After evaluating your cycle with this method, if you do not see indications of ovulation you should make an appointment with Dr. Bullaro or with our Nurse Practitioner to discuss it further. An infertility workup may be needed and it involves you and your husband. This involves a semen analysis for your husband, analysis of your Thyroid and prolactin levels, a radiological exam to verify your Fallopian tubes and uterus are normal. Depending on the findings your practitioner may recommend the drug Clomid to stimulate ovulation.

Infertility affects between 12% and 15% of the women in the U.S., with the problem being with either partner. The most common cause in women is problems with ovulation. Less common causes are blocked fallopian tubes due to pelvic inflamation, endometriosis or entopic pregnancy surgery; fibroid problems in the uterus, or other physical problems with the uterus.

This process was traditionally used to provide permanent birth control. The physician would laparoscopically burn the Fallopian tube around their mid-portion. The tubes are then effectively blocked so that sperm cannot reach the egg for fertilization. This process incurs the risks of general anesthesia and laparoscopic surgery.

We now recommend that patients consider the Essure permanent birth control procedure. This is discussed in detail under the Essure/Ablation menu.

 

The most common definition for menopause is the lack of periods for over 12 consecutive months in women starting at about age 40. Most women, however, notice early symptoms while still having periods. Common symptoms are:

• Hot flashes and/or night sweats
• Loss of libido
• Irregular periods (early symptom)
• Vaginal Dryness
• Mood Swings

You may also notice fatigue, some hair loss or skin changes, diffculty sleeping, breast pain, joint pain, depression, anxiety and irritability.

A change in the balance of the natural hormones estrogen and progesterones is a naturally occurring process of aging. The result is one or more of the symptoms described above. Often irrgular periods are an early indicator of the onset of menopause. While laboratory tests for hormone levels are available, they are usually not required to accurately diagnose menopause. The treatment for menopause is to adjust your hormone balance using hormone replacement therapy (HRT). HRT is not recommended if you have had blood clots, stroke, heart disease, or breast or uterine cancer.

We can advise you on both synthetic and bioidentical hormones. See the FAQ for bioidentical hormones on this page. The decision to use hormones is entirely personal. We can explain the risks and benefits, and the prescription options available to you so that your choice is as well-informed as possible.

A Pap smear is a test using a sample of cells taken from a woman's cervix. It is used to look for changes in the cells that ay develop into cancer. The Pap smear is done during a pelvic exam. A doctor uses a device called a speculum to widen the opening of the vagina so that the cervix can be examined. A plastic spatula and small brush are used to collect cells from the cervix. After the cells are taken, they are placed into a solution. The solution is sent to a lab for testing. While the test is not painful, the pelvic exam may be a little uncomfortable.

Generally Pap screening is recommended to begin at age 21 (or 3 years after becoming sexually active) and should be repeated every 2 years until age 29. After that, testing can be done every 3 years if you have had 3 consecutive normal screenings.

Abnormal Pap Test

An abnormal Pap smear means the cells do not look normal. It is important to note that this is not a diagnosis of cervical cancer. There are many types of cell anomalies that can be seen from a Pap test, ranging from insignificant to precancerous to cancerous. . Sometimes repeat Pap smears are needed. Different tests also may need to be done, such as a colposcopy. This is explained in the next question.

A Colposcopy is an in-office procedure that is done to allow your doctor to visually examine the vagina and cervix. A colposcope is a lighted magnifying glass similar to binoculars. A camera may be attached. This test is usually done when the results of a Pap smear are abnormal. Your doctor may use a cotton swab or cotton balls to apply a solution on the vagina or cervix to help see the examined areas more clearly.

If abnormalities are seen in the tissue, a sample of the specific tissue may be taken for examination (biopsy). See LEEP under the Services tab.

Bioidentical Hormone Replacement Therapy (bHRT) is an attractive alternative to synthetic hormones for women who have problems or concerns with the traditional hormone therapy. The usual synthetic hormones are not molecularly matched to any one person's natural hormones. They are a "one size fits all" approach where your doctor can vary the specific synthetic (Premarin, prempro, Provera, etc.) and the dose to accommodate your specific needs.

Bioidentical hormones are matched specifically to the molecular structure of your body's own natural hormones. Some patients have had far better results with less undesireable side effects using this approach.