I gave this presentation not too long ago at the Massachusetts Health Council’s Women’s Health Care Conference. As I prepared this talk, I had a hard time narrowing my topics. I could easily have addressed at least 20 questions I hear from women each and every day in the exam room. But these 10 seem to be the most frequently asked.
Regardless of how many I have addressed here, the sub-title of my presentation and the theme of the conference is also key: “Getting Healthy. Staying Healthy. Knowledge is Everything.” If I can leave women with one message, it’s to ask – ask your doctor questions about symptoms you’re experiencing and changes to your body. The answers can help guide you and your doctor to find treatments and solutions for you that will help you feel better and get and stay healthy.
This is a lot of information to take in all at once, so I will publish these 10 questions and answers in a 3-part series. So, à la David Letterman style, the top ten list – in reverse order – is:
#10. Is there anything you can you give me so I won’t want to kill everyone for a few days every month?
Ah, PMS, aka premenstrual syndrome. It’s real, and there’s even a more extreme kind – premenstrual dysphoric disorder – that causes even more extreme feelings. We still don’t know everything, but we are learning more every day about what causes PMS. Today, we believe that it has to do with some of the steroids our ovaries produce at that time of the cycle, and we also know it has something to do with changes in some of the neurotransmitters in our brains, particularly serotonin. The lower the serotonin levels in our system, the more our mood seems to spiral to the dark side. It also possibly explains our cravings for carbs like chocolate – eating carbs releases natural tryptophan, a precursor to serotonin and therefore increasing levels of serotonin in our brains.
If you feel these symptoms need some intervention, talk to your doctor. The first thing he or she should do is to identify the cause and make sure the source is not some form of anxiety or generalized stress state. If it is coming from your cycle, I often first recommend (and will throughout this talk) regular exercise and relaxation techniques like meditation. There used to be some belief that taking birth control pills helped by smoothing the hormone levels, but this has been of only marginal help. More recent work has shown that selective serotonin re-uptake inhibitors (SSRIs) like Prozac can significantly help given they do impact serotonin levels. These can be taken for just a few days at the same time each month if your cycle is pretty regular or every day if especially you’re not happy most days for a variety of reasons. I caution women on side effects, however, especially a possible trouble with having an orgasm. Like most things, determining lifestyle choices and priorities is key.
#9. And when exactly am I supposed to get my next pap smear?
This has changed dramatically over the past few years and has left a lot of women confused. At Harvard Vanguard, we put together a blog post and video to explain the changes and why, which you can see here. But to summarize, women 21-30 should now get a pap smear every 3 years, a big change indeed from the annual test most women expect. For women over 30 and up until age 65, they also need a pap smear every 3 years, BUT, if they also get an HPV test at the same time as their pap smear (it’s taken from the same specimen), they may be able to stretch their pap test to every 5 years. I need to point out that these are the general guidelines for an average woman – if you have a history of abnormal pap smears, a history of maternal exposure to DES or have a compromised immune system, you should work with your doctor to understand what frequency is right for you.
Sometimes when I tell this new schedule to women, they become skeptical and wonder if this is “an insurance thing” to save money. It is not. A lot of research has taught us a great deal about what causes cervical cancer (which, by the way, is the only kind of cancer screened for in a pap test – it does not screen for ovarian or uterine cancers). We know that cervical cancer is essentially 100% a sexually-transmitted disease and comes from certain strains of human papilloma virus (HPV) which we can identify.
We’ve also learned that, with too-frequent pap smears, it’s more possible to get an abnormal result which may possibly lead to treatment that in fact is too aggressive. Since the next step would be to take a very small section of the cervix to remove the affected cells, this can thin and weaken the cervix, possibly affecting a woman’s ability to support a full-term pregnancy. Therefore, we now feel we can provide the same level of screening security while mitigating some of the historical risks.
#8. Is my clock really ticking?
Yes, and faster than you think! Most people in our society when asked would say that a woman’s chances of conceiving drop and more problems occur around the age of 40. Fertility studies have shown that a woman’s body is most responsive to getting pregnant between 20-25 years. From age 25-30, we see a slight drop, but then, at 32, we see a big change in the curve, both in the ability to get pregnant as well as an increase in the risk of genetic abnormalities in the baby.
So, in our new estimation, 35 is really the new 40 when it comes to optimizing the chance of healthy conception and birth. For women who want to balance a career and family, they should know this and consider what personal choices would be best for them. If a woman chooses to delay starting a family, she should also work with her doctor to make sure she becomes or stays as healthy as possible, which will help her as she tries to conceive.
#7. Is there a bathroom nearby?
This one is a problem for many women. It’s not just the problem of leaking urine itself, but the discomfort and even social embarrassment that may come with it, making some women cut back on healthy behaviors like exercise because they leak when they do. Unfortunately while this is something your doctor should ask about at a physical, they often don’t, so you may need to bring it up.
It’s also a complicated problem. Most women assume it’s just caused by having babies, but the bladder is more complex than we might think it is. Think about it: when the bladder fills, the muscles at the top have to stay relaxed to allow it to fill, while the muscles at the bottom need to be tight to support it. When you go, the muscles at the top need to contract to push out the urine, while the bottom muscles need to loosen to enable the process to go smoothly. If the muscles at the bottom do not have sufficient tone for whatever reason (this might be where having a baby affects it), it causes urinary stress incontinence (that leakage we talked about above), but if muscles of the bladder are too irritable, they contract (the overactive bladder) and it’s known as urge incontinence, the sensation of needing to go more frequently.
The urethra, the tube at the end of the bladder, can also be affected by poor muscle tone around it and not work or close properly. These muscles are estrogen-dependent, so menopause can really play havoc, too.
To address urinary incontinence, Kegel exercises can help, as they can tone up those bottom muscles. Detrol can help in some cases (but not all) for urge incontinence. If you have any urinary problems and they are of real concern to you, and especially if it is affecting other healthy activities like exercising and social interaction, talk to your doctor and see a gynecologist or a urogynecologist, who is an expert in these problems and can really pinpoint a treatment plan best for you. At Harvard Vanguard, we are fortunate to have some great urogynecologists in our practice and one of them, Dr. Gerry Campos, did a blog on the topic of urinary stress incontinence.
Check back for questions #6, 5, and 4: Could my weight be a thyroid problem? What is happening to my hair? and Could I have low T?