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Ask the GYN

Online Health Chat with Devorah Wieder, MD

May 14, 2010 | Reviewed on January 27, 2014 by Jean Uy-Kroh, MD

Introduction

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Devorah Wieder.

Devorah Wieder MD, MPH is a practicing obstetrician and gynecologist at the Cleveland Clinic providing comprehensive Women's health care across the lifespan. She earned a joint MD/MPH from the University of Pennsylvania while studying access to prenatal care in Philadelphia. Dr. Wieder completed her residency training at MetroHealth Medical Center and the Cleveland Clinic. She maintains an active obstetrics and gynecology practice, with a range of office and operating room procedures, in addition to several research projects and teaching responsibilities for fellows, residents and medical students. Dr Wieder sees patients at the Center for Specialized Women's Health at the Cleveland Clinic Main campus as well as at Hillcrest Hospital.

We will be discussing common questions regarding women’s health across the lifespan, including contraception, menopause, osteoporosis, abnormal menstrual bleeding and general women’s health.

Cleveland_Clinic_Host: To make an appointment with Dr. Devorah Wieder or any of the other specialists in our OB/GYN and Women’s Health Institute at Cleveland Clinic, please call 216-444-4HER. You can also visit us online clevelandclinic.org/womenshealth.

Let’s begin with the questions.


Women’s Health Recommendations: General Information

JackieO: What are the current recommendations for breast cancer screening?

Speaker_-__Dr__Devorah_Wieder: Monthly self-exams have been under fire lately, but the truth is, most women find breast lumps themselves. The best time to examine your breasts is after your menstrual cycle is finished. Have your breasts examined by a healthcare provider at least once every three years after age 20, and every year after age 40.

Have a baseline mammogram at 35 if there is a family history of breast cancer, and a screening mammogram every year after 40 in all women.

GolfT: How do I know if I’m developing osteoporosis?

Speaker_-__Dr__Devorah_Wieder: Within two years of menopause, it is a good idea to talk to your physician about whether you need a bone density test. This test is a simple, painless scan that determines bone mineral density.

Osteoporosis has been called a silent epidemic, as the vast majority of women begin rapid bone loss after menopause and this usually occurs without any symptoms.

BrennaK: You hear so much in the news about vitamin D, how much of it do I need?

Speaker_-__Dr__Devorah_Wieder: Most people need to take a vitamin D supplement. Recent evidence has suggested that adequate levels of vitamin D intake can reduce cancer incidence by 70 percent and increase longevity. Even areas in the country with more sunshine than Cleveland, OH - up to 50 percent or more of the general population are vitamin D insufficient.

I recommend at least 1,000 international units (IU) of vitamin D3 (cholecalciferol) daily (and some people need at least 2,000 IU daily). It is very easy for your doctor to check your vitamin D level with a 25-OH vitamin D blood test.

marymary: After having a Dilation and Curettage why did the bleeding start again?

Speaker_-__Dr__Devorah_Wieder: Postoperative bleeding after a D&C can occur for about 6 weeks and may be continuous or stop and start. Depending on your age and menstrual cycle, you may get your next period during this time. If the bleeding is extremely heavy or persistent, you should see your doctor to check for other problems.


Menstrual Periods

momdear: I have very heavy periods. Should I be concerned about cancer?

Speaker_-__Dr__Devorah_Wieder: Heavy bleeding does not usually point to cancer. However, depending on your age and other risk factors, cancer or pre-cancer should be considered among other causes. You should visit your gynecologist to determine the cause of your heavy bleeding, and treatment options. It’s also important to learn about the many non-surgical alternatives to treat heavy periods.


Birth Control

Nellie: How do I know which birth control pills are right for me?

Speaker_-__Dr__Devorah_Wieder: Your physician will help you choose the right pill for you. They fall into two main classes: progesterone only, and combined estrogen and progesterone pills.

Progesterone only pills work by thinning the uterine lining and thickening the cervical mucus and making it more difficult for the sperm to fertilize the egg. They are particularly appropriate for women who can’t take estrogen for medical reasons, such as high blood pressure or a history of clots, and for nursing mothers. One downside of progesterone only pills is that they must be taken at the same time every day. If a woman misses the time by more than three hours, she will not be protected. In addition progesterone only pills are associated with increased spotting.

Combined oral contraceptives come in many different combinations, with varying levels of estrogen and progesterone. They work by inhibiting ovulation. Some are marketed specifically to suppress periods for an extended length of time. These preparations are attractive to women who do not want the inconvenience or pain of a monthly period.

A woman’s health specialist will share the pros and cons of each. Fortunately, there are so many choices that if you aren’t happy with the particular pills you start with, there are plenty more to try.

jellybelly: Birth control pills - What happens if I miss a pill and start bleeding, how long will it last and will I get my period again when I get to the sugar pills?

Speaker_-__Dr__Devorah_Wieder: It is best to set a routine around how you take your birth control pills to avoid missing pills. If you forget to take a pill at the usual time, take it as soon as you remember. Depending on what type of pills you are on and where in your cycle you are, spotting or prolonged bleeding may occur. Call your doctor to discuss how to manage the bleeding and whether you need to use a backup method of birth control. If your schedule makes it hard to keep up daily pill-taking, you may also want to discuss other types of birth control, such as a vaginal ring or IUD.

baker: Do I have to take the placebo pills or can I start a new pack?

Speaker_-__Dr__Devorah_Wieder: Most birth control pills contain 21 active pills and 7 inactive or reminder pills, also called placebo or sugar pills. These extra pills serve to keep you in the habit of taking a daily pill during the week you are not taking active pills. In some formulations, these 7 pills may contain iron or even low doses of estrogen.

Some women may choose to skip the "off week" due to pain or other symptoms related to a period and take active pills continuously to try to delay bleeding. The longer you are on active pills the more likely you are to experience breakthrough bleeding. Most women will need to stop active pills every 2-3 months to prevent spotting.

Talk with your doctor to see if extended cycle pills are right for you. Your doctor can also help you manage breakthrough bleeding if it occurs while on extended cycle pills.

mustangmommy: If you have the Mirena® inserted & it moves out of place, does that increase risk of pregnancy?

Speaker_-__Dr__Devorah_Wieder: An IUD needs to be properly positioned to be effective. Expulsion of an IUD is most common in the first 3 months and is usually related to improper placement of the IUD. Your doctor should teach you how to check for the IUD string to ensure that it is in the right place. If you cannot feel the string, see your doctor. If your doctor can't see the strings, the IUD may need to be checked with an ultrasound.


Pregnancy

grabbag: If I am on my period today and the doctor switched me to a new birth control pill today, can I start the new pack today or do I have to wait until next month?

Speaker_-__Dr__Devorah_Wieder: Birth control pills can be started in 3 ways: On the day your period starts, "Sunday start" or the Sunday after your period starts, or "Quick start" on any day of the cycle. Backup contraception may be needed during the first pack of pills. The "Quick start" method can be associated with a greater degree of irregular bleeding and may not be as protective during the first cycle.

joker: How soon after I have sex can I take a pregnancy test?

Speaker_-__Dr__Devorah_Wieder: Home pregnancy tests measure the amount of pregnancy hormone in urine. The test will usually turn positive when the next period would have occurred or about 2 weeks after ovulation. The time of ovulation differs slightly for every woman and is usually related to the overall length of the cycle.

HPowers3: I’m trying to get pregnant but haven’t so far. How long should I wait before I see a fertility specialist?

Speaker_-__Dr__Devorah_Wieder: Infertility is generally defined as not conceiving after one year of unprotected intercourse. If you have been trying for a year or more, you and your partner may benefit from an evaluation.

Some couples should seek help earlier. Women over age 35 are advised to have an evaluation after six months of trying to conceive. Women with irregular periods and/or pelvic pain, men with a history of urologic problems, and couples who are stressed from their inability to conceive also are among those who should seek evaluation earlier.

imdrnoor: What is required for the hypertensive patients if they want to keep their pregnancy without any danger?

Speaker_-__Dr__Devorah_Wieder: See your Ob/Gyn for counseling even before you start trying to get pregnant. Maintain a healthy weight with an appropriate level of exercise and see a nutritionist for tips. Call your OB as soon as you know that you are pregnant for advice on what medications to stay on and which to stop. Follow up for all scheduled prenatal appointments and recommended testing. Talk to your doctor about the warning signs for pre-eclampsia (also known as toxemia), such as headache and visual changes, as well as usual pregnancy concerns such as vaginal bleeding or cramping. Make sure you know who to contact with questions even after office hours.


Menopause & Hormone Replacement

Blank_321: I am having horrible hot flashes and wake up in the middle of the night soaked in sweat. Is there anything I can take for this?

Speaker_-__Dr__Devorah_Wieder: For some women, menopausal symptoms are a minor inconvenience. For others, continual hot flashes and night sweats lead to sleep deprivation, physical discomfort and social embarrassment.

Estrogen is a very effective treatment for hot flashes and night sweats. It is usually combined with progesterone to protect the uterus from endometrial cancer, unless a woman has had a hysterectomy.

Experts recommend that menopausal hormone therapy be prescribed in the lowest possible dose for the shortest amount of time necessary to achieve results.

Estrogen is not the only treatments for hot flashes. Other medications that may be tried include antidepressants or anti-seizure medications.

bangbang: I’m postmenopausal and began using Prempro 2 months ago. Last week I started bleeding, like a period, and have very tender breasts. Is this normal or should I see my doctor? Will it stop on its own?

Speaker_-__Dr__Devorah_Wieder: These symptoms often occur after initiating hormone therapy and may be related to the strength, formulation or dosing schedule of the hormones you are taking. Occasionally, vaginal bleeding may be related to other conditions such as benign polyps, pre-cancer or cancer of the uterus or cervix. Speak with your doctor to discuss if watchful waiting, changing your hormone regimen or further testing is right for you.


Ovarian and Uterine Cancer

playdough: What do you recommend for treatment of an ovarian cyst (3 cm) in a 47 yr. old menopausal woman.? Pain in lower back associated with this cyst. History of dermoid tumor on left ovary, and mother had ovarian cancer.

Speaker_-__Dr__Devorah_Wieder: Ovarian cysts after menopause commonly cause anxiety for patients. Multiple factors should be considered to decide if the cyst can be followed with repeat imaging or should be removed surgically: the size and features of the cyst on ultrasound, additional symptoms such as pain, as well as your personal and family history. Your doctor may order a CA-125 blood test, but this test should not be considered a screening test for ovarian cancer. See your doctor to discuss your concerns.

arlene: Can Premarin cause uterine cancer?

Speaker_-__Dr__Devorah_Wieder: The estrogen contained in hormone therapy promotes growth of the uterine lining. This can lead to uterine precancer and cancer. Women who have not had a hysterectomy should take progesterone in addition to estrogen to protect the uterus from too much stimulation. The progesterone may be taken continuously or for only 2 weeks out of every month.


HPV: Human Papilloma Virus

really: Can HPV go away if it is left untreated? Even if it did, can it cause other problems?

Speaker_-__Dr__Devorah_Wieder: Infection with HPV (Human Papilloma Virus) can lead to cervical cancer and pre-cancer and genital warts. For some women, the immune system will clear HPV within 24 months. For other women, the virus can persist indefinitely. Screening for HPV and frequency of pap tests depends on your age, personal health history and risk factors. Follow up routinely with your doctor for regular pelvic exams and to establish when your next pap test should be done. Ask your doctor if you are a candidate for the HPV vaccine.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Devorah Wieder is now over. Thank you again Dr.Wieder for taking the time to answer our questions about women's health.

Speaker_-__Dr__Devorah_Wieder: It was a pleasure chatting with all of you. Thanks for all the great questions!


More Information

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2014. The Cleveland Clinic Foundation. All rights reserved.