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Straight Talk about Women’s Concerns from Puberty to Menopause

August 24, 2009 | Reviewed on February 5, 2014 by Linda Bradley, MD

Introduction

Cleveland_Clinic_Host: Linda Bradley, MD is an internationally recognized gynecologic surgeon known for her expertise in diagnostic and operative hysteroscopy, endometrial ablation, alternatives to hysterectomy, hysteroscopic sterilization and the evaluation of abnormal uterine bleeding.

She is a gynecologist at the Cleveland Clinic in Cleveland, Ohio and is Vice Chair of Obstetrics, Gynecology, and Women’s Health Institute as well as the Director of The Fibroid and Menstrual Disorders Center and Director of Hysteroscopic Services. She was recently elected to the Board of Governors at the Cleveland Clinic Foundation, 2006-2010.

Dr. Bradley is certified by the American Board of Obstetrics and Gynecology. Additionally she is certified in advanced laparoscopy and hysteroscopy.

Dr. Bradley specializes in the evaluation, diagnostic testing, and surgery for uterine fibroids and menstrual disorders. She has been very active in endoscopy for over 20 years. Her expertise in endometrial ablation technology makes her an innovative leader in the field of hysterectomy alternatives. Female sexual dysfunction, menopause, and contraception are her other areas of interest. She recently was involved in several multicenter clinical trials involving endometrial ablation, uterine fibroid embolization compared to abdominal myomectomy, and hysteroscopic sterilization procedure.

She is the principal investigator for two new hysteroscopic procedures currently in development for endometrial ablation and operative hysteroscopic myomectomy and polypectomy. With over 1000 referrals for uterine fibroid embolization (UFE), she maintains an excellent collaborative practice with the interventional radiology department for a UFE Fibroid Registry database. She has published extensively and presented internationally on this topic.

A gynecologist at the Cleveland Clinic for over 18 years, she has performed over 10,000 office flexible hysteroscopic procedures and over 2,000 operative hysteroscopic procedures including myomectomy, polypectomy, and endometrial ablation. With her extensive medical background and clinical expertise, she can speak to her patients not only as an expert, but also as a woman who understands their concerns.

Dr. Bradley is committed to educating women around the world about their bodies, their health concerns, and most importantly, their options.

To make an appointment with Dr. Linda Bradley, or any of the other specialists in our OB/GYN and Women’s Health Institute at Cleveland Clinic, please call 216.444.4HER (444.4437) or call toll-free at 800.CCF.CARE, extension 46601. Visit us online at my.clevelandclinic.org/ob_gyn

Welcome to our Online Health Chat with Linda Bradley, MD We are thrilled to have Dr. Bradley here today for this chat. She is committed to educating women around the world about their bodies, their health concerns, and most importantly, their options. Let’s begin with some general questions about Women’s Health.


Women’s Health: Annual Exams

janpan: What are the current recommendation regarding breast exams?

Speaker_-_Dr__Linda_Bradley: It is recommended that self breast exam (SBE) begin monthly at age 20 years. It is best to perform the exam about one week after your menstrual cycle. If you do not have menstrual cycles, then choose the same time each month to do a breast exam.

A doctor should perform a breast exam yearly and mammogram yearly after age 40 years (if no risk factors that would suggest an earlier mammogram.)

janpan: What are the current recommendations regarding pelvic exams?

Speaker_-_Dr__Linda_Bradley: Pelvic exam should be initiated at onset of sexual activity for STD checks. If not sexually active, at age 21. Yearly pelvic exams are recommended.

However, a PAP smear is not always a part of the pelvic exam. Neither are STD checks. Physicians perform pelvic exam if there is pain, vaginal odor, discharge or abnormalities of the menstrual cycle.

babybee: Kegel exercises – is this taught by PT or your doctor or a nurse?

Speaker_-_Dr__Linda_Bradley: You can teach yourself Kegel’s, it is that easy. Check the Internet, your nurse or physician for directions. It does not require a PT.

newtonm: At what age do you recommend a younger girl start seeing a gynecologist, versus continuing to see their pediatrician?

Speaker_-_Dr__Linda_Bradley: Most pediatricians will follow their patients until age 21. Likewise, if there are complaints or gynecologic health issues that the pediatrician cannot address, then a referral to a gynecologist would be made.


Contraceptive Update

honeybee: Any new contraceptives on the market?

Speaker_-_Dr__Linda_Bradley: Mirena® (progesterone only intrauterine contraception - IUC) have gained renewed interest by physicians and marketing (commercials.) It is very safe method of contraception, inserted by a health care professional in the office and provides 5 years of hassle free contraception. Additional benefits include very light menstrual cycles, decreased menstrual cramps and 99.9% pregnancy avoidance. It is reversible.

The other newer contraception is Implanon®, a single rod is inserted in the arm and provides 3 years of contraception.

There are also 2 new sterilization procedures that do not require incisions on the abdomen. They are performed with a hysteroscope (Essure® and Adiana® procedures.) The Adriana procedure was just released July 6, 2009. These two sterilization procedures take less than 20 min. to perform in the office by a qualified gynecologist.

lasherdog3: Regarding the new sterilization procedures, how do they work to prevent pregnancy?

Speaker_-_Dr__Linda_Bradley: Both sterilization procedures block the fallopian tubes. The Essure® procedure utilizes a metal coil with a matrix embedded that will block the fallopian tube.

The Adiana® device utilizes heat plus a matrix that blocks the tube.

Both require a confirmation test - HSG (hysterosalpingogram) 3 months after hysteroscopic sterilization. Patients must use a contraceptive method for 3 months after the procedure until the HSG confirms tubal occlusion.

lasherdog3_2: Is it common for IUD removal to delay normally-regular cycles? If so, are there an average number of cycles it takes to return to normal?

Speaker_-_Dr__Linda_Bradley: There are two types of IUD's currently available. One is the copper IUD which usually when removed results in regular menstrual cycle. The progesterone IUD may require 2-3 months before re-establishing normal menses. However, again, if you are perimenopausal periods may skip. Also you need to check for pregnancy if your IUD has been removed and your periods have not returned to normal.


STD’s (Sexually Transmitted Disease)

steve: Can you get a STD from oral sex? For instance - if one person has a fever blister? Or - if a person has an STD, is oral sex still okay?

Speaker_-_Dr__Linda_Bradley: Yes - STD's may be transmitted orally during oral/anal sex - including GC (gonorrhea), Chlamydia, Herpes and Hepatitis. If there are blisters or ulcers or any lesions present, you should abstain from this activity.


HPV (Human papillomavirus)

newtonm: Can you please talk about the safety of the HPV vaccine? My daughter (who is 14) has gotten the first shot. A coworker told me the she didn't want her daughter (who is 12) to have it because of safety reason. I am now rethinking my decision.

Speaker_-_Dr__Linda_Bradley: The HPV vaccine represents one of the greatest bench to bedside breakthroughs for women. Just think about it - we have eradicated Polio, chicken pox, measles, mumps and rubella infections all with a vaccine. We now know that cervical cancer is caused by a HPV virus. This vaccination helps prevent cervical cancer. While there are minor aches, pains, redness in the inoculated area, major safety issues have not been raised.

goaskyourmom: Is there any relation between chronic cervicitis and HPV?

Speaker_-_Dr__Linda_Bradley: Chronic cervicitis is a non-specific finding on PAP smears. If it coexists with a vaginitis (bacterial vaginosis, yeast, trich) then cervicitis may be noted. However, if there are no vaginal complaints, the HPV virus is not present and there are no cervical lesions then we ignore these findings.

helpme: I have had a cone biopsy for dysplasia. Would that be from HPV?

Speaker_-_Dr__Linda_Bradley: Most causes of dysplasia are due to the HPV virus. It is only recently that we have been able to test for the presence of the HPV virus. If you have had a cone biopsy (or LEEP procedure) then make sure that you get PAP smears regularly as well as HPV testing.

lasherdog3: Is there value to testing for HPV in the absence of any clinical findings?

Speaker_-_Dr__Linda_Bradley: Yes - the current recommendation is to begin HPV testing at age 30 years when the traditional PAP is performed. HPV is very common. Approximately 50-70% of women will acquire an HPV infection during her lifetime. For most women, the virus clears up.

HPV testing is done until 65-70 years unless sexually active.


Fibroids

lasherdog3: My GYN doctor has mentioned I have some small fibroids but they are not clinically significant. If they begin to grow or cause problems, what type of symptoms will they cause?

Speaker_-_Dr__Linda_Bradley: Fibroids are found in 50-80% of women. Luckily, most women have no symptoms. Most common symptoms can be change in menstrual bleeding (intensity, quantity & duration), cramps, infertility and cosmetic effects (markedly enlarged abdomen). And urinary frequency, constipation and pelvic pain.

As you can imagine there are many conditions that can mimic fibroid related symptoms. It is best to check with your doctor to determine if the fibroid are a culprit for symptoms. We do not endorse therapies such as hysterectomy or fibroid removal when patients are asymptomatic. We believe "if fibroids do not bother you, we do not bother them."


Menopause & Hormone Therapy

joyce: What are your thoughts Dr. Bradley about switching from conventional HRT meds after 18 years to naturopathic remedy since I have concerns about breast cancer and cardiac risks as per some studies? Coming off HRT treatment would this mean that my extremely bad symptoms would reappear? My G.P. told me so, which is also a concern. I am 64. Pretty confused at to what to do next.

Speaker_-_Dr__Linda_Bradley: The current guidelines suggest that symptomatic women consider HRT. The symptoms that are currently approved by the FDA for treatment include: vaginal dryness, pain with intercourse, hot flashes, night sweats and osteoporosis prevention. Additionally, treatment with the least amount of hormones for the shortest period of time (5 yrs. or less) is advisable.

If you suddenly stop HRT you might experience rebound hot flashes and night sweats as well as irritability. Doctors do not have the right formula for how to withdraw patients from HRT. So if you stop suddenly and you are fine – great! If not, weaning off over 2-4 months (or even longer) may be required.

Now that you are older, many of these symptoms may likely already be resolved due to aging. Give it try - to taper or stop the medication.

GRAMMYRUTH: My husband says that I snore since I have entered menopause! I have tried over the counter things & also sleeping on my stomach. What is available through surgery & how successful is surgery?

Speaker_-_Dr__Linda_Bradley: I would recommend discussing this with your primary care physician who may advise an ENT or sleep disorders consult. It is probably coincidental to menopause.


Perimenopause

lasherdog3_2: Can a sudden onset of regular mid-cycle spotting (day 11 - 14) be an early sign of perimenopause? If so, is 38 years old too early to experience it? Thanks!

Speaker_-_Dr__Linda_Bradley: Perimenopause can begin in your mid-30's until the cessation of menses at age 51-58. So that changes you described can be due to perimenopausal changes, but most likely based on the timing you discussed to be mid-cycle ovulation bleeding which is normal.


Sexual Dysfunction

pamski: What to do when you are Perimenopausal--symptoms low sex drive?

Speaker_-_Dr__Linda_Bradley: Decreased sex drive is normal throughout the seasons of our life. Most importantly - what is the quality of your relationship with your sexual partner? Conflicts (financial, in-laws, kids and stress) can and do affect sexual interest. Also, following traditional sexual habits can become routine and boring.

I recommend erotic books, films and movies. Additionally, speak with your partner about your concerns (this conversation should not occur in the bedroom) As we age, it takes longer to achieve lubrication, orgasm and getting in the mood. If vaginal dryness is a problem, consider OTC lubricants, increase foreplay with manual, oral or mechanical stimulators (vibrator). Let your partner know what is happening and what you would like to happen. Begin sexual activity outside of the bedroom (fantasy, dates and planning for sex). Exercise helps, minimize alcohol or drug use. Certain medications may also contribute to a decrease in libido. Talk with your doctor.


Closing

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

Speaker_-_Dr__Linda_Bradley: Great questions. These questions and answers to many others can be found in the 2nd edition of The Cleveland Clinic Guide to Menopause by Holly Thacker, MD.


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. .


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