In Health: Modern Women Modern Options

Dr. Carol Dehasse

In Health: Modern Women, Modern Options

From scheduling well-woman check-ups, to undergoing procedures to improve sexual function, today’s women have many choices
for their gynecological care. We asked several local experts about current tests and treatments.
By Elena Acoba | Photography by James Patrick

May is Women’s Health Month, so it’s a good time to remind women that eating well, exercising regularly and reducing stress go a long way toward maintaining gynecological health.
Tucson physicians also urge women of all ages to get annual well-woman check-ups and schedule cancer screenings on a regular basis. And they encourage women to see a gynecologist as soon as any changes occur that create concern.
Several Tucson health care professionals suggest women, teens and even preteens establish a relationship with a doctor early, before issues come up.
“It’s nice to have the patients come in when they’re younger and don’t have a problem,” says David B. Mainman, M.D., of Desert Bloom Obstetrics & Gynecology. “The big point is we don’t always do a gynecological exam on a younger patient at her first visit.”
Physicians suggest that women make that first appointment no later than when they become sexually active.
There is a lot of confusion as to how often to come in for check-ups following the first appointment. It’s because many patients confuse the concept of a well-woman exam with a Pap smear test, which is used to detect cervical cancer.
The test and the pelvic exam have been so closely tied that “a lot of women say, ‘I’m going for my Pap smear,’” says Linda Turner, M.D., a gynecologist with Ironwood OB/GYN, one of the practices within the Genesis OB/GYN medical group.
Recommendations as to how often to get a Pap smear are changing, and because of that, an annual physical may not include one. However, doctors still recommend a once-a-year visit to keep track of the need for tests and screenings.
Gynecologists often can help women address general health needs as well, such as thyroid conditions, weight concerns, diabetes, bladder and ear infections, and depression.
“Women over the years have gone to see ob/gyns for other things,” says gynecologist J. Manuel Arreguin, M.D., executive medical director for professional staff services at Tucson Medical Center. “There is a trust factor here about women talking with their gynecologists.”
Specialized health services have consolidated over the years to make it easier for women to address their needs. Of course, obstetrics, which deals with maternity, and gynecology, which focuses on conditions and diseases that specifically affect females, have been paired for a long time.
TMC for Women brings together doctors and other health professionals, diagnostics, surgical units and childbirth facilities into one section of Tucson Medical Center. The Joel M. Childers, M.D., Women’s Center essentially is a one-stop location for women’s health needs throughout their lives.
Some doctors offer aesthetic procedures that can be performed in their offices. For instance, Dr. Mainman conducts laser treatments that rid the body of fat. He says he offers the service for patients who say they would like to take care of this cosmetic procedure at the same time they visit him for health issues.
Tula Wellness, owned by gynecologist Arianna Sholes-Douglas, M.D., is a place where women can get medical care, cosmetic procedures, weight-loss and nutrition programs, sexual function consultations and massages. Dr. Sholes-Douglas calls it “one big pot of services.”

“Robotic surgery has made pelvic reconstruction easier and recovery better. It can be a viable alternative to a hysterectomy.” — Carol Dehasse, M.D., gynecologic surgeon, Northwest Allied Women’s Health.

Conditions and Diseases
Pelvic pain and irregular bleeding are two symptoms that should not be ignored, especially if they affect everyday
Pelvic pain may come or go in the menstrual cycle, says Carol Dehasse, M.D., a gynecologic surgeon with Northwest Allied Women’s Health who is associated with Northwest Medical Center. She urges a doctor visit “if you’re missing work or can’t have intercourse or are having pain during intercourse or taking pain medication.”
If you’re post-menopausal, see a doctor right away after experiencing these symptoms, Dr. Dehasse advises. “We want to make sure there isn’t a malignancy,” she says.
Dr. Mainman concurs. “Once you’ve been menopausal and not had a period, any bleeding needs to be evaluated,” he says. “It may be safe, but it’s never normal.”
The pelvic area is complex, says Dr. Turner, and involves not only reproductive organs, but the bladder, intestines and colon. A gynecologist can help pinpoint what is causing a problem.
The initial work-up for both symptoms is essentially the same: a physical examination, ultrasound test and blood tests.
Depending on the condition, treatment can be as convenient as oral medication and lifestyle changes, or as serious as surgery.
Much of the surgery for gynecological issues isn’t as invasive as a decade ago. For instance, a hysterectomy to remove the uterus today is often done using laparoscopy, which requires only three small incisions instead of one large incision that exposes the organs. Robotic surgery provides better precision in repairing or removing organs or malignancies.
These newer surgical techniques reduce the length of an operation, as well as post-surgical pain, complications, recovery time and scarring. “When you’re doing laparoscopy or, better yet, robotic surgery, it’s not uncommon for women to recover within two weeks,” says Dr. Arreguin.

Dr. David B. Mainman

Heavy bleeding. Frequent, long-lasting or heavy blood flow that causes you to miss work or social activities can lead to anemia and other problems that need addressing, Dr. Dehasse says.
Doctors will look for polyps, fibroids and cysts and check for endometriosis, when uterine tissue grows outside of the uterus, and endometrial hyperplasia, when the lining of the uterus is too thick.
If exams turn out to be normal, hormones, including birth control, can help regulate flow.
Another option is endometrial ablation, which cauterizes the uterine lining. “It is a very quick, easy technique for women who have heavy menstrual flow,” says Dr. Turner. The in-office procedure can lighten or eliminate periods.
Fibroids, or benign tumors, can be removed (myomectomy) while keeping the reproductive organs intact. Women not considering pregnancy can opt for a hysterectomy. An oral treatment is a GnHR agonist — a medication that puts the body into a menopausal state.
Women suffering from endometriosis also may find relief with a GnHR agonist, as well as with a host of other hormone treatments. Outpatient laparoscopy can remove tissue to relieve endometriosis. A hysterectomy is another option.

Childbirth. TMC’s Women’s Center reduces the need to move patients around for tests, monitoring, delivery and post-partum care. “We know every mom’s wish is to have a safe birth with a healthy baby,” says Mimi Coomler, vice president and chief nursing officer for TMC. “The center is designed for the best outcomes possible.”
The Women’s Center at Northwest Medical Center is exclusively a labor and delivery facility equipped and staffed for every contingency. Other birth centers are at Banner—University Medical Center Tucson and Carondelet St. Joseph’s Hospital.

Urinary incontinence. If you lose urine when you sneeze, pick up something or do another action, you have stress incontinence. If you suddenly need to urinate and you can’t hold it, that’s urge incontinence.
Menopause and childbirth often lead to weakened muscles that create the condition. Dr. Sholes-Douglas says doing pelvic floor exercises throughout your life, especially after delivery, will keep those muscles strong. “Pelvic tone is part of your sexual health,” she says.
A polypropylene mesh sling can be inserted to hold up the urethra. This is a different procedure from the controversial mesh used for pelvic organ prolapse. “Complications are relatively uncommon” for the sling, Dr. Mainman says.
A procedure that helps build up collagen in the vagina can alleviate urinary incontinence for some patients. The MonaLisa Touch, offered by the Genesis medical group, and ThermIVa at Tula Wellness, stimulate the immune system to regenerate thinning and dry tissue around the urethra.
A type of urge incontinence called overactive bladder can be controlled with medication.

“Regular Pap smears and human papillonavirus (HPV) testing remain the cornerstones of screening for pre-cancerous conditions of the cervix.”  — David B. Mainman, M.D., Desert Bloom Obstetrics & Gynecology.

Pelvic organ prolapse.
The same weakened muscles that cause urinary incontinence also cause other pelvic organs, such as the uterus and bowel, to sag. Sometimes the pelvic floor is so weak that the uterus starts to slide into the vagina.
A remedy from the ancient Egyptians is a valid treatment today, says Dr. Dehasse. She describes the pessary as a rubber apparatus that’s inserted into the vagina and pushes organs into place.
For sexually active women, pelvic reconstruction used to be a last-resort procedure, says Dr. Dehasse, but “robotic surgery has made the procedure easier and recovery better. It can be a viable alternative to a hysterectomy.” The surgery can be conducted through the abdomen or through the vagina.
Transvaginal mesh is used when repairs to the vaginal wall need reinforcement and as a way to keep the organs in place. Significant complications with the mesh — which is larger than the sling used for urinary incontinence — include pain, mesh erosion and infection. However, Dr. Mainman says, it’s an effective treatment for some women and surgeons continue to use it.
For women who no longer are sexually active, another treatment option is to sew the vagina shut, Dr. Dehasse says.

Dr. Linda Turner

...The ease of birth control use is crucial. "The bottom line is what is going to work for each patient.... If you're not using the contraception, it's not working." — Linda Turner, M.D., gynecologist, Ironwood OB/GYN.

Cancers. Confusion by patients over when to screen for cervical cancer has already had real impact.
“Regular Pap smears and human papillomavirus (HPV) testing remain the cornerstones of screening for pre-cancerous conditions of the cervix,” Dr. Mainman says. Yet, the disease may not be caught early enough if women aren’t getting regular Pap smears or tests for HPV, which causes the cancer. “We already are beginning to see more cases of higher-grade abnormalities in our practice,” he adds.
This is happening even as cervical cancer has decreased 50 percent in the last 30 years, says Dr. Turner, thanks to the screenings and the use of the HPV vaccine, recommended for boys and girls between 9 and 26 years old, and preferably before they become sexually active.
You should have your first Pap smear at 21 years old. Results at an earlier age show many false positives. Dr. Turner recommends further screening every three years until age 30, then every five years with the HPV test. After 65, Pap smears aren’t usually necessary.
Researchers are developing a probe that will better test for the presence of HPV, says Dr. Arreguin. If none is detected, it’s also likely that cervical cancer cells are not present. This could change the use of Pap smears. “I think the Pap smear by itself would largely be eliminated,” he predicts.
When to have mammograms to detect breast cancer is even more confusing. “There are so many different alternatives,” says Dr. Arreguin, “and sometimes you have competing organizations fighting each other. The best advice is working with your doctor to determine the optimal schedule for you.”
Genetic testing could be a crucial component in that determination. Dr. Mainman says finding genetic markers for breast cancer, as well as for ovarian and endometrial cancers, can help measure your risk for getting these diseases. Having a higher risk “makes a huge difference in what the (screening) recommendations are,” he says.
Early detection through screening could mean better treatment and cure.

Dr. J. Manuel Arreguin

When to have mammograms to detect breast cancer is even more confusing.... "The best advice is working with your doctor to determine the optimal schedule for you." — J. Manuel Arreguin, M.D., executive medical director for professional staff services, Tucson Medical Center.

Young females having their very first well-woman exam with a gynecologist often talk a lot about reproductive health. That’s a good thing.
“We need to get away from the stigma of talking about reproductive health,” says Dr. Arreguin. A gynecologist can help teens navigate healthful sexuality even before they become sexually active, he says.

Contraception. Long-acting reversible contraceptives are quite effective and popular methods of birth control for teens and young women. The intrauterine device (IUD) and subdermal implant require one insertion; then it’s essentially forgotten, absent any complications. They can be removed when the user wants to become pregnant.
There are lots of other methods, including birth control pills, patches and rings. How to sort it out requires discussion with your doctor. Some issues to consider, Dr. Turner observes, include what has worked in the past, how well you can follow medication instructions, and your plans for children.
Most of all, the ease of birth control use is crucial. “The bottom line is what is going to work for each patient,” she says. “If you’re not using the contraception, it’s not working.”

Vaginal rejuvenation. Vaginal dryness, loss of sensitivity, painful intercourse and vaginal laxity are some of the consequences of childbirth, menopause, cancer treatments and other conditions. Vaginal cream has been the go-to treatment for these conditions. Two Tucson practices offer alternative in-office procedures to improve these conditions by increasing collagen in the vagina.
ThermIVa at Tula Wellness and the MonaLisa Touch from the Genesis medical group work on the same principle — using heat to stimulate collagen, a natural protein, that improves the vaginal canal. Both procedures take only a few minutes. Neither is covered by insurance.
The MonaLisa Touch uses a laser to generate heat. “Little beams of laser stimulate the immune system,” Dr. Turner says. “In sort of an injury response, this very thin layer regenerates into a very nice, moist enclosure.”
The initial MonaLisa Touch procedure requires three treatments six weeks apart. That is followed by an annual maintenance treatment. European studies claim improvement in 95 percent of patients, Dr. Turner says.
ThermIVa uses radio frequency to produce heat. The procedure, which treats both the vagina and labia, consists of three treatments about a month apart.
Dr. Sholes-Douglas says she receives many comments, particularly from women over 60 years old, who have improved sexual response after the treatments. “Women are excited to have options that are non-invasive and non-surgical, comfortable, safe and with no down time,” she says. TL