Tuesday, February 8, 2011

the Doctor's Note

The powerful doctor's note.

 Some people think we will write anything on their behalf.

Two recent requests for doctor's notes come to mind. One from a woman who was pulled over for not wearing a seatbelt. She wanted to take a Doctor's Note to court excusing her from wearing a seatbelt because she is claustrophobic. As far as I know, not wearing your seat belt makes you a flying object in a car, and a menace on the road. I don't think doctors have the right to waive that requirement. Perhaps she should consider a public conveyance that does not require restraint like a bus.

The second one is from a woman who wants a Doctor's Note to take to Weight Watchers. She doesn't want to lose weight. It's her husband, you see, she does his cooking and feels that she deserves to be a lifetime member of weight watchers. This one I don't understand at all. That's what cookbooks are for, and all the literature WW gives its members. I don't think they allow you to audit this course.

Of course there are the "too numerous to count" disability requests due to pregnancy. Women  have had the audacity to ask for permanent disability at two months of pregnancy when they had a 9-5 desk job while I was "out to here pregnant" on my feet all day and most nights. The letters of medical necessity for an at home gym because we recommend exercise, the letters to extend sick leave when the patient has recovered "because I have another two weeks".

Then there are the drug fraud scams that patients will request you to approve. You prescribe a medication for two weeks for an acute illness. The patient requests you make it out for 90 days, because the copay is the same. Are they selling this stuff on the black market?

Not to mention the "get me out of jury duty" letters. The excuses for that one are legendary. "I am going to be on my period that week." " I have to go to the bathroom every two hours." " I had surgery" ( last week, last month, last year, ten years ago) you get the picture. I take medication.What does that mean? What happened to a jury of peers or civic duty?

Then there are the endless requests for controlled substances: sleeping pills, narcotics, tranquilizers that I have no diagnosis for and have never prescribed. The famous, I lost my prescription is popular especially at night, on the weekends and on Friday at 3pm.

Remember who selection committees pick for medical school. Doctors tend to be straight shooters who don't want to lose  medical licensure due to fraud.

So when you are denied prescription requests, doctor's notes, or letters for court, remember we are liable for the veracity of our statements, and generally believe in accountability.

Until next time......

Friday, February 4, 2011

Abnormal Uterine Bleeding and Modern Gynecology

I thought I would write a bit about abnormal uterine bleeding. There are a number of causes, but things basically boil down to two groups:

 Hormonal and Anatomical.

Most hormonal problem bleeding is irregular. Some women will tell me they have never had a regular period in their menstrual life. Some women will develop this in their 30's and 40's after having had normal spontaeous periods. Oh, let's differentiate between spontaneous periods and those on hormones. I am talking about spontaneous periods. Usually irregular bleeding with birth control pills/ Depo Provera/ Mirena IUD and progestin only birth control pills is due to taking the medication. No periods when you are not pregnant also fall into this category.Most irregular bleeding with spontaneous periods is due to hormonal issues. There are four levels where things can go wrong. The uterus, the ovaries, the pituitary gland and the hypothamus. Your gyn will check these depending upon the clinical scenario.

Anatomical abnormal bleeding is generally in the form of heavy bleeding or abnormally light bleeding. This is generally due to problems with the uterus itself. Most of which is benign, but could be premalignant ( precancer ) or malignant (cancer). This includes fibroids, polyps, hyperplasia, cerivcal problems, infections, you get the idea.

Methods of understanding what is going on depends upon the clinical picture, but blind D&;C has pretty much been abandoned as a diagnostic tool. Hysterectomy has been reserved for cancer and large tumors.Ultrasound, saline infusion hysterogram ( "water test"), hysteroscopy and endometrial biopsy help the gyn to diagnose the exact issue, and then target therapy. Some bloodwork may also be done.

Many therapies exist for heavy periods that did not just a few years ago. The use of  agents to induce clotting now has been approved by the FDA and is finding a place to treat those one to two days of heavy bleeding some women experience. The use of a progesterone bearing IUD is another great way to manage heavy bleeding without surgery.Hysteroscopic removal of fibroids and polyps helps eliminate these frequent and specific problems.Uterine Artery Emobolization is a nonsurgical way of treating the heavy bleeding due to fibroids. Some practitoners perform these in the office Endometrial ablation is  a permanent outpatient surgical procedure that has been around in a number of forms for twenty years.. I have never found that to be too comfortable, but recent studies show that most women find the discomfort associated with this as an office procedure acceptable.

The bottom line is that irregular, absent, or heavy bleeding as a problem should not be ignored, and that many specific diagnostic studies are available to target specific therapies.

Until next time....

Friday, January 7, 2011

Bioidentical Hormones, the Confusion and Balance

Good day dear Readers

The issue of Bioidentical Hormone Replacement had come up again and again. Here in South Florida it is touted as a feel good, safe option and antiaging, youth enhancing, and general good for you regimen.

There is a webinar called "The Buzz on Bioidenticals" that is a good but somewhat biased resource. It presents the facts regarding bioidentical hormone replacement, and why practitoners like transdermal preparations. It was developed by a group called "the Red Hot Mamas" and Dr.Elizabeth Lee Vliet.
I found the discussion informative but biased against compounding pharamacies. 

The truth is of course, always somewhere in the middle.

Both FDA approved and compounding pharmacies dispense bioidentical hormone replacement. Until I arrived in South Florida, the need to prescribe compounded products was almost negligible. It seems to be local custom to get creams and gels from the compounder instead of the pharmacy. Not a problem for me, but buyer beware. The compounding pharmacist uses the same precursor ingredients as the phamaceutical industry, and is regulated by your individual State Board of Pharmacy. They are not compounding roots and berries. These products are essentially all from plant source originally.Any preparation that is compounded does not get you the FDA required information regarding side effects, risks and benefits. Many women interpret this as it must be "natural and safe". No, it is a drug and has the same risks and benefits as FDA monitored medication.

Depending upon your global location, you will have estradiol( E2), and progesterone available to you. Estrone (E1)is a weak estrogen that is not usually secreted until after menopause, it is biologically mostly inactive. Estriol ( E3)  is another estrogen made by the placenta during pregnancy. Neither of these is necessary as a postmenopausal hormone. They are often combined with estradiol in compounds, but are unnecessary.
Estradiol is the predominant estrogen prior to menopause.It is secreted by the ovarian follicles (eggs) every day.

Progesterone is secreted by the ovary after ovulation and during pregnancy. It stabalizes the uterine lining.It stops being secreted if you are not pregnant and a period ensues.Progesterone is not necessary after hysterectomy. It only serves to increase side effects and risk.

Testosterone is used rarely for short intervals for those women who need more control of hot flashes or increase in sexual thought. It has lots of side effects including hair growth, acne, adverse effects on lipids and cardiac risk. Like most anabolic steriods, it give people a feel good effect, but underneath is treacherous.

Methods and forms of administration vary from oral to topical cream, gel, lotion, patch and transvaginal gel and rings. In some localities there are subdermal pellets and implants. I try to stick with the cheap and easy to administer transdermals. Research shows these pose the least risk and are easy to manage.Remember that the sooner you start the most benefit and least risk is derived from HRT.

Good resources are:www.menopause.org,www.acog.org; http://www.thebuzzonbios.com/

I believe in evidence based medicine. We know what works, what the issues are with the problem/solutions and what to expect. Unfortunately that doesn't occur with each and every problem, issue or solution. I try to stick as close to that as possible to protect my patients. Sometimes I need to draw outside the lines and go to compounding, but rarely. If you are wondering about what to do, stick with the tried and true first. Most people respond just fine and the costs tend to be much lower. If you are having difficulties with your HRT talk to your provider and work them her/him to get to your happy place. I have worked with thousands of women in menopause and have yet to find one that didn't find her happy place. Sometimes it just takes a bit of doing.

Wednesday, December 29, 2010


I have a lovely patient whose issues with her sexuality I understand. She has always been very sexually responsive, and this waned recently. For  her, it was most distressing. We tried a few things, and found the right balance to get things back on track. For this she is most appreciative. She gave me a bottle of
 KY Intense for Christmas. What a woman!

What I really like about this lady, is that she did not give up with the first try. She allowed me to work with her to get to her happy place. That is most unusual as we have been led to believe that answers, solutions, and cures are almost instantaneous with coming to a doctor's office. Testing sometimes is done in real time with immediate read outs of imaging and results of tests. Online access to results fast tracks communication.

Medical problems are usually not acute, and develop over time. Diagnosis and treatement sometimes takes time, as well as healing. Just some thoughts next time you go to the Doctor. Discuss time. Be explicit about your expectations for the visit, and make sure you and the doc communicate on the importance of your problems to you. We can then address the issues with you on a level that speaks to you clearly.

Hope this helps.

until next time..........................

Tuesday, December 14, 2010

The Unhappy Vagina or Something's Wrong Down There

OK, I have become an ambulatory gynecologist. What does that exactly mean? After doing annual womens' health screening, my number two most seen problem is the UNHAPPY VAGINA.

I just returned from a meeting of the American Society of Colposcopy and Cervical Patholgy. Otherwise known, as cervix , vagina and vulvar specialists. We wreaked havoc on the psychological health of the media guy who ran the slide shows. We were fascinated by all the varying lumps and bumps on the vulva, new and terrific diagnoses of "Unhappy Vagina Syndrome".

Many women come in to see the gyn with a "something's wrong down there" problem. It's up to me to figure it out and fix it. AND FAST. This is usually a problem that occurs on Friday and needs to be fixed by Friday night. Monday, hmmm somthing may not be quite right. Tuesday, OK maybe I should get something. Wednesday is a trip to the drugstore. Thursday, it's not gone, and getting worse. Friday gets a call to the gyn. GET ME IN NOW!

Most of what women self diagnose as yeast infections are not. They are a myriad of other problems, some infectious, and many are from irritants and allergens.

About one third are correctly self diagnosed and treated at home with over the counter medications. Of those that need the doctor, we never see anything uncomplicated. It can be from a week to years in the making. From normal cervical mucus, to a mixture of problems that envies an onion. After upteen years I have gotten pretty good at figuring this stuff out.

I have a secret weapon, Ladies Magic Cream. I have sent the secret formula to Clevland Clinic to see if it is worth commercializing. We'll see. In the mean time, it is always worth a trip to the gyn to figure out if it is an infection, what type, mixed or single. Irritant, allergen, hormonal, or normal.

Yeast grows in especially hot and humid conditions. For heaven's sake, lose the underwear at bedtime.
Cool and dry makes a happy vagina.

Bacterial Vaginosis is the newer name for nonspecific vaginitis, gardenerella, etc. This is an upset in the normal bacterial ecology. Someone other than the lactobacilli grow, and a stinky discharge with burning is the winner. This is treated with antibiotics. Over the counter stuff rarely works.

Irritants come in all types. The changes in your detergents, soaps, clothing, shampoo, pads, etc will make you red and on fire. The tip is to lose the irritant and soothe the unhappy vagina. It ususally takes a trip in to see the extent of the damage to Rx something to relieve inflammation and institute a regimen of healing.
The bathtub is your friend. No soap, just water.

Allergens are rare, and have a delayed reaction. That is the key difference between them and irritants. Again, discovery and avoidance is how it is managed.

All in all, my experience validated me as a major geek interested something that would get you in prison in several countries.

Until next time...........

Wednesday, December 8, 2010


Hello all
The Holidays are upon us, and cyber week was a grand success! I was minding my own business when...I browsed through Amazon.com to find a movie one of my sons's wanted. In the featured cyber week ads were TVs.

Hmmm I thought, wonder if one would like to find its way to my bedroom? Or maybe the spirit of Xmas will fill me and I will see if my Mom would like one to replace her ancient tube. Well I am on the Amazon page, and call Mom. No she says, her tiny kitchen TV is just right for her and that 32 inch flat screen won't fit. OK then, now I am still thinking about the bedroom, when the mouse wanders over to the upper right hand of the screen, and I click to close out the page.

At least that's what I thought I did. No, I find out on Tuesday next. I look up the " Where's My Stuff" part of Amazon to find the movie I purchased for sonny boy. It asks if I want to track my ORDERS, emphasis on the S.
Just what have I done? Well looks like that 32 inch flat screen is on a truck headed for Grandma's house. I have ONE CLICKED MY MOTHER A TV.

This is at 8:30 am. My Mother is a night owl and rarely wakes prior to 9am. I call her. Ma, Ma listen, I need your help. I accidently ordered a TV and it is headed to you NOW. It is on the truck for delivery. I have her attention.

She bolts out of her fog, and starts up with " I can't wait all day for UPS, I have a hair appointment" and I have to go to the doctor. My ride is going to pick me up at such and so. I am now begging her to help me out of my embarassing mess. I frantically look up the returns part of Amazon. Seems simple enough. Reason for return... hmmmm. stupidity is not listed. OK, not wanted anymore ( or ever, actually ). I click, the instructions say, not to worry, the UPS driver will come get this TV tomorrow with a return label. My cost can go up to a total of $18.86. Chump change for idiocy. I am so happy free shipping goes both ways. I am hoping that this will not be a disaster.

By now my mother has all her feathers ruffled, going on and on about the UPS driver, needing to be home, and having to go to her appointments. I am pleading, just let him push it in the door and wait for another nice man to come take it away......Please Please...... She is near hysterical thinking they will leave it in her hallway in a NYC apartment building. God no I hope, gone in 60 seconds flashes through my mind.

Now I am guilty thinking I am going to give some poor guy a hernia dragging the TV to her apartment just to have her tell them what a moron her daughter has been, then the next guy the same rant when he comes to pick it up. I am sunk.

OK Mom, its not going to be a little box. It's a 32 inch flat screen TV. Big Box. Ok, ok, hopefully they won't show up until 7pm when you are back from the doctor. Ok she says. I cross my fingers.
Give me the tracking number she asks. Ok, I whimper.

I am terrified to call her in the evening to see how things have gone. She has called UPS to track the package. On the truck, out for delivery they say. They advise her to refuse delivery. Return to sender.
The driver eventually drags the TV to her apartment. Its a woman. Worse than I feared. She pleads with my mother to keep the TV. Lady, its a 32 inch flat screen TV someone wants to GIVE YOU for Xmas!!

No, Mom insists, her little tube is just fine. TAKE IT BACK. Ok, the driver says and drags the thing back to the truck. Now my mother lives on the 19th floor of a high rise. This has not been a good day for the UPS lady. I am doubly guilty again hearing the tale.

Well, its back on the truck. I hope.

Hope your HOLIDAYS are filled with the joys of the season. I know mine are.

Until next time ................

Wednesday, November 17, 2010


This is not a disease. This is a curse, like diabetes. It robs people of their lives. Starts young and goes forever. Most cancers get better and more effective treatment. Most of you know that endometriosis is a benign gyn condition where uterine lining is found outside of the uterus. Lots of theories abound how this is possible. The most common theory is that menstrual lining refluxes through the tubes back into the abdomen and becomes like seeds on the sidewalk. A few take hold in the cracks and grow.
Another more recent theory is that of genetic predisposition and metaplasia of otherwise normal tissue turning into endometrium.

At any rate, either way, it is a bitch.
With each menstruation the uterine lining finds itself bleeding, which in the places where it shouldn't be, means pain. The fluid/tissue is irritating and causes moderate to severe pain on a monthly basis. Eventually it causes pain every day which can become debilitating. It sometimes leads to infertility as well.

Diagnosis is only by direct vision of the stuff in your abdomen by the doctor and sometimes a biopsy. No xray or blood test is helpful, however the story of painful menses leading to pain during more times in the cycle, painful intercourse is suggestive of endometriosis.

Treatment has centered around hormonal therapies simulating times when a woman is normal but not menstruating such as pregnancy, breastfeeding or postmenopause. These are commonly known as treatment with birth control pills, progestin only contraception such as Depo Provera, and GNRH analogs such as Lupron and now aromatase inhibitors such as Femara. They all work to some degree, but are temporary fixes.Conservative surgery has been the hallmark of diagnosis and treatment for some time, with hysterectomy being the final assault on the problem.

Conservative surgery includes laparoscopy with ablation/ cautery or excision of endometriosis lesions. The excision is the best therapy, however it can be tricky and sometimes technically impossible. There is always more, so hormonal therapy follow up is what I recommend.

When I was a medical student a million years ago, the professor taught us that young women with difficult periods needed to marry young and have their children early. Still good advice. A life plan is a critical part of this problem. Those words from the professor still ring true. For women with endometriosis, the sooner they complete their families the better. New and improved medical and surgical approaches are coming, but not soon enough for many women.

Until next time.........