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By Kassandra Patton

Many people have concerns about social media’s impact on their mental health. Social Media (SM) includes Facebook, Twitter, Instagram and Snapchat, to name a few. 40% of the world’s population has at least one SM account. This translates to roughly three billion people with most users averaging 2 hours of SM use per day. What impact does this usage have on overall health? How does it impact our feelings about ourselves? Our relationships with others? The answer may surprise you!

At first, statistics around SM usage seem to contradict themselves. While a 2014 study showed a worsening of mood after 20 minutes of Facebook usage versus general internet usage, another study cites that the more women use Twitter, the less stress they report. A 2016 study showed a three-fold increase in depression and anxiety in those who use a higher number of social media platforms while another study showed an increase in overall well-being in some heavy SM users due to support and encouragement received when they posted about problems they were experiencing. While these statistics seem confusing at first, it may be helpful to look at how social media impacts different areas of our lives.

Self Esteem– One-half of 18-34 year olds report feeling that social media sites make them feel inadequate and unattractive. Women especially, compare themselves to other’s selfie photos that can be doctored with filters and effects to enhance looks. Overall, women who spent more time on Facebook reported feeling less happy and confident with themselves.

Insomnia– Internet and screen usage in the few hours prior to bed have been linked to difficulties in both falling asleep and staying asleep. The blue light emitted from tablets and phones held close to the face has been shown to decrease the brain’s production of melatonin. Melatonin is the hormone that the body releases in response to decreasing light to tell the body it’s time to go sleep (which explains why you can be tired at 5:00 p.m. in December!). While social media itself cannot be directly tied to sleep disruption, there is a clear connection between increased screen usage and insomnia.

Loneliness– While it may seem that social media connects us to others, a study of 7,000 19-32 year olds found that those who spent the most time on social media also reported the most social isolation. This may be a cause and effect issue since those who feel more isolated may try to connect to others via the internet. In fact, one of the positives of social media is its ability to stay connected to distant relatives and friends. Also, those who feel overwhelmed or apprehensive about contact in person, such as people with certain anxiety disorders, may gain a sense of connection with others in the comfort and safety of their own home. This may explain the statistic that notes an increase in anxiety in those who use seven or more social media platforms versus those who use two or less. It could be that those with the most anxiety are more likely to be trying to connect with others via social media. The study couldn’t determine whether social media caused the anxiety or the anxiety increased social media usage. 

Stress– People use social media to vent their daily stresses and frustrations, which can be a good thing. An outlet to share concerns with those who can offer support may help improve moods. Those able to express their emotions and receive support from friends and family are more likely to benefit from social media and report a better overall sense of well-being. However, not everyone uses social media to support those that post their true thoughts or feelings and negative comments can lead to worsening of stress in someone seeking relief from frustrations. In addition, if a person posts negative comments to express their feelings, their news feed may be filled with other stress-related posts, increasing overall stress when viewed. 

Relationships– The mere presence of a cell phone while people are interacting face to face can decrease the overall recall of what was said during the conversation. In a study with people conversing in a private, one on one environment, half had their cell phones with them and the other half did not. Even though they did not use their cell phones during the conversations, those who had them had a decreased ability to recall what was said. They also reported less meaningful conversations and were less likely to report a sense of closeness to the other person. 

This study does not have anything to do with social media directly, but cell phones are frequently used to access social media sites and are often the first thing somebody reaches for when they are bored or when there is a moment of downtime which might lead to the next topic in conversation. 

Addiction– While there is not a medical diagnosis of “Social Media Addiction” at the time of this writing, there is a diagnosis of “Internet Addiction Disorder” that is defined as “any online-related, compulsive behavior which interferes with normal living and causes severe stress on family, friends, loved ones, and one’s work environment.” Excessive internet usage has been linked to problems in relationships, worsening school achievements and a decrease in “real world” activities. Anyone can fall into the trap of internet addiction, but those with few ties in real life may be more vulnerable. In other words, those reporting more social isolation can be using social media the most. At the other end of the spectrum, those considered “highly extroverted” or very outgoing may also be more at risk for Internet addiction as they seek more social interaction or positive reinforcement from both “real life” and social media. 

What Can We Do– What can we do to incorporate social media into our lives in a healthy way? Here are a few recommendations to help maintain a healthy balance: 

Turn off notifications from your social media sites. This will help keep you from being pulled from the “real world” into the online world. Establish a time each day when you check your news feeds and then that’s it for the day! 

Pick up the phone! Actually make phone calls or set up times to meet with people face to face. 

Then put down the phone! When you are interacting with people, make sure your device is stashed in your purse or bag and not within eyesight. 

Hide negative posts and people in your news feeds by unfollowing them. Fill your news feeds with positive people, pages, and things that bring you joy. 

If you have a good, supportive online network, reach out and share your struggles. You may be surprised to find how often others share the same difficult issues. They may be able to offer you advise on how to get through hard times or at least lend a sympathetic ear. 

Limit your tablet and smartphone usage in the 2 hours prior to bed. Watching TV from a distance should not impact ability to fall asleep as much as screens that are held close to the face. 

If you still feel like you are struggling, make an appointment to see your health care provider to discuss your concerns. They may have additional resources to help you. 

Kassandra Patton, WHNP joined Kalispell OB/ GYN in March of 2013, moving to Montana from Illinois with extensive experience as a women’s health nurse practitioner. Prior to becoming a nurse practitioner, she worked for 10 years as a labor & delivery nurse. Kassandra has a strong interest in teenage wellness exams, reproductive health and contraception management. She and her husband, Jeremy, have two children, three dogs and two cats. They love the outdoors and moved to Montana looking to enjoy a better lifestyle in our beautiful Big Sky Country.

406 Woman Magazine / Health /

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Birth Control – Part 1

There are so many birth control options available to choose from today that picking which method is best for you may seem a bit overwhelming. Let me help by breaking down the options based on how often each method requires your attention. Working with your provider, we can find the best birth control to fit your lifestyle.

Daily

Oral Contraceptive Pills (OCP’s) or “The Pill” 

Combined Oral Contraceptive Pills (COCP) COCP’s contain a dosage of both progestin and estrogen to prevent ovulation and thus prevent pregnancy. The hormones also work by thickening the cervical mucus and making it difficult for semen to get past the cervix and into the uterus. COCP’s generally have three weeks of an active pill and one week of placebo or “sugar” pills. Some COCP have three months of active pills and one week of placebo pills, which allows the user to have a period every three months. COCP’s come in many different formulations and dosages, which mean that a woman can usually find a pill that works well with her body. The most common side effects of COCP’s are slight nausea or headache in the first few weeks, mood changes, irregular bleeding for the first few months, and weight gain. If you are over 35 and smoke, have a history of cardiovascular disease or high blood pressure; this medication may not be appropriate for you. Effectiveness of this birth control is from 93-99% when used and taken properly. 

Progestin Only Pills (POP). POP’s contain a single dose of progestin for each day of the pill package with no placebo days. A woman may experience a light period during her normal, expected time, or she may have no period at all. The most common side effect with POP’s is irregular bleeding or “spotting”. A woman with pre-existing depression may also find that POP’s may worsen this so it is important to discuss any concerns with your provider prior to starting this method. Effectiveness is anywhere from 93-99% when used and taken properly. This method is safe to use when breastfeeding. It is important to take this medication at the same time each day to maintain the highest effectiveness.

 Weekly

Ortho Evra Patch. This patch has the same type of ingredients as the COCP’s, but instead of daily usage, you apply a patch that is changed once per week to the skin on your hip for three weeks. During the fourth week, a patch is not used which allows the user to have a period at a predictable time during that week. There is only one available dosage with this product and its effectiveness is anywhere from 93-99% depending on actual usage. There has been some evidence that the patch may not be as effective in women weighing more than 198 pounds thus an alternative method may be needed.

Monthly

Nuva Ring

The Nuva Ring is a small plastic ring-shaped device that is inserted into the vagina once per month. It is removed after three weeks and thrown away. The woman does not use anything for one week and it is during this week that she should have a predictable period. The device works the same way as the COCP and patch, using progestin and estrogen to prevent ovulation and increase cervical mucus. The Nuva Ring is able to use a lower dose of estrogen than either the patch or most COCP’s and so estrogen-based side effects such as nausea, breast tenderness and headache are reduced. Effectiveness is anywhere from 93-99% depending on actual usage. 

Every 3 months

Depo Provera Injection

Depo Provera is a single dosage of progestin given every 3 months through a shot in the muscle at the doctor’s office. It boasts 97-99% effectiveness with minimal effort on the part of the woman using it. Some women experience irregular bleeding in the first 3 months, but the majority of women will go on to have an overall decrease or complete absence of periods. This is considered healthy and is no cause for concern. A drawback of using Depo Provera is a loss in bone density that is noted in women who use this product for more than two years; although this loss is reversible once the medication is stopped. It may also take a user of Depo Provera up to 18 months to return to fertility after the last injection given, so this choice may not be the best for those seeking a very short-term form of birth control. This method is considered safe for breastfeeding mothers.

We will conclude this discussion in our next 406 article, when we will go into detail about long term birth control options. These include Intrauterine Devices that are effective for 3 or 5 years, as well as some effective for up to a decade!

With so many choices available for birth control, we urge you to speak with your health care provider to decide the best option for your health and lifestyle. 

Kassandra Patton WHNP joined Kalispell OB/GYN in March of 2013, moving to Montana from Illinois with extensive experience as a women’s health nurse practitioner. Prior to becoming a nurse practitioner, she worked for 10 years as a labor & delivery nurse. Kassandra has a strong interest in teenage wellness exams, reproductive health and contraception management. She and her husband, Jeremy, have two children, three dogs and two cats. They love the outdoors and moved to Montana looking to enjoy a better lifestyle in our beautiful Big Sky Country.

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Kalispell OB•GYN Associates by Kalispell Ob/gyn - 4M ago

by Kimberley Forthofer, ARNP |Kalispell OB/GYN

Osteoporosis literally means porous bones. Following menopause, women are at increased risk for development of osteoporosis due to the sharp decline in estrogen levels during this transition. One in two women over the age of 50 will break a bone due to decreased bone density or osteoporosis. There are varied risk factors for osteoporosis. Women should understand their individual risks, talk to their practitioners about when screening is right for them, and learn about prevention and if needed, treatment of osteoporosis. 

Risk Factors

Caucasian women have about a 20% risk of developing osteoporosis whereas Black women have about a 5% risk. Women who start with lower bone density, such as petite women or those who have gone prolonged periods without menstruating, are at greater risk for development of osteoporosis. Typically, after age 30 women are no longer building bone density but begin the gradual loss of bone density. Women between the ages of 20 and 80 lose about one-third of their bone density during this time. Having a family history of osteoporosis also increases risk. Smoking and excessive alcohol intake increase a woman’s risk of fracture and once an osteoporotic fracture occurs, women are at increased risk for additional fractures. 

Screening

Current guidelines recommend starting screening at age 65 unless risk factors exist. If a woman has one or more risk factors, screening can be obtained prior to age 65. All women who are post-menopausal who have suffered a fracture should begin screening. Screening is most typically done with low radiation dual energy x-ray absorptiometry (DXA). Diagnosis is based on what is known as a T-score. A T-score of -2.5 is indicative of osteoporosis. 

Treatment

Calcium and vitamin D are always recommended in the treatment of osteoporosis. Adequate dietary calcium is preferred, but supplementation may be required if women cannot obtain enough calcium from their diet. The current recommended dosage is 1,200 mg of calcium and 400-1000 IU of vitamin D a day. Weight bearing exercise also helps to improve bone density and daily exercise is recommended. Unfortunately, biking and swimming do not fall into this category but various other forms of exercise do, including weight training and tai chi, which have additional benefits of improving balance. 

Medications may also be recommended. Therapy may range from a daily oral pill to once yearly intravenous medication. Hormone therapy with estrogen may be an effective and safe option for women who are also experiencing menopausal symptoms. Vaginal estrogen preparations are not absorbed well enough to benefit bone health; however, other preparations of estrogen such as patches may be an effective option. 

Women who are post-menopausal, whether through surgical removal of the ovaries or the natural process of menopause, lose bone density at an accelerated rate for a period of approximately 5 to 8 years. Nearly half of all Caucasian women 50 or older have low bone density without a diagnosis of osteoporosis. 

Taking steps to prevent bone density loss by assuring adequate calcium and vitamin D intake, along with weight bearing exercise, helps maintain bone health. 

After menopause, women need to talk with their practitioners and discuss their personal and family history to determine when to start screening for osteoporosis. Taking steps to prevent bone density loss by assuring adequate calcium and vitamin D intake, along with weight bearing exercise, helps maintain bone health. Exercise also has the added benefit of fall prevention and reduces the risk of osteoporotic fractures.

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Kalispell OB•GYN Associates by Kalispell Ob/gyn - 4M ago

By Kim Forthofer, ARNP – Kalispell OB/GYN

It has been estimated that 9 out of 10 Americans do not grasp a full understanding of the information given to them during their health care visits.   This can include instructions on taking a medication, information about their diagnosis, treatment recommendations, and plans for managing their health.

Think of the devastating consequences that are possible from improperly taking a medication or not understanding the need for continued monitoring of a patients’ diabetes, high blood pressure, or other chronic health problem!

Health Literacy is defined as,

“the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions”

(The Patient Protection and Affordable Care Act of 2010, Title V). 

Health care is a partnership between patient and provider, and every effort should be made between the individual and the professional to make sure that there is understanding of the information conveyed to one another.  There can be several factors that contribute to inadequate health literacy.

However, there are ways to improve the time spent in your doctor’s office to make sure you and your health care professional make the most of your visit.

Ask Questions

It is essential to ask questions of your health care professional.  If you do not understand the information that is given to you, ask questions or better yet, ask that the information be written down.  There are reputable websites that are free and easily accessible to you or your provider, an example is Medline Plus Health Information Library (www.medlineplus.gov).  From here you can print information about health conditions, lab tests and more.

Additionally, the website offers videos and information that can be listened to rather than read.  Your health care provider should strive to give you information in as simple of terms as possible, thoroughly explaining complicated terms, lab tests or results and procedures in ways that you are able to fully understand.

Write Things Down

Bring a list of the current medications, vitamins and supplements you take to your doctor appointment. Having a pen and paper handy during your appointment is valuable for jotting down questions and writing down information as you and the provider talk.  Ideally, having an accompanying adult can help to alleviate stress, be a second set of ears to hear instructions, and to ask the questions that perhaps wouldn’t otherwise be asked.  This can lead to a more thorough understanding of the information provided by the practitioner.

During College, I had an excellent professor who taught us to go through our patients’ medications one-by-one and advised us to state the medication to the person and ask why they take the medication.  For example, the Nurse Practitioner asks: “I see you take Metformin. Can you tell me what you take this for?” Oftentimes, the patient can’t remember why they take the medication or when it was first administered.

We as health care professionals must do a better job of educating our patients on the medications they take and why they take them.  

As people age the natural risk of disease increases, older individuals in turn have higher rates of polypharmacy (use of multiple medications at once) and are at higher risk for adverse reactions related to improper medication use.

Our health care and insurance systems are dynamic and are becoming increasingly complicated.  This places older individuals at higher risk for health complications as they often have the highest health demands compounded by difficulty understanding or managing their complex health conditions.

This is why it’s important to list all the medications you take and to be honest with your provider about your health history.

As we enter into this month of love and relationships, I felt that this was a fitting subject.  We should take care of and love ourselves by assuring that we are our best advocate when it comes to our health.

So, ask questions, be involved in the discussion, and know that you and your health care provider are working together towards a mutual goal — your overall health.

Kimberley Forthofer, ARNP joined Kalispell OB/GYN in July of 2013. Kimberly earned her Bachelor of Science in Exercise Science from Montana State University and worked as Physical Therapy Aide and Athletic Trainer before returning to school and earning her Master of Science in Nursing from Pacific Lutheran University. She offers a wide range of experience in primary care as well as women’s health. 

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Kalispell OB•GYN Associates by Kalispell Ob/gyn - 4M ago

by Dr. Jenna Huff | Kalispell OB/GYN

It wasn’t too long ago when women were getting Pap smears yearly and so the answer to “when was your last Pap?” was easy. But as Pap smear recommendations changed, first to every other year and then on to every 3-5 years, the answer seems to be a bit more puzzling. Add in the confusion between Paps, speculum exams, and pelvic exams and this question seems to stump even more people. So “when was your last Pap” goes from being a gimme question at your exam to a much deeper discussion on what’s been going on with your health. So, what is the difference between a Pap, a pelvic, and a speculum exam?

If you’ve ever had that question, read on!

Pap smears were invented by Dr. Papanikolaou way back in the 1920s when he noticed that prior to developing cervical cancer, which was very common at that time, cells on the cervix started to look abnormal. Back then, we didn’t know why that was, so people would get “Pap smears” (because Papanikolaou smears was a little too long and hard to say) yearly to see if anything was abnormal on the cervix. Back then; if they were abnormal, people were treated more aggressively with a hysterectomy to help prevent cervical cancer.

Fast forward almost 100 years and we know a whole lot more about Pap smears and HPV, or Human Papillomavirus, and the progression of cervical cancer. In learning more, we have found that the abnormal cells on the cervix are caused by HPV, which is a sexually transmitted virus. Like the cold virus, it is recognized by the body’s immune system as something to fight off, and for most people, the body can fight it off. For some people though, they can’t get rid of the virus and it continues to make cells, which becomes more and more abnormal on the cervix and can even become cervical cancer. Luckily, we can catch this before it happens and we have more conservative treatments than in the past.

So, with this new information, we found that doing Paps yearly was over aggressive and that we ended up over treating many people. This is the basis of the new guidelines. The latest guidelines for Pap smears are: Start at age 21, with a Pap smear every 3 years. From age 30-65, a patient is to have a Pap and HPV test every 5 years. Spacing out the screening has resulted in fewer unneeded procedures while still catching abnormal cells that could lead to cancer before it ever gets there! Medical success!!

While there may be some confusion on how often to be seen, we still recommend a yearly exam with your provider. Paps, speculum exams, and pelvic exams are something that may or may not be done at every exam but it is something to discuss with your provider each year.

A speculum exam is an exam that is done, usually during an office appointment but possibly performed in the ER, using a small metal or plastic device that looks like a duck beak. We use this to perform a Pap smear or examine the vagina for any abnormalities and to visualize the cervix. While no one looks forward to these exams, they are quick and an important part of making sure your gynecologic health is taken care of. A Pap is performed in the office (almost NEVER in the ER!) and is done with a speculum exam and a little brush to get a sample of the cells. The sample is then sent off to our friendly pathologist, the doctor who looks at those cells under the microscope, and he/she tells us whether the cells are abnormal or not.

A pelvic exam is an exam performed by your medical health professional to give more information about your uterus and ovaries. Also known as a bimanual exam, we are able to feel the size, shape, and mobility of your uterus and ovaries. This is typically performed yearly at your annual exam to help detect masses of the uterus and ovaries. While not as successful as Pap smears in preventing cervical cancer, it is one way we monitor for ovarian and uterine cancer. I promise none of us care if your legs are hairy, but you get bonus points for fun painted toes!!

While there may be some confusion on how often to be seen, we still recommend a yearly exam with your provider. Paps, speculum exams, and pelvic exams are something that may or may not be done at every exam but it is something to discuss with your provider each year. So even though you were told you don’t need a Pap for 5 years, don’t miss your annual appointment to check up on your health. Prevention is one of the best ways to help live a long, healthy life!

See you soon!

Dr. Jenna Huff joined the staff of Kalispell Regional Medical Center and started practicing at Kalispell OB/GYN in October 2017. She attended medical school at the University of North Dakota School of Medicine and did her residency at Akron General Medical Center in Akron, Ohio. For 4 years following that, she practiced obstetrics and gynecology in Loveland, Colorado.

Dr. Huff is board certified in Obstetrics and Gynecology. She specializes in normal and high-risk obstetrics, contraception management, abnormal bleeding and minimally invasive surgery, including robotics. She enjoys caring for women throughout their life, from puberty through childbearing years and then through menopause, and strives to develop a supportive relationship with her patients. She believes in educating women and helping them make the best possible decisions to improve their quality of life.

Dr. Huff is a Montana native and she, her husband and three young children are excited to be back in Montana to be near family. They enjoy everything that the Flathead Valley has to offer.

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At Kalispell OB/GYN, we work hard every day to help promote and protect the health, safety and quality of life for all women. All our providers are strong advocates for women’s health care. It is our mission to provide the best care for women in all stages of life through a professional and compassionate health model, a conversational approach with our patients and a supportive team consisting of our outstanding physicians, nurse practitioners and physician assistant. Assisting them is our excellent support staff of RNs, LPNs and Medical Assistants, as well as the rest of our helpful, friendly office staff.

Established in 1962 by Dr. Van Kirke Nelson and later adding Drs. Heine and Sowell, Kalispell OB/GYN has provided quality OB/GYN care longer than any other OB/GYN practice in the Flathead Valley. We’ve grown and changed with the times and the area we serve has spread outside the Flathead Valley to include many surrounding communities, such as Libby, Eureka, Cut Bank and Shelby.

Drs. Nelson, Jonas, Lavin and deHoop took stewardship of Kalispell OB/GYN and enjoy the practice of general obstetrics and gynecology, with a combined total of over 75 years of delivering babies and caring for women’s health. With continued growth of the practice, we have just added a fifth physician, Dr. Jenna Huff, so we are better able to offer our patients the best possible care.

All our physicians are board certified in Obstetrics and Gynecology, are accomplished laparoscopic surgeons, offer minimally invasive and robotic surgery, vaginal surgery and prolapse repair. They participate in teaching the University of Washington medical students during their rotations at Kalispell Regional Medical Center and help train the residents of the Family Medicine Residency Program.

Our providers enjoy caring for women who are either pregnant or hoping to become pregnant. They are strong advocates of offering women the option of having a vaginal delivery after a prior cesarean section and, along with Kalispell Regional Medical Center, offer this service to their patients. Kalispell OB/GYN is also happy to collaborate with certified nurse midwives for women who desire midwifery care. We look forward to helping women make the best health care decisions for their families and themselves.

Dr. Kathleen Nelson began practicing with her father, Dr. Van Kirke Nelson, in 1995.

Having grown up in Kalispell, she attended undergraduate school at Stanford University, received her medical degree from the University of Washington and completed her residency at the University of Wisconsin.

Dr. Gwenda Jonas moved to the Flathead Valley in 2001 to practice with Kalispell OB/GYN.

Prior to that she spent four years in private practice in Phoenix, Arizona and was an Associate Clinical Professor for the University of Arizona School of Medicine.

She received her undergraduate degree from University of the South in Sewanee, Tennessee, her medical degree from the University of Alabama and completed her residency at Good Samaritan in Phoenix.

Dr. John Lavin started his career in family practice 33 years ago.

He received his medical degree from the University of Nevada Medical School and in 1989 he returned to University of Colorado to pursue his OB/GYN specialty training.

He was in solo OB/GYN practice in Kalispell before joining Kalispell OB/GYN in 2004.

He continues to practice at this location, but is currently employed by Kalispell Regional Medical Center.

Dr. Thomas deHoop moved to Kalispell from Cincinnati, Ohio in 2011 to join Kalispell Regional Medical Center and practice with Kalispell OB/GYN.

He attended medical school at the Medical College of Wisconsin, where he also completed his internship.

His residency was at the University of Cincinna Medical Center, where he remained for 16 years as an Associate Professor of OB/GYN before moving to the Flathead Valley.

Dr. Jenna Huff , a Montana native, will join the staff at Kalispell Regional Medical Center and practice with Kalispell OB/GYN starting in October 2017.

She attended medical school at the University of North Dakota School of Medicine and did her residency at Akron General Medical Center in Akron, Ohio.

For four years following that, she practiced in Loveland, Colorado.

We are a strong, independent practice and are proud too offer diverse options for women’s health care. The women of the Flathead Valley are our friends and neighbors and we want the best care possible for them.
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By Kassandra Patton

Screening

The American College of Obstetricians and Gynecologists recommend a young woman’s first visit to the gynecologist sometime between the ages of 13 and 15 years, unless indicated sooner. This information may make any teenager reading this want to hide the magazine…But wait! Things have changed significantly in the last 10 to 15 years in regards to a young woman’s screening and wellness care in our offices. Gone are the days when a teenager is required to have a full female exam just for setting foot in a gynecologist’s office. The newest recommendation is that there is no need for a pelvic exam on women under the age of 21 that is not having symptoms consistent with genital tract disease or dysfunction, even if she is sexually active. A Pap smear is also not required on any woman under the age of 21 regardless of sexual activity.

If there is concern of sexually transmitted disease, we will most likely be able to screen a sexually active woman by using a urine specimen obtained in complete privacy by the patient during her visit.

So, what exactly happens at a female screening or wellness visit for a teenager? 

A thorough medical history is obtained as well as detailed information about your periods and any other concerns.  I prefer to have a parent or guardian present during this portion of the visit as many teenagers do not have knowledge of their family histories. When it comes to asking more personal questions, such as about sexual activity and any private questions that the patient might have, I will offer to have the parent or guardian step out of the room to allow for questions that might feel too embarrassing to ask with an audience.  Counseling may also be done at this time regarding safe sex, substance abuse, and healthy lifestyle.

After we are done taking a complete history, a brief physical exam is often performed.  For patients younger than 18, a physical exam similar to that at a pediatrician or family practitioner’s office will be performed.  If she is older than 18, a breast exam may be taught and performed as well.

Sexual Activity

Ideally, a teenager will be seen prior to having sex. It is a good rule of thumb to come into the gynecologist if the patient has a steady boyfriend or if she is considering “taking things to the next level”. It is also good to start on birth control prior to becoming sexually active as some methods take one month before they are fully effective. Many teenagers are afraid to report that they are having sex because they do not want to have an exam. This is concerning as it is important for her to not be afraid to come to our office for evaluation. A pelvic exam is rarely needed. A careful history and a lot of counseling will be the focus of this visit. A urine sample may be taken for STI testing.

Gynecological Concerns  Period Problems

If the patients periods are heavy or painful enough that they are interfering with their school work, sports or job, further evaluation is needed. If they are experiencing very irregular periods or periods that don’t appear for 3 months or more, or if their periods have not yet stared by age 15 despite other signs of puberty (such as breast development) they should be seen in our office.

Yeast infection/vaginal irritation

If the patient has concerns about vaginal discharge, odor, itching, or burning, they may have an infection that needs attention. This is especially common in the summer months as prolonged exposure to wet bathing suits or clothes damp from sweat can make ideal conditions for growth of a yeast infection.

Other concerns

Any other concerns that a patient may have about your gynecological health can be addressed with a visit to a gynecological practitioner. The patient may no longer get a sucker or sticker when they leave the doctor’s office, but what they will get as a reward is peace of mind that their health can be carefully maintained without fear of GYN visits.

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by Dr. Thomas deHoop – Kalispell OB/GYN

Female Athlete Triad

It is hard to imagine that only 50 years ago a woman competed in the Boston Marathon for the first time. Never before have women enjoyed the benefits of regular exercise and competitive sports as they have in the past several decades. A major shift occurred in 1972 with the introduction of Title IX which states that “Any secondary or collegiate school that receives federal assistance must offer equal athletic opportunities to men and women, requiring equity in areas of participation, scholarship, dollars, and athletic benefits.”

At that time, only one out of 24 girls played high school sports, now it is approximately one in three. This has lead to significant health benefits and contributed to improved physical fitness and overall wellbeing for women. For some, however, risk exists for the development of one or more of a triad of medical disorders that has been described in the literature as the FEMALE ATHLETE TRIAD.

In 1992, the American College of Sports Medicine coined the term to describe a triad of distinct and interrelated medical conditions: disordered eating (including a range of poor nutritional behaviors such as bulimia), amenorrhea (irregular or absent menstrual periods) and osteoporosis (low bone density which can lead to weak bones or fractures).

Disordered Eating

Today, it is recognized that each of the components can express itself on the spectrum from subtle to extreme. The disordered eating seen in the triad has been better described as an energy imbalance and is the key to developing the triad. More calories are utilized than are taken in during the course of a day.

All women face societal pressure to be thin, but athletes can feel additional pressure where a lean physique and/or low body mass can confer a competitive advantage such as cross country running, gymnastics or dance. In response to this pressure to lose weight, women and girls may practice unhealthy weight-control methods, including restricted food intake, self-induced vomiting, consumption of appetite suppressants and diet pills, and use of laxatives.

Specific eating disorders are anorexia nervosa and bulimia are not as common, but all women who practice any disordered eating can progress to this extreme. As many as 75% of competitive gymnasts report a disordered eating pattern at sometime in their career. Perfectionism, compulsiveness and high personal expectations are traits of high level athletes, but also of those with eating disorders. There are psychological reasons for disordered eating. For instance, many of these athletes lead such regimented lives that their control over their diet is the only control they possess. The effects are counterproductive as they lead to impaired health, decreased performance and loss of muscle mass, often leading to injury. Eating disorders can also cause fatal cardiac complications or electrolyte imbalances. It is the responsibility of coaches, trainers, parents, friends and fellow athletes to be aware of signs of disordered eating in young athletes to avoid the consequences.

Warning signs to look for in disordered eating include
  • Excessive or rapid weight loss or wide fluctuations in weight
  • Preoccupation with weight, food, mealtime rituals and body image
  • Avoiding team meals or secretive eating
  • Extra workouts in addition to team practices
  • Overuse injuries such as stress fractures
  • frequent sore throats despite no infections
  • Swollen cheeks from swollen parotid glands from self-induced vomiting
  • Dental issues or foul breath from repeated self-vomiting
  • Depression or low self-esteem, irritability or mood swings
  • Yellowing of the skin
  • Soft baby hair on the skin
Amenorrhea

Amenorrhea (the loss of menstrual cycles) and the less severe disorders of menstrual function are recognized to occur more frequently in female athletes than in the general population. As opposed to the 2-5% of the general population who has amenorrhea, the incidence is much higher in competitive athletes and has been reported to be as high as 40-50% in elite runners or ballet dancers. It may occur as a milder form of amenorrhea with only a few cycles missed every year. There is controversy as to the exact cause of these menstrual irregularities. The “critical mass theory” claims once a woman’s body fat falls below a certain threshold, the ovaries fail to ovulate. Others claim irregularities are due to the high level of endorphins produced during exercise that inhibit the brain’s ability to stimulate ovulation. Still others claim that the physiologic stress of exercise release stress hormones that prevent ovulation. It is likely a combination of these theories that can prevent the brain’s stimulation of the ovary to ovulate. Any female who has not begun menstruating by age 16, misses three consecutive periods or has periods that occur at an interval greater than 35 days should undergo an evaluation.

Osteoporosis

The incidence of the last component of the triad, osteoporosis, is difficult to determine since young women do not routinely undergo bone density testing because it is usually not recommended until age 65. Many young women present with stress fractures or other injuries typically seen in women of advanced age. Studies comparing bone density in young athletes found those who maintain regular menstrual cycles have greater bone density than those with irregular cycles. The bone loss is due to the lack of estrogen when there is a failure to ovulate. Since estrogen is the key to achieving and maintaining bone density, the lack of estrogen prohibits young women suffering from the triad from reaching their maximum peak bone density. This is further compounded by poor nutrition.

Long-term, these women will enter menopause with a less than optimal bone density and be at risk of osteoporosis at an earlier age. For instance, a woman at 50 years old may have the bone density of a 70 year-old woman. She will have a risk of hip and spinal fractures greater than her cohorts who had regular cycles. This exponential increased risk of the triad can be minimized or prevented.

All women face societal pressure to be thin,but athletes can feel additional pressure where a lean physique and/or low body mass can confer a competitve advantage such as cross country running, gymnastics or dance.

Prevention and multidisciplinary collaboration are the keys to success. Primary prevention involves providing the education necessary so that parents, teammates, coaches, trainers, medical professionals, communities and the athletes themselves have an awareness of the triad and can avoid practices that encourage potentially harmful behavior and intervene as necessary.

Secondary prevention involves recognizing, screening and treating subtle signs and symptoms of the triad in a multidisciplinary approach. Talk to your health care professional. Preventing and reversing bone loss can be as simple as taking an Estrogen replacement oral contraceptive medication. More severe eating disorders may involve counseling or psychiatric intervention. Young athletes should reap the benefits of regular exercise without the risk of harms that may occur as a result of disordered eating or menstrual irregularities. The goal of exercise is to maintain health so avoiding problems associated with the female athlete triad helps achieve that goal.

Dr. deHoop is a KRMC physician practicing at Kalispell OB/GYN – In 2011 he moved to Kalispell from Cincinnati, Ohio where he was an Associate Professor of Obstetrics and Gynecology at the University of Cincinnati Medical Center for 16 years. He practices general obstetrics and gynecology, with a special interest in robotic and minimally invasive surgery. He came to Kalispell with more than ve years of experience using the daVinci® robotic surgery system.

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by Alisha Pinkerton, PA-C

Infertility is a problem that many couples struggle with each year.  When dealing with infertility it is helpful to understand the basics of the menstrual cycle, available testing and treatment options.

According to UpToDate.com, 85% of couples will conceive within the first 12 months of attempting pregnancy, however the other 10-15% of couples will struggle with infertility.  Fertility is the capacity to conceive and produce offspring.  Infertility is the inability to conceive after 12 months of regular unprotected intercourse, however, if a woman is older than 35 years of age, infertility is considered after 6 months of trying to conceive without success.  Therefore, your age and amount of time having unprotected intercourse without success determines when a diagnostic evaluation is indicated.  Other factors may warrant a diagnostic evaluation sooner than 6-12 months regardless of age, such as but not limited to: irregular menses, damaged or blocked fallopian tubes, stage III-IV endometriosis, a family history of early menopause, history of certain cancer treatments and male subfertility.

If you are having difficulty conceiving or are concerned about your fertility, you should talk with your healthcare provider about the plan that is best for you.  At the initial visit your healthcare provider will review your history and perform a physical exam.  Once this is completed, the appropriate testing will be ordered.  Testing should be done in a focused and cost-effective way and should take the couple’s preferences, the duration of infertility, the woman’s age and specific factors revealed through the medical history and physical examination into account.

Basic infertility testing available includes: ovarian reserve testing, hysterosalpingogram, saline infusion sonogram and semen analysis.  Other tests may be done to rule out thyroid disorders and high prolactin levels.  Androgen levels may be checked in women who have increased hair growth (hirsutism) and/or irregular menses.  Ovarian reserve testing is used to help the healthcare provider predict whether the patient can produce an egg or eggs of good quality.  This testing may include blood tests, transvaginal ultrasonography or both.  A hysterosalpingogram or HSG for short, is a test used to check if the fallopian tubes are open and to assess the shape of the endometrial cavity (the inside part of the uterus).  A saline infusion sonogram can also be used to assess the inside part of the uterus.  Surgical procedures such as hysteroscopy and laparoscopy may also be warranted.

Once testing is completed, a follow up visit should be scheduled with your healthcare provider to discuss results and treatment options.  There are many treatment options available, such as:  medications to help women ovulate and assisted reproductive technology (ART).  Medications used to induce ovulation may be given to women with irregular menses or no menses at all.  Ovulatory dysfunction frequently occurs in women with polycystic ovary syndrome (PCOS), obesity, hyperprolactinemia (increased levels of the hormone prolactin), thyroid disease, eating disorders, extreme exercise and/or weight loss, among other things.

Fertility medications used to induce ovulation are not only used in women with irregular or no menses, they are also used in women without ovulatory dysfunction.  In these women, the goal is to produce more than one follicle per menstrual cycle, in turn causing the woman to release more than one egg at a time.

This is referred to as controlled ovarian stimulation (COS) or superovulation.

Medications used for ovulation induction can be taken orally or by injection and can be combined with timed intercourse, intrauterine insemination (IUI) or In-vitro fertilization (IVF).  Timed intercourse is the process of timing intercourse appropriately with ovulation.  IUI is also timed with ovulation.  The IUI process consists of sperm collection from the man prior to the procedure, followed by washing of the sperm with a special solution in the laboratory.  The IUI is then completed by passing a small catheter through the cervix and injecting sperm into the inside part of the uterus (endometrial cavity).  IVF is the process of surgically removing a woman’s egg(s) from the ovary and combining the egg(s) with the man’s sperm in a laboratory dish.  The desired result is formation of an embryo or embryos.  If the egg is fertilized and an embryo has formed the embryo will then be transferred into the woman’s uterus.  If multiple embryos are formed, more than one embryo may be transferred simultaneously, however, this would be decided by you and your healthcare provider.  Remaining embryos may be frozen and used at a later time.  One advantage of IVF compared to other treatments, is your healthcare provider can limit the number of embryos transferred, thus reducing the possibility of multiples.

The most common medications used for ovulation induction include clomiphene citrate (CC), aromatase inhibitors (i.e. Letrozole), and gonadotropins.  The gonadotropins include FSH, LH, hMG (human menopausal gonadotropin), and hCG (chorionic gonadotropin).   Depending on the underlying diagnosis, other medications may be used for treatment, such as medications to help with high prolactin levels (hyperprolactinemia) and high insulin levels (hyperinsulinemia).

Gonadotropins are injectable medications commonly used with IUI and IVF.  These medications are used to cause multiple follicles to develop at the same time.  Each follicle has the potential to contain a good egg.  Many women are concerned this type of treatment will diminish her overall egg supply quicker than with a natural cycle, however, this is not the case.  This type of treatment rescues eggs that would have otherwise died off naturally.  Fertility medications, like all medications, have potential risks and complications, such as multiple pregnancy.  These risks and complications should be discussed with your healthcare provider, prior to initiating treatment.

In summary, if you are having difficulty conceiving or are concerned about your fertility, talk with your healthcare provider to discuss the plan that is best for you.

If you would like more information on this topic please refer to: www.acog.org, www.asrm.org, and www.uptodate.com.

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Dr. Nelson examines a patient after surgery

May 03, 2017 at 6:02 pm | By KATHERYN HOUGHTON Daily Inter Lake

From a wing in one of two hospitals serving the Marshall Islands, Flathead Valley medical workers joined a team of doctors to treat a growing line of patients, many who had waited years to visit a women’s health clinic.

In the pop-up clinic’s two weeks, the volunteer gynecology specialty team treated more than 450 patients. The group, organized by the nonprofit Canvasback Missions, included eight medical workers from the Flathead.

Kasey Patton, a women’s health nurse practitioner at Kalispell OB-GYN Associates, said she didn’t know what to expect when she signed up for the short-term mission.

As the cohort flew into Majuro in February, the plane tilted right revealing the narrow strip of land they would be operating a women’s clinic. From the windows, the nurse practitioners, surgeons and technicians could see the collection of islands in the central Pacific Ocean made from the rim of a submerged volcanic crater.

“It was beautiful, and I knew it was an isolated area,” Patton said.

That isolation was part of the reason why they were there, she added.

Kasey Patton with child at the hospital in Majuro

Canvasback Missions has provided medical supplies and multiple specialty teams annually to the underserved populations of Micronesia since 1981.

Dr. Kathy Nelson, a gynecologist at Kalispell Regional Medical Center, said the primary purpose of the trip was to offer cervical cancers screening.

“There were women with advanced cervical cancers we rarely see in the U.S. because of screening,” she said.

The medical staff at the one-story hospital in Majuro cleared out several rooms and an operating room for the temporary clinic.

Patton said from 8 a.m. to 6 p.m., the clinic’s waiting room held an average of 75 people. Some women needed a routine preventative exam while others had tumor masses large enough to appear pregnant.

“We saw women from 18 on up to 65, some who never had a female exam done before,” Patton said. “In the U.S., if someone has a little twinge, they’ll usually go to the doctor. But these women won’t say anything — they don’t expect to have treatment.”

Nurse practitioners staffed the clinic and conducted routine exams while spotting cases they needed to send along to a physician. They worked with Marshallese nurse-practitioner students who provided translation between the foreign workers and patients.

The medical team taught the students how to conduct exams while the students taught the team how to operate within the community’s cultural norms.

Simultaneously, the visiting mammography and ultrasound technicians paired with Majuro medical workers to teach them how to use the equipment.

“They were really happy to have us there,” Nelson said. “But it wasn’t that they just expected us to come in there and fix everything. Otherwise, what happens when a person needs help two, three weeks or years later? They wanted to learn.”

She said Canvasback chose the location because the hospital had the infrastructure to set up a successful short-term clinic.

“It was amazing how they made due with limited resources, and we don’t do that anymore — everything here has to be amazing, and [in Majuro] they can provide really good care despite limited resources.”

When rain dripped through the ceilings onto the hospital hallways, surgical buckets collected the water. Plastic lawn chairs were in waiting rooms. Some patients shared rooms, separated by curtains. And people brought their own food, sheets and water when they needed an operation or had a hospital stay.

Patton said with the number of people waiting to be served paired with logistics of the Majuro hospital staff tweaking their routine to help the mission, the clinic operated in a constant rush.

Patton said without the local crew’s help, the drop-in team wouldn’t have been able to operate.

“I always felt like we were trying to just get through as much as we could,” she said. “Some people waited in line all day, so when there were still women in line past hours, the [Majuro] staff would stay even though they didn’t get paid for staying after 5 p.m. — they want to help their own.”

For more information about Canvasback Missions, visit http://www.canvasback.org/kalispell.

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