Breast Density – What does it mean?!?

Mammogram reports now frequently include a notation of breast density and a disclaimer that this may reduce the ability of the mammogram to detect cancer.  Naturally this is a bit alarming

First of all, it is important to realize that dense breast tissue is not abnormal.  Almost half of women have dense breast tissue and women with dense breasts do NOT have an increased risk of dying from breast cancer. The term itself is a term that describes how your mammogram image looks, not how the breast tissue feels on exam.  It is the relative amount of black (fat tissue) on the image to white (glandular tissue) on the image.

Increased density is more common in women who are younger, on hormones, have a higher weight,  with history of previous pregnancies and those who have used tamoxifen or have family history of dense breasts. There is also subjective differences in assigning breast density, meaning different radiologists may interpret the image differently.

The scale that defines the breast density is called Bi-Rads and categorizes women into 4 groups:

  • A – Almost entirely fatty
  • B – Scattered areas of fibroglandular density
  • C – Heterogeneously dense (may obscure small masses)
  • D – Extremely dense (lowers the sensitivity of mammography)

For most purposes, the term “dense breasts” refers to either heterogeneously dense or extremely dense breasts (categories C or D).

Denser breasts have a few implications.  First, it may obscure the detection of a mass in the breast.  Second, it does slightly increase the risk of developing breast cancer. For these reasons it is important not to ignore the classification, but it is equally important not to over inflate the significance of it.

While studies have shown that breast ultrasound and MRI can help find some breast cancers that can’t be seen on mammograms, they can also show more findings that are not cancer. This can lead to more tests and unnecessary biopsies. Additionally, the cost of an ultrasound or MRI may not be covered by insurance.   So really the trick is figuring out who needs additional imaging because they have increased breast cancer risk and who “just has normal dense breasts”.

There are several online tools that can help estimate your risk of breast cancer such as https://bcrisktool.cancer.gov/.  In general, these models do not take breast density into account, but can still guide the decision how to follow up after a mammogram with this finding.

  • A woman with <15% risk of breast cancer, then no additional screening is recommended regardless of breast density.
  • A risk of 15-20% is a gray zone, with most organizations recommending a shared decision with your provider. Additional imaging with MRI or ultrasound may be an option, but neither modality is routinely covered by insurance for this risk category in most states.
  • With a risk >20% most groups recommend supplemental testing. Frequently women with higher cancer risks will be referred to a specialty breast care center to determine the best management options.

Regardless of risk, there are lifestyle factors which can decrease your chances of developing breast cancer.  Exercise and limiting weight gain, especially in the postmenopausal years, a low-fat diet, limiting alcohol intake and not smoking have all been shown a lower breast cancer rate. Screening modalities can be different as well.  Digital tomosynthesis, or 3D mammography, may be more sensitive for women with dense breasts and pick up more cancers than traditional 2D mammograms.  Most women who have had 3D imaging do not need further imaging because of dense breasts.

Special request from Bedford Commons OB-GYN – Please get vaccinated!

As you probably are aware, we are seeing a dramatic surge in COVID-19 cases.  After two years of providing healthcare in this new environment, many of us are exhausted; we are sure you are exhausted too.

This is our special request – please get vaccinated. 

With the rising COVID-19 cases in New Hampshire, we unfortunately have seen some of the sad outcomes that can occur with COVID-19.  We have witnessed firsthand the devastating effects of severe COVID-19 in pregnancy, seeing our patients hospitalized, some required ICU care, long term oxygen supplementation, and all of whom were in fear of harm to their baby.  Compared to those who aren’t pregnant, pregnant women infected by COVID-19 with symptoms are 3 times more likely to need ICU care, 2 to 3 times more likely to need advanced life support and have a 70% increased risk of death.  Severe COVID-19 can also cause issues for babies including a 60% increased risk of very premature birth, extended stays in the neonatal ICU, and risk of stillbirth.  All major medical organizations and we, your doctors, feel that COVID-19 vaccination in pregnancy is very safe and critically important because pregnancy is considered a high-risk condition for severe illness with COVID-19.

If you’re pregnant, get vaccinated as soon as possible.  We get calls daily from unvaccinated pregnant women who recently tested positive for COVID-19, asking us how they can prevent complications from COVID-19.  Unfortunately, there really isn’t anything that can be done once someone has COVID-19 other than monitor symptoms and treat a fever.  The only way to prevent complications from COVID-19 is vaccination.

If you’re not pregnant, make sure you get a COVID-19 vaccine and talk to friends and family members who are pregnant and encourage them to get vaccinated.  If you’re already vaccinated, thank you.  Be sure to also get your booster dose.

We know that everyone is really tired of this.  Please do your part and get vaccinated.

We care deeply about you so please, let’s work together to keep each other safe.

COVID Vaccine Boosters – Do I need one?

The short answer is YES.  As of November 29th, 2021, the U.S. Centers for Disease Control and Prevention (CDC) recommends that everyone ages 18 and older should get a booster dose.  

If you received Pfizer-BioNTech or Moderna vaccines: You should get a booster at least 6 months after completing your primary COVID-19 vaccination series.
If you received the Janssen (J&J) vaccine: You should get a booster 2 months after completing your primary COVID-19 vaccination.

Which booster should you get?
You may choose which COVID-19 vaccine you receive as a booster shot.  Some people may prefer the vaccine type that they originally received, and others may prefer to get a different booster.  CDC’s recommendations now allow for this type of mix and max dosing for booster shots.

For any adults 18 years old or older who completed their primary Pfizer-BioNTech or Moderna vaccine series at least 6 months ago OR received the Janssen (J&J) vaccine at least 2 months ago, a booster dose of the COVID-19 vaccine is recommened.

Where can I get a booster?  Although we are not giving COVID19 boosters at Bedford Commons OBGYN, if you are eligible for a booster dose, you can schedule an appointment at any retail pharmacy or can inquire about an additional dose through your primary care provider office.  Find a vaccine location by clicking here: https://www.vaccines.gov/.  If you haven’t gotten a flu shot this year, consider getting the flu vaccination along with your COVID19 booster.  Both can be given on the same day.

What about boosters in pregnancy?  We strongly recommend that our pregnant patients receive the COVID-19 vaccine and also strongly recommend the COVID-19 booster for our pregnant patients who qualify.  For more information about the COVID19 vaccine and pregnancy, click here.

What is a DO?

Throughout my training and career, this question has certainly come up more than once. Now, more than ever, with the topic of DO physicians making news and headlines (all press is good press, right? Not necessarily…) are we presented with the opportunity to educate and share exactly what “DOing” is.

DO stands for Doctor of Osteopathic Medicine whereas MD stands for Doctor of Medicine.  Like MDs, Doctors of Osteopathic Medicine are fully licensed physicians who can practice in all areas and specialties of medicine.  We practice evidence-based medicine, using the latest science and technology.  During our medical school training, like MD students, the first two years are centered around classroom learning, and the last two gaining clinical experience in various specialties during clinical rotations.

Many DOs sit for the same licensing exams as MDs (USMLE) during medical school in addition to their osteopathic licensing exams (COMLEX).  The field has grown 300% (wow!) in the last three decades, currently making up 11% of the physician population.  In addition, 42% of actively practicing DOs are female!

In many circumstances, patients may not even notice a difference between their DO or MD physicians.  Where DOs differ is the underlying philosophy that is incorporated in our medical school training.

The hallmark of Osteopathy emphasizes a “whole person” approach (a person is a unit of “body, mind and spirit”).  We are trained that the person and body is whole and interconnected, and each body system affects the other.  DOs have an additional 200 hours on top of general medical school curriculum that focuses on Osteopathic Manipulative Treatment (OMT).  OMT is a hands-on approach, where we learn in depth musculoskeletal exam and treatment of musculoskeletal dysfunction, which may be related to visceral (other body systems/organs) or somatic (musculoskeletal) causes.  While not every DO uses OMT in their day to day practice, this inherent philosophy of treating the person as a whole is how osteopaths are trained to approach each and every patient.  Many of my MD colleagues approach their patients with a similar view due to their compassionate personality, but this philosophy is not part a focus their medical school curriculum.

One of the best parts of being a DO, like all differences, is being able to bring a different perspective to the table.  I am proud of my training and where it has led me (here at BCOG!)!

Flu Vaccine – coming to Bedford Commons OBGYN October 1, 2020!

“Ouch, that hurt!  Why did you do that?!?” — that’s what my 5 year old daughter yelled at the nurse giving her the flu vaccine last year.

In the midst of the current COVID-19 pandemic, it’s easy to forget the flu season is just around the corner.  Or maybe you haven’t forgotten because you have seen signs advertising the flu vaccine at many national pharmacy chains.  I think I saw my first flu vaccine advertisement at the end of July, more than 2 months before the onset of the flu season!

The Center for Disease Control (CDC) recommends the flu vaccine every year for everyone 6 months of age and older.  It is especially important this year given the overlap of symptoms caused by COVID-19 and the flu.  Getting your flu vaccine is one of the best ways to protect against the flu.  Although the flu vaccine is currently available at many pharmacies, the CDC recommends waiting until late September to get vaccinated because getting the vaccine too early may cause reduced protection against the flu later in the flu season.

As we have been so focused on COVID-19, I think it is important to remember that last year, more than 410,000 Americans were hospitalized due to the flu and more than 24,000 people died from the flu.  Although wearing a mask can help prevent the flu, the best way to protect yourself is to get the vaccine.

At Bedford Commons OB-GYN, we will begin to offer the flu vaccine to our pregnant patients starting October 1, 2020.  We recommend the vaccine for all of our patients but due to a limited supply, we are only able to offer the vaccine in our office to our obstetric patients.  For our non-obstetric patients, we would recommend heading to your primary care or a local pharmacy to get vaccinated.

Click here for more information from the CDC about this year’s flu vaccine.

 

Hormone Replacement Therapy (HRT) – Is it for me?

What’s in your hormone therapy? (The facts about bioidentical hormones)

As your gynecologists, we know you are interested in bioidentical hormones.  We can prescribe such hormones and we are interested in talking to you about your menopausal symptoms.

Prior to 2002, HRT (hormone replacement therapy) was widely prescribed to treat menopausal symptoms and was once prescribed for prevention.  The WHI, or Women’s Health Initiative, was started to study HRT’s effectiveness in lowering the risk of heart disease and other medical conditions in women ages 50-79.  In 2002, the Women’s Health Initiative study was paused because of the increased risk of breast cancer, heart attack, stroke and blood clots seen in women on estrogen and progesterone.  In turn, there was an abrupt decrease in prescriptions for HRT.

Since then, women’s health providers have been able to make better sense of this data and can have a meaningful discussion with our patients about the many benefits of HRT as well as the risks.

There are many women who benefit from HRT and there are many forms of HRT.  Over the last few years I have seen more and more women come to their annual or for a consultation other than for menopausal symptoms, after having seen another provider to obtain compounded bioidentical HRT.

A bioidentical treatment is a plant derived compound that is chemically similar or structurally identical to those produced by the body.  There are bioidentical hormones approved by the FDA.  I get it that my patients are not excited to use hormones that are sourced from the urine of pregnant horses found in a commonly prescribed form of estrogen.  There are options for bioidentical micronized estrogen and progesterone that are monitored by the FDA.

As the compounded forms of hormone therapy are not regulated, a patient is ultimately unaware of the purity, potency or quality of the product used.  I also see many women having their hormone levels checked which is not necessary.  Let me discuss each issue further.

Many compounded hormones use combinations of the 3 types of estrogen produced by our bodies: estriol, estradiol and estrone.  Estriol is the weakest of the estrogens and is often used in the highest amount in compounded hormones.  However, estriol is less bioactive so to get the improvement in symptoms, there is the risk of overdosing on this estrogen.   Estradiol is more bioactive, is bioidentical, and is included in the options approved by the FDA.  Such options have doses that are stable and well-studied.  High doses of any estrogen can lead to the risk of cancer of the uterus and blood clots. For women with a uterus on estrogen in doses high enough to treat hot flashes, progesterone is needed to protect a woman from the risk of cancer of the uterus.  Compounded progesterone that comes from certain wild yams may not be bioavailable, so a woman may not be receiving the protection the uterus needs.

As far as hormone testing, steroid hormones do not meet the criteria for requiring individualized testing.  Steroid hormones have a large range of levels that lead to a desired effect.  These hormones are not directly eliminated by the kidneys in our urine and they are metabolized by our GI tract.  There are no known therapeutic and toxic concentrations base on large studies of blood levels.  Furthermore, checking salivary levels do not provide a representation of blood levels.  Salivary levels depend on a patient’s diet, time of day and the specific estrogen being tested. When I prescribe HRT, I do not check hormone levels.

When a patient needs HRT I discuss the FDA approved options that make sense for her individualized history.  I prescribe the lowest dose that provides benefit.

Thanks for your time and I encourage you to talk to your provider if you are interested in learning more about HRT.

Anal SEX: What You Need To Know

As with any sexual topic, what is “normal” really is in the eye of the beholder. Anal sex involves inserting the penis through the anal sphincter. The anal area has a lot of nerve endings and, for some, is very erogenous. It is estimated that 5-10% of sexually active, heterosexual women engage in anal sex. For these couples it is “normal”. That being said there are unique health risks to be aware of and precautions to be taken.

The anus is a tighter entrance and lacks lubrication that is present in the vagina. This combination increases the risks for tears. Commonly these are small tears throughout the skin or thin mucosa. Adequate lubrication can help decrease this. On rare occasions, significant trauma can occur if the colon wall is perforated.

Beyond the pain the tears cause, they significantly increase your risk of contracting an STD (such as HIV, hepatitis or herpes). Studies have shown a 30% increased risk of HIV infection compared vaginal intercourse. HPV also increases the risk of anal warts and anal cancer. For women who regularly practice anal intercourse it is not unreasonable to do a rectal pap smear in addition to the routine cervical pap smear.

Aside from STD-type infections, the anal area has a high count of bacteria from feces. This puts partners at increased risk of infection. Likewise, vaginal or oral sex after anal penetration increases risk for infection. If you notice a discharge or pain in the days after engaging in anal sex, you should be evaluated by your physician.

The anal sphincter is a muscle intended to keep stool inside. Over time, penetration of the sphincter can lead to weakening or damage to the muscle. This can lead to problems with gas or stool incontinence. Just like the vagina, the anal sphincter can be strengthened with Kegel exercises.

It is also important to realize you can still get pregnant practicing anal sex. Sperm can find their way into the vagina and to a readily awaiting egg.

So bottom line – yes, anal sex is OK if it is consensual, but take the following precautions:

  1. Wear condoms to prevent STD and pregnancy
  2. Use copious lubrication to decrease pain and trauma
  3. Avoid vaginal or oral sex after anal intercourse
  4. As with any sexual practice, if it is not enjoyable, tell your partner and stop.

April is STD Awareness Month

With STDs continuing to rise in the United States, it’s important to know the facts. April is STD Awareness Month, a perfect time to get informed on what can be a silent health risk, even leading to death.  Here’s what you’ll want to know:

  • The Centers for Disease Control and Prevention (CDC) estimate there are more than twenty million new STD (chlamydia, gonorrhea, and syphilis) infections in the U.S. each year.
  • While curable with antibiotics, many cases go undiagnosed and untreated. Consequences of this can be severe, including infertility, ectopic pregnancy, stillbirth, increased HIV risk, even death.
  • Certain groups are at increased risk, including sexually active women under 25.

The CDC currently sponsors four STD Awareness Campaigns:

  • GYT: Get Yourself Treated is for young people to understand the myths and misconceptions surrounding STDs and to learn about appropriate testing and treatment.
  • Test. Treat. Three simple actions by patients and healthcare providers can protect the health of the individual, their partner, and patients at large. First, have open and honest discussions with each other. Second, get tested or recommend appropriate testing. Finally, get or prescribe treatment.
  • Syphilis Strikes Back focuses on the prevention, diagnosis, and treatment of this potentially deadly disease which can impact pregnant women and newborn babies, among others.
  • Treat Me Right encourages patients to be proactive about taking care of their health and ask providers for what they need while equipping providers with critical communication and health information to treat their patients right.

Talk with your healthcare provider about your risk for STDs and any tests they might recommend. For more information from the CDC, go here.