Capital Women's Care Division 23

The annual gynecological exam, also known as a gynecological well-visit, is a yearly preventative and diagnostic examination which serves to maintain the wellness of female patients, as well as monitor any ongoing physical and hormonal conditions. This annual visit is an opportunity for doctors to counsel patients about maintaining a healthy lifestyle and minimizing health risks. The annual gynecological exam includes a routine breast and pelvic exam, and may include a screening for sexually transmitted diseases, such as chlamydia or gonorrhea. A Pap test may also be performed depending on the age and sexual history of the patient. The American College of Obstetricians and Gynecologists recommends that women begin annual pelvic exams at the age of 21. During the annual well-visit, a physical examination will be performed to assess the patient's overall health. The examination may vary based on the patient's age and sexual history, but most annual gynecological examinations may include the following: Pelvic exam Breast exam Pap smear HPV screening Blood pressure check Height and weight measurement Urine screening Cholesterol screening every 3 to 5 years Complete blood count Thyroid screening Screening for blood in stool In addition, there are several other tests that may be recommended for patients. These may include monthly self examination of the breasts, mammograms, bone density screenings, skin and mole examinations, blood sugar tests and others, based on age, individual medical history, family history, and lifestyle habits.

Breast exams are physical and visual inspections of the breasts. They are an important part of an OBGYN checkup because breast exams can help identify any unusual lumps or suspicious growths around the breasts. In addition, a doctor can teach a patient how to perform these exams at home every month in order to recognize any changes on their own breasts. Breast exams can be a very useful tool for the early diagnosis of breast cancer. During a breast exam, a doctor may ask the patient place their arm in several positions to view and examine the breast from various angles. For the physical portion of the exam, the doctor will rotate his or her fingers around the entire breast, applying changing levels of pressure to feel areas near the surface as well as deeper within the breast. Both breasts will be examined. Women are encouraged to do self-breast examinations every month, about five days after their period begins. This is the time that the breast are the least tender and lumpy. If patients feel anything different or suspicious during the breast exam, they should consult their doctor immediately. In some cases, patients may be sent for a mammogram to further examine their breast.

A mammogram is an X-ray examination of the breast. It is performed to detect breast cancer in its earliest stages, often before any signs or symptoms of the disease are present. Mammography allows doctors to detect small tumors that are easier to treat than larger, more developed tumors. And it can also detect small abnormal growths in the milk ducts of the breast, called ductal carcinoma in situ (DCIS). Early removal of these growths will remove the risk of future harm. Mammograms are an effective way to detect cancer early and can aid in the goal of successfully treating and beating the disease. Reasons for a Mammogram A mammogram can show abnormalities, such as a tumor, in the breast tissue long before they can be felt. Mammograms may be performed for screening or diagnostic purposes. Both screening and diagnostic mammography can help diagnose breast diseases, lumps, cysts and benign and malignant tumors. Candidates for a Mammogram It is recommended that women older than 40 have mammograms annually. Patients with the following risk factors should take extra care to be screened regularly: Personal or family history of breast cancer Abnormal changes in the breast Long-term use of hormone therapy Studies have shown that regular screenings can help reduce the number of breast cancer deaths in women. Detecting cancer early and treating it immediately, before it spreads, increases a patient's chance of remission. Preparing for the Procedure Patients should not schedule a mammogram the week before they have their period, as the breasts are usually tender at this time. The doctor may ask the patient not to wear deodorant or lotion under the arms or on the breasts on the day of the mammogram. Otherwise, there is no special preparation needed for the procedure. The Mammogram Procedure During a mammogram, the breast is placed on a small platform and compressed with a paddle while it is exposed to a very low dose of radiation. Compression helps even out the thickness of the breast so that all breast tissue can be visualized, and it also holds the breast still to minimize blurring of the image caused by patient movement. Images of the breast tissue are produced and then displayed on a computer screen for the doctor to view. The patient may experience pressure on the breast from the compression, which may be uncomfortable if the breasts are sensitive. Most patients tolerate the mammogram procedure with no problem. Risks of a Mammogram A mammogram is considered to be a safe procedure for most women, including those with breast implants. Patients should advise their doctors if they are pregnant or have any preexisting medical conditions.

Pregnancy testing is performed to determine whether or not a woman has a fertilized embryo in her uterus. A pregnancy test detects the presence of the hormone human chorionic gonadoptropin (hCG) in the body. This hormone is usually only produced when an egg has successfully been fertilized and attaches to the uterine wall. Levels of hCG rise quickly and within a matter of days after a woman becomes pregnant. There are two types of pregnancy tests that are commonly performed; one uses a sample of urine, and the other, a sample of blood. Both tests measure the levels of hCG in a woman‘s body. Urine Tests A home pregnancy test allows a woman to find out, in the privacy of her home, if she is pregnant. For the most accurate results, a woman is advised to wait 1 week after a missed period before taking a home pregnancy test. The test usually contains a stick that the woman holds under her urine stream. The stick is then inserted into a plastic container and, after a few minutes, an indicator gives a positive or negative result for pregnancy. Although most often used at home, a urine test is also used at a doctor‘s office. If the results of a home pregnancy test are positive, a woman should see her doctor for further testing to confirm the pregnancy. In some cases, a urine test produces a false negative if it is taken too early. Therefore, a woman whose result is negative but who is experiencing typical signs of pregnancy, such as fatigue, nausea and breast tenderness, should schedule an appointment with her doctor. Blood Tests Pregnancy testing through a blood test is performed only by a doctor. A blood test is considered the most accurate form of pregnancy test because it can measure even a very small quantity of hCG. A quantitative blood test, also known as a beta hCG test, measures the exact amount of hCG in the blood. These tests are very effective, and provide an accurate pregnancy result approximately 6 to 8 days after ovulation.

A prenatal consultation serves as an opportunity to meet with the doctor to discuss the details of pregnancy. Regular doctor's visits are recommended and will allow for professional monitoring of the mother and baby's health. These visits also provide time to develop a trusting relationship and discuss any potential complications that may affect the patient and her baby. The Initial Prenatal Consultation During the first appointment, the patient will be able to ask questions about the pregnancy and the options available. A physical examination and review of the patient's medical history will be done. The following prenatal care tests may be conducted: Urinalysis Blood pressure Weight Fetal heart tones Height of the fundus Ultrasound Blood tests Recommendations During the Prenatal Consultation The physician will most likely want to discuss various lifestyle changes that need to be made to ensure the mother's health and the health of the baby. Some of these recommendations may include: Avoiding exposure to toxic chemicals Establishing an exercise regimen Being vaccinated Creating a healthy diet Becoming aware of the need for health care during pregnancy Restricting travel Taking prenatal vitamins or supplements A prenatal consultation is usually recommended for expectant mothers 8 weeks after the last menstrual period. Prenatal consultations are important regardless of the number of pregnancies the mother has had. Prenatal care is crucial to the mother and the baby's healthy development.

Prenatal care is essential to ensure the healthy growth and development of a fetus. Women who receive prenatal care have healthier babies, are less likely to deliver prematurely, and have fewer pregnancy-related problems. Prenatal care should begin as early as possible. Doctor visits are usually monthly, and become more frequent as the pregnancy progresses. Routine tests at these visits include urine testing and blood-pressure checks. In addition to routine tests, there are several prenatal tests that are performed at specific times during the pregnancy. They are administered to monitor the health of the fetus and, in some cases, the mother. Types of Prenatal Tests A variety of prenatal tests are performed to monitor the fetus's health, and identify anything that can lead to complications. Certain tests are administered at different times throughout the pregnancy. After initial blood and urine tests to confirm a pregnancy, additional prenatal tests often include those below. Urine testing is performed throughout the pregnancy to test for diabetes, preeclampsia and infection.

Sonography (ultrasound procedure) is a quick, painless diagnostic imaging technique. It uses high-frequency sound waves to produce images of the internal organs. A sonogram is the image that is produced by performing sonography or ultrasonography. During pregnancy, a sonogram is performed to obtain information about how the fetus is developing. It is used to check the fetus's blood flow and heartbeat, as well as estimate its age and delivery date. It is also performed to check the female pelvic organs during pregnancy. Reasons for Sonography Sonography is used to monitor and diagnose a wide variety of conditions within nearly any system of the body. A sonogram is often considered a standard part of prenatal care because it can reveal a broad range of information regarding the overall health of both the mother and fetus. Generally, sonograms are conducted in the first trimester of pregnancy, although additional ones may be ordered throughout the second or third trimesters. Additional uses for sonography include the following: Determine whether multiple fetuses are present Identify problems in the ovaries, placenta or uterus Assess the growth, positioning and gender of the fetus Identify any physical or developmental problems with the fetus Discover the presence of an ectopic pregnancy or miscarriage Investigate complications such as infection or bleeding Sonography is usually part of prenatal care, but for some patients, frequent sonograms are recommended. Women who have previously miscarried, as well as those who experience spotting or complications, may need to undergo additional sonograms as precautionary measures. The Benefits of Sonography Sonography is a noninvasive and simple way to procure images of soft tissue, which usually does not show up well on X-rays. It is safe for pregnant women because there is no ionizing radiation involved, and it has no serious side effects. In some cases, however, a sonogram may not detect all birth defects, or may indicate the presence of a birth defect that is not actually there. In most cases, however, a sonogram is considered extremely helpful in detecting abnormalities, and improving a woman's chances for a healthy pregnancy and delivery. The Sonography Procedure Most women will have at least two sonograms during a pregnancy. Preparing for sonography varies, depending on the objective of the imaging. A women who is having a sonogram of the uterus or ovaries should have a full bladder; this enables the organs to be more easily viewed. Sonography begins with the patient's lying down on an examination table, and gel being applied to the skin at the area targeted for imaging. The sonographer moves a special hand-held device (transducer) across the area. The transducer enables sound waves to be transmitted between the body and the device, which then relays information to a computer. Sonograms are typically painless, although some patients may experience slight discomfort. In some cases, sonography may be performed transvaginally. A transvaginal sonogram involves attaching the transducer to a probe that is inserted directly into the vagina. Whether performed abdominally or transvaginally, a sonogram usually takes about 30 minutes to complete. The images produced by either method are viewed on a computer screen in real time. Results are then analyzed, and findings discussed with the patient.

A transvaginal ultrasound is a diagnostic imaging test used for examining female reproductive organs. It may be performed to diagnose the cause of various abnormalities, including menstrual irregularities, pelvic pain, infertility, and uterine fibroids, or it may be performed to monitor a fetus' growth during the early stages of pregnancy. Reasons for a Transvaginal Ultrasound A physician may decide a transvaginal ultrasound is necessary when the patient suffers from: Abnormalities such as cysts or fibroid tumors Menstrual problems such as abnormal bleeding Infertility Ectopic pregnancy Pelvic pain The Transvaginal Ultrasound Procedure Other than emptying the bladder beforehand, no preparation is usually required for a transvaginal ultrasound. On the day of the procedure, it is best for the patient to arrive wearing comfortable, loose-fitting clothing, although she may be asked to change into a gown before the transvaginal ultrasound begins. During the transvaginal ultrasound, the patient will lie down on her back with her feet in stirrups. The transducer, responsible for producing images, will be wrapped in protective covering and gel and then inserted into the vagina. As the transducer is moved around, the images it produces will be immediately sent to a nearby television screen. A transvaginal ultrasound usually takes between 30 and 60 minutes to perform, and is virtually painless. The results of a transvaginal ultrasound are usually available a few days after the exam when the doctor will discuss the results with the patient. If the test results indicate any abnormalities, the doctor will develop a customized treatment plan based on the patient's condition.

A woman who has previously delivered a child by Cesarean section (C-section) may be able to deliver her next child vaginally. This process, known as vaginal birth after Cesarean section, or VBAC, had not been an option in the past. Once a woman delivered by C-section, all successive births were C-sections. Medical advancements and improvements in surgical methods have now made VBAC a safe and fairly common delivery procedure. Benefits of VBAC There are a number of reasons, including wanting to experience a vaginal delivery, for a patient to choose VBAC. Other advantages of VBAC over C-section may include: No abdominal surgery Shorter recovery period Fewer complications Less risk of infection Less blood loss VBAC also benefits a woman planning to have several children. A woman who has undergone multiple C-sections may not be a good candidate for vaginal delivery because she has a greater chance of complications. However, a woman who has delivered only one child by C-section experiences fewer risks with each successive vaginal birth Risks of VBAC Vaginal birth after C-section carries a small risk of uterine rupture at the C-section incision, depending on where the incision was made. A woman who has had a previous C-section with a high vertical incision, which is made down the length of the uterus, may not be eligible for VBAC because this type of incision is more likely to rupture. VBAC is considered safe for a woman who has had a C-section with a low transverse incision, which is made across the side of the uterus.The majority of C-section deliveries use this type of incision. Considerations for VBAC VBAC may not be the best method of delivery if the baby is particularly large or more than one baby is being carried. VBAC has a higher success rate if labor occurs naturally, before or on the due date. However, if the pregnancy goes past the due date, the success rate begins to drop. Other factors that should be considered before VBAC may include: Number of previous C-sections Prior uterine rupture Other pregnancy-related problems A patient who opts for VBAC needs to remain flexible when it is time for labor and delivery. In most cases, the vaginal birth will proceed as planned, but there are situations that can arise during labor that might increase the risk of complications in a vaginal delivery for the patient or baby. If that occurs, the patient should be prepared to follow the advice of her medical team on how to proceed with delivery.

A cesarean section, also referred to as a C-section, is surgery to deliver a baby. During a c-section, a doctor surgically removes the baby through the mother's abdomen using surgical incisions in the abdomen and uterus. A C-section is considered a surgical procedure and takes place in the operating room of a hospital. A C-section may be planned by a physician ahead of time due to pregnancy complications, however in some cases, a C-section may be necessary when unexpected problems arise during labor or delivery. Reasons for a C-section A cesarean section may be necessary for several reasons and may be planned in advance, but in some instances it is an emergency procedure. A C-section may be planned in advance because of the following reasons: The baby is in a breech position There are multiple fetuses There are placenta problems The mother has had a previous C-section A C-section may also be performed when unexpected issues arise during delivery. These may include: Signs of fetal distress Health of the mother is in jeopardy The baby cannot fit through the vagina during delivery Umbilical cord problems Labor is not progressing A C-section may also be necessary if the mother has any underlying health problems such as a heart condition, or an HIV or herpes infection. Because of the possibility that a C-section may be necessary, most women with high risk pregnancies are advised to go to a hospital when they are in labor. The C-Section Procedure A C-section is performed in a hospital setting and is commonly performed while the mother remains awake. Prior to the surgery, a catheter is placed in the urethra to drain urine. A spinal block is used to deliver regional anesthesia to the lower part of the mother's body (mid abdomen and below). The doctor makes an incision in the abdomen near the pubic hairline and then a second incision is made in the uterus. The baby is then delivered through the incision, the umbilical cord is cut and the placenta is also removed from the uterus. The uterus is stitched closed with dissolvable stitches, and the abdomen is closed with either stitches or staples. The catheter is usually removed from the bladder within a few hours after the surgery. Recovery from a C-Section After the C-section, the mother and baby will typically stay in the hospital for 3 days. Soreness at the incision site is common and pain is treated with prescription medication. While recovering, woman may experience common symptoms that occur after giving birth, which include cramping, and vaginal bleeding or discharge for about 4 to 6 weeks. After leaving the hospital, physical activities may be limited while the incision heals and sexual intercourse should be avoided for at least 4 to 6 weeks. Risks of a C-Section As with any surgery, there are risks associated with a C-section that include: Infection Increased bleeding Reaction to anesthesia Blood clots Injury to other organs Women who have had a C-section have a higher risk of complications with subsequent pregnancies including: uterine rupture, heavy bleeding and placenta problems.

A contraceptive skin patch is a hormonal method of birth control. A small adhesive patch is worn on the skin; it releases hormones that are absorbed by the body. The hormones released are estrogen and progestin, which prevent a woman's body from ovulating (releasing an egg). In addition, progestin causes the mucus within the cervix to thicken, making it difficult for the sperm to reach the egg. The contraceptive skin patch is a convenient form of birth control because, unlike oral contraceptives, which have to be taken daily, the patch is used for a week at a time. Prescription and Use of the Contraceptive Skin Patch A contraceptive skin patch is prescribed by a physician after a physical examination. The doctor determines which levels of hormones are appropriate for each individual. The patch can be worn on the chest, buttocks, arm, upper back or abdomen. A new patch is worn for a week at a time, for a total of 3 weeks in a row. On the fourth week, a patch is not worn, which allows menstruation to occur. Benefits of the Contraceptive Skin Patch The contraceptive skin patch can be removed, if desired, at any time. In addition to preventing pregnancy, a contraceptive skin patch has all the benefits of hormonal methods of birth control, which include the following: Lighter and shorter periods Reduced menstrual cramps Decrease in acne Decreased risk of uterine and ovarian cancers Hormonal birth control methods such as the skin patch may also be used to treat abnormal or painful uterine bleeding, and endometriosis. Risks of the Contraceptive Skin Patch Although the contraceptive skin patch is a common and safe form of birth control, it does have some side effects and risks, which include the following: Skin irritation Irregular bleeding Heart attack Blood clot Headache Weight gain Stroke High blood pressure The contraceptive skin patch does not provide any protection against HIV or sexually transmitted diseases. Women who are older than 35 or who smoke have a much higher risk of heart attack or stroke when using hormonal birth control methods such as the contraceptive skin patch. No contraception method is 100 percent effective. Women should consult with their doctors about the different types of oral contraception available, and to get answers to any questions they may have about contraception and family planning.

Emergency contraception is a form of birth control used to prevent pregnancy after a woman has had unprotected sex. Emergency contraception can also be used to prevent pregnancy after a sexual assault, or when any method of birth control is not used correctly. One form of emergency contraception is often referred to as the "morning after pill." It is a form of oral contraception that contains hormones, and is most effective when taken within 72 hours of unprotected sexual intercourse. In some cases, a copper intrauterine device (IUD) is used as a form of emergency contraception; it must be inserted within 5 days of having unprotected sex to be effective. Types of Emergency Contraception Some forms of emergency contraception are available only with a prescription, whereas others can be purchased over the counter at a pharmacy. Over-the-Counter Oral Contraception Available without a prescription, these forms of emergency contraception are pills that contain high levels of the hormone progestin, which works to delay ovulation. In some cases, proof of age (17 and older) is required before they can be purchased. The pills should be taken as soon as possible after unprotected sex, and are most effective within 72 hours of unprotected sex. They may be sold under the following: Plan B One Step® brand name Next Choice One Dose® brand name My Way® brand name In some instances in which emergency birth control is needed, women may take a higher dose of the birth control pills they are currently using, although this should only be done under the direction of a physician. Prescription Contraception Ulipristal acetate (sold under the Ella® brand name) is a type of emergency contraception pill. Ulipristal acetate works to delay ovulation, and may help prevent implantation. This form of emergency contraception requires a prescription. It is effective if taken within 5 days of unprotected sexual intercourse. An IUD is a form of prescription contraception that is placed into the uterus by a physician; it can be used in emergency situations and as a regular form of birth control. An IUD may be effective if it is inserted within 5 days after having unprotected sex. The IUD works by stopping sperm from joining an egg, or preventing a fertilized egg from attaching to the uterus. The IUD may be removed after the next menstrual cycle or, if desired, can be left in place as a future method of birth control. Risks of Emergency Contraception Emergency contraception should not be used if a woman thinks she may already be pregnant. Side effects of oral emergency contraception include the following: Nausea Vomiting Dizziness Headaches Breast tenderness Abdominal pain Fatigue Side effects from an IUD are rare, but may include pelvic inflammation or injury to the uterus. Methods of emergency contraception should not be used as a regular form of birth control.

Intrauterine devices (IUDs) are a method of birth control that has few side effects. They can provide long-term effective protection towards prevention of pregnancy. The devices require precision and care to be fully effective and protect against infection. Improper insertion of an IUD can lead to pelvic inflammatory disease and other pelvic infections. IUDs should only be inserted or removed by a trained health care professional who will minimize risks for complications or serious damage. During proper IUD insertion, the cervix and uterus are measured and the IUD is inserted to the proper depth with a tube. A string is left hanging in the cervical canal for maintenance and removal purposes. During removal, the strings are located and grasped with a clamp to slowly release and remove the IUD.

Tubal ligation is a surgical procedure that involves blocking, tying or cutting a woman's fallopian tubes to prevent eggs from traveling into the tubes and being fertilized. It is a permanent form of birth control so you must be sure that you do not want to have more children in the future. Tubal ligation is not 100% effective; pregnancy can occur if the tubes grow back together or create a new passage. This is a rare occurrence and the procedure is effective for most women. Tubal ligation is performed either laparoscopically, with tiny incisions in the abdomen, or through a laparotomy or mini-laparotomy, which is open surgery with a larger incision. A full recovery usually takes about a week, and complications with this procedure are rare. While a tubal ligation is reversible, it does not have a high reversal success rate. It is important to discuss the different birth control options with your partner before undergoing a permanent procedure. Talk to you doctor today if you are considering this procedure.

A vaginal ring, which is a hormonal method of birth control, is a flexible, plastic ring that is placed in the upper part of the vagina, where it releases the hormones estrogen and progestin. When the estrogen and progestin are absorbed through vaginal tissue into the body, they prevent a woman's body from ovulating (releasing an egg). In addition, progestin causes the mucus within the cervix to thicken, making it difficult for the sperm to reach the egg. Although it is only available through a prescription, a vaginal ring does not require a personalized fitting, and can be removed at any time. Prescription and Use of the Vaginal Ring A vaginal ring is prescribed by a physician after a physical examination. The physician determines which levels of hormones are appropriate, and when use of the vaginal ring should begin. The vaginal ring is inserted by the woman into her vagina, and left in place for 21 days. She then removes it, which allows menstruation to occur. After 7 days, she inserts a new ring into her vagina for 3 more weeks of pregnancy protection. Benefits of the Vaginal Ring In addition to preventing pregnancy, a vaginal ring has the benefits of hormonal methods of birth control. These benefits include the following: Lighter and shorter periods Reduced menstrual cramps Decrease of acne Decreased risk of cancer of the uterus and ovaries Hormonal birth control methods such as the vaginal ring are also used to treat abnormal or painful uterine bleeding and endometriosis. Risks of the Vaginal Ring Although the vaginal ring is a convenient and safe form of birth control, it does have some side effects and risks, which include the following: Vaginal irritation Vaginal discharge Breast tenderness Breakthrough bleeding Heart attack Blood clot Headache Nausea Stroke The vaginal ring does not provide any protection against HIV or sexually transmitted diseases. Women who are older than 35 or who smoke have a much higher risk of heart attack or stroke when using hormonal birth control methods such as the vaginal ring. No contraception method is 100 percent effective. Women should consult with their doctors about the different types of oral contraception available, and to get answers to any questions they may have about contraception and family planning.