August 2009

Q. Im 27 years of age and didnt had my period in ages i know it can be my hormones is it possible that you can tell me whet to use to get it right agen please im very desprate to get pregnant.

A. If you haven't had a period in 4-6 months or more - you probably aren't ovulating and may have a number of treatable reasons for it. You should start with a good gynecologist who can help you find the cause. It is also important for women who haven't had a period to have the lining of their uterus checked to be sure there is no build up - and possibly to take a hormone each month to bring on the period.
I hope everything works out for you.

Q. I just saw your interview on Good Morning America talking about the subject of women taking SSRI medication while pregnant and I have to say that I am in a state of shock in how you, in good conscience, endorse the use of antidepressants pregnancy.
My cousin has two children. One before she ever used SSRI medication and the other while she was pregnant and taking SSRI drugs. It doesn't take an MD to figure out which one is normal and which is clearly abnormal and the abnormalities are a direct result of using SSRI drugs while pregnant.
Although depression is a very serious illness, introducing chemical compounds to the fetus that have a direct effect on the neurochemistry of the central nervous system lines in along the same logic of taking hallucinogenic drugs and thinking that after the trip is over that everything will be as it was.
Drugs, regardless of their makeup will effect the mind and recommending a pregnant woman to use drugs is not irresponsible, it's criminal...
SSRI medications are, unfortunately, one of the most widely used medications. I use the word unfortunate because of the multitude of side effects and the dependency of having to use them for years if not for a lifetime. A better class of drugs or better yet, a better understanding neurochemistry of the human mind is needed before throwing drugs at a problem like depression; especially for the unborn.
I feel so bad for my cousin who took the advice of a doctor who apparently didn't understand or appreciate the risks involved with SSRI drugs and pregnancy. I hope no other woman has to go through what she's going through...

A. Thanks for sharing with me your concerns about SSRI's in pregnancy. As an internist we have always been cautious about recommending any medication, including SSRI's, during pregnancy. And as I mentioned in the interview, I believe that many women should wean off their medications before they get pregnant if they can. Women with severe depression however who have been suicidal in the past have a much higher chance of relapsing if medications are stopped. Taking medication for them may be there only choice - and it is always a difficult one.
On the other hand, the purpose of this report was to share with doctors the research on untreated depression as well and to point out that the risks of untreated depression are considerable to the baby as well as the mother and that treatment with drugs like SSRI's need to be considered. Unfortunately there is very little research on the effects of these medications and I do share your concerns. That said, there are some women with severe depression who make the decision with the advice of their doctors to take the medication during pregnancy as they see they have no other choice. The experts all agreed that much more research needs to be done - but that taking medications under certain circumstances may be necessary.

Q. Diane Sawyer told viewers at the end of the segment that we could post comments and that you would respond but I couldn't find a place to do that. (I sent an email to ABC too.) In any case, if I may pose a question to you here...what about the safety of farm raised fish and what about cod and haddock (very common on Cape Cod and south of Boston).

A. Thanks so much for writing and asking this question. The EPA has a list on their website of the mean levels of mercury in fish and you will see that haddock is low, cod is a little bit higher and fish like halibut higher. Flat fish such as flounder is low in mercury. However since 80% of fish is imported (and most of this fish is not checked for mercury) it is hard to know exactly what you are getting from commercial fish. Many local public health departments will provide information on the fish in your area...so you may want to ask this question of your local authorities. Generally the risk of mercury is cumulative so that eating any fish on occasion is not considered a risk.

Q. I saw you commentating on mercury levels in fish and the frequency in which you can eat them. I keep hearing that farm raised salmon is dangerous to eat more than once per month due to non-mercury reasons. Would you happen to know where I can find more information on the risks and proper quantities of farm raised fish, such as salmon?

A. Thanks so much for writing and asking this question. The EPA has a list on their website of the mean levels of mercury in fish and discuss farmed raised salmon and wild salmon.
But first a reminder, 80% of fish is imported (and most of this fish is not checked for mercury) it is hard to know exactly what you are getting from commercial fish from different areas. In general, farmed fish is fed with fish oils and processed fish feeds which have been found to contain all sorts of contaminants including PCB's and other unknown substances. Manufacturers of the fish feed claim they are removing many of these contaminants but I have no idea of the quality control and safety of other additives. Since farmed fish however grow quickly they don't have time to accumulate the same amount of mercury that a wild salmon, who feeds on smaller fish over their longer lifetime, does. The good news about wild salmon is that it seems to contain much less mercury overall than a predatory deep water fish such as tuna.
Many local public health departments will provide information on the fish in your area...so you may want to ask this question of your local authorities. Generally the risk of mercury is cumulative so that eating any fish on occasion is not considered a risk.

Q. I am a 39 year old woman. For the last 2-3 years I have experienced sudden and infrequent pain specifically in the vagina. I have no discomfort at all during sex with my husband. The pain occurs once approximately every 3-5 months. I have mentioned this to my GYN (and of course have had routine pap smears). He says everything appears to be fine and doesn't know why that might be happening. I don't think of it often, but when the pain hits, I have to literally stop what I am doing because it is so severe. It can last anywhere from about 1-3 minutes and then it's gone....until the next time. It has hit a few times after walking or running on the treadmill, but sometimes sitting, sometimes standing - it doesn't seem to make a difference. I have regular periods - I can pinpoint it each month within a couple of days.
I am going for my routine pap smear next week. Does this sound like anything you've seen before?

A. This is a tough one. On the one hand it sounds as though your vagina looks healthy and since the pain is unpredictable, almost certainly isn't originating from the tissues or areas of the vagina. The only remote thoughts (and I say remote as this seems like an unusual but fortunately not serious complaint - although it sounds disabling when you get the episode) are that a nerve or blood vessel could possibly be involved - almost like a "pinched nerve" or funny blood vessel with transient episodic attacks. I suppose you could be reassured by a vaginal ultrasound to be sure your pelvic tissues all look healthy (uterus, ovaries, etc.) but to be honest, symptoms that are so episodic and transient often are hard to pin down - and almost always not serious. However easy for me to say...you have to live with the uncertainty which I confess I too would want some attempt to find the cause...even if just an ultrasound or ?? not sure.
I guess I would let your GYN know that it is worrisome to you - is there any other test just to reassure you that all is well??

Q. Hello' I'm a 49yr old man. I think i have gh(gential herpes).I was married in 1999 and my wife said she had it. I remember her telling me when she gets it she go'es to her doctor & get it cut off. Well in a few months i remember getting several clear bumbs on my penis, well we still had intercourse. 2 yrs ago i went to the health clinic, they told me, there is no test for gh. I have not had intercourse since 2002. So my question is , i have 2 brown spots on my penis. Can i do something to get reed of the spots? I feel very conscious of them. I am a veteran, so i go to a va clinic. Should i talk to my doctor about it ??

A. I am not sure what your wife had - if she indeed had something "cut off" that sounds like genital warts from HPV (human papilloma virus). HPV is very infectious however once you are exposed to it, your body's immune system will fight it off and you will "get rid of it". So I wouldn't worry about pasisng on HPV if you have not been sexually active. HSV (herpes) is a chronic infection that lies dormant (I explain all this in great detail in my book, which I do think men enjoy and learn lots from too)...and when it appears, causes very painful blisters and "nerve type pain". I am sure you would know if you had that. The brown pigmentation is likely from an old inflammation from any number of causes. The skin is so delicate it is hard to do anything to change it...other areas such as the face and hands can be treated with retin A - but obviously not sensitive tissues. And YES, the VA is usually staffed by excellent dermatologists and university trained doctors so I would start with them.

Q. I am a 51 year old woman, was married for 17 years ( from the age of 23), sex WAS ALWAYS PAINFUL for me, before, during, & after marriage. I GAVE up on my Male Gynecologist years ago. HE told me that my uterus was seriously tipped, could be "tacked" or something like that? BUT was SURE despite my telling him otherwise (no kids for me it was an abusive marriage) that kids would solve the problem! Here I am years later..........FINALLY away from that, now going through menopause (and using my GP as my Gyno). I am finally emotionally ready to enter the dating world again, but this is now a HUGE issue!!!!!!!!!!!!!! Where do I go what do I do?

A. Congratulations on your new beginning...you must feel tremendous relief. If you have a great GP, talk to him/her about your concern. As you are perimenopausal, your biggest concern will still be birth control (unless you have gone through the change - no period for over a year) and perhaps dryer vaginal tissues from lower estrogen. Ask you doctor where things stand - what does your pelvic exam and vaginal tissues look like? Does she see any problem for you? It is hard for me to guess how things may go for you but I can only imagine that the tremendous relief you must feel from the burden lifted should give you the best chance for success in a new relationship. I guess most important is that you know and trust this "someone" as much as you can before having a more intimate relationship - although I understand that can be hard and things don't always work that way. The last thing you need is for someon to take advantage of you again.
I trust things will go fabulously well.

Q. I saw your segment on Good Morning America last week regarding problems after menopause. I am 57, post-menopausal and having trouble with vaginal dryness and painful intercourse. Vaginal lubricants are not helping. My general practitioner has recommended Vagifem tablets. Research on the internet and side effects listed with the prescription are enough to scare a person to death. Do you feel this is a safe solution? Should the Vagifem be taken with a progestin? Do you feel utilizing Vagifem is worth the risks? Is there a safer alternative?

A. I am in the same boat as you - and have experienced similar difficulties. I spend a chapter in the book talking a lot about this. Vaginal lubricants help symptoms but don't fix the underlying problem. As our estrogen falls (and some women have lower estrogen and make very little from too few fat cells after menopause - such as my case) the tissues of the vaginal and urethral area become very thing and fragile, often tearing with little more trauma than toilet paper...not to mention sex. It is true that the only thing that will correct the problem, thicken the cells/tissues, and bring back the friendly acid-loving bacteria and lubrication is estrogen. Although there is concern about taking systemic estrogen long-term for some women, taking it locally by the vaginal cream or tablet route provides negligible systemic absorption and very little if any risk. I presume you never took other hormones after menopause and stopped bleeding a number of years ago?? The average age is about 52. If that is true, you could safely use Vagifem (that is what I also use as it is not messy, and the systemic absorption is theoretically less than a cream). If you continue the estrogen locally for a long time, you could have your doctor prescribe Prometrium (progesterone) for 10 days every 4-6 months or so just to see if any uterine build up has occurred. If it has, then taking prometrium more often may be advised...or lowering the amount of local estrogen used. Once vagifem starts working in a few weeks - you will notice a huge difference.
Your pap test will often show the low estrogen effect too - which emphasizes just how important estrogen is to the health of the vaginal cells.

Q. Is the digene HPV test only for women?
Is it reasonable to suggest that because the dangerous forms of HPV are typically invisible and the benign ones are visible but symptomatically treatable, that sexual contact with a male who has an HPV wart is no more dangerous than one who does not?

A. Unfortunately there is no good way to test men for active HPV infections and of course no reason to screen them for persistent HPV infections a there is no equivalent burden of disease for them (other than the increased risk of cancer of anal transformation area in men who have sex with men and in this setting the HPV test can be used as it has been helpful in clinical trials) - yet on the other hand screening in women is primarily to identify women who have a persistent high risk strain of the virus in their cervical transformation zone which has been shown to be extremely sensitive/specific in predicting who is at future risk of dysplasia/cancer.

It is not recommended that the HPV test be used to identify women with active high risk infections and that is why screening recommendations with the HPV test don't begin for women until age 30, an age when a positive test is more likely to suggest persistence of the virus rather than active infection.

As to your second question, theoretically you are right - however since genital warts are so highly infectious, men should wear condoms to help (but not eliminate) avoid passing on the virus and other sexually transmittable viruses...and of course STI's frequently coexist.

Q. I am a 64 year old female. I lost my husband 9 months ago after a 3 year plus battle with cancer. Even during our last few years we always had a more than wonderful sex life together. However, intercourse did become painful even though we used KY jells and enjoyed much foreplay. I set this problem aside as my husband was my first priority.

Now after time taken to get back on my feet I want to address this issue, not because I'm in anykind of relationship, ( I'm not involved with anyone) but because I feel a tenderness on the right side of my vagina, and it's very sensitive. I have spoken with my doctor of 20 plus years and to date he hasn't come up with any suggestions or solutions.

I did have a DNC recently due to spotting, and that seems to have corrected that problem, but this constant awareness I have concerning the vagina is concerning. I haven't ruled out a future sexual relationship if it presented itself, but this vaginal makes me hesitant.

My husband was the one in a million man we all hope for, and the love of my life. His loss has been the most traumatic event of my life, however, I know I have to go forward.

A future relationship is a secondary issue for me, and frankly not likely to happen simply because I'm busy with business and family, however, I know anything is possible as my dear husband and I were both in a second marriage, we had waited a long time to find each other and what we had was perfect. The lesson is, know when your happy and appreciate each day, I simply couldn't have asked for more in another human being than what my Bob gave me.

Didn't mean to go on and on, but when I saw you on Good Morning America, I thought, "Wa LA", perhaps this woman has the answer I'm looking for.

A. Your email has touched me so much. I am so sorry about your loss. It sounds like you both were extraordinarily lucky and will have your memories forever.

It sounds as though you have vaginal thinning from low estrogen which almost always happens to women eventually. Your doctor may not have considered this a problem or unusual since it is quite typical. However I can say from experience (and I describe this in my book in great detail) the vulvar and vaginal tissues can get quite tender and even tear. If your doctor has ruled out anything serious as the cause of your recent spotting (this too could be from low estrogen) and has examined your vagina where you are tender to be sure all is okay - then a small dose of an estrogen cream can be used safely and make a huge difference. I would also suggest you consider using baby wipes with aloe rather than toilet paper for hygiene - especially after bowel movements. Baby wipes can be gentler than toilet paper. Also minimize soap and rubbing as the tissue can be so thin.

Best of luck to you - and again - so sorry for your loss.

Q. Thank you for your informative response, and kind words, both are appreciated.

I neglected to tell you I ordered your book yesterday, it will arrive today, and I am looking forward to the read.

I thank you for the guidance regarding a good approach to solving this problem, it's quiet nice to know I'm not alone.

Bob and I always felt sorry for couples that really didn't know how to enjoy, or give joy, and pleasure to ones mate, it is one of the most wonderful gifts given to us, and more often than not over looked. So often couples feel, " Well, this is all there is ", and that is simply a fallacy.

Good luck with your book, and continuing to educate people.

Q. Hi I recently had an internal sonogram and it showed that I have fibroids. One quite large that sits on top of my uterus. I went and had an mri with contrast and it pretty much showed the same as the sono. I also have abnormal thickening of my uterine lining. I am so scared and confused as to what to do next. My doctor initially spoke of surgery but I have no other symtoms. No heavy bleeding or pain. Sometimes my period will not come for 2 months but then I will get it. 26-30 days. I am afraid of cancer although paps have always been normal. I guess I am wondering what to do next. I am feeling very overwhelmed. Thank you for any help or advice you can give me.

A. It sounds like you have two separate issues. The first are the fibroids. As you heard me say, fibroids are not cancerous and rarely do you need to have surgery unless you are having trouble getting pregnant - or they are pressing on your ureters or causing a lot of pain. Too often women regret having surgery and the good news is that fibroids do eventually shrink as your hormones go down and you go through menopause. That leads to the second issue: the thickening of the lining. How old are you? Have you been on any hormone/birth control pills? Are you overweight? A thicker lining could mean you aren't ovulating, your period was due, or it can be an abnormal build up that may need to have an endometrial biopsy to determine the cause. Some women who have long cycles don't ovulate regularly.

What has your doctor suggested you do about the thickening? My book will help you ask better questions to your doctor and make better decisions.

Q. How many women really achieve vaginal orgasms? At 60 years of age I have never had a vaginal orgasm through penis penetration. Oral sex or manual stimulation, but never vaginally. I feel like a freak!

A. It may surprise you to learn that most women require stimulation of outside tissues through oral sex, vibrator, or touch to achieve an orgasm and that the concept of a "vaginal orgasm" simply from penetration alone is no longer considered typical. Obviously every woman is different and needs to find what works best for her..

Q. Well, that's a relief!!! I can tell my husband it's not just me. A BIG THANK YOU!!!

Q. I just turned 19 years old. I recently got married and when I met my husband about 2 years ago,I had a very high sex drive. I have never had an orgasm and I'm not sure why. But my main concern is that for the past couple of months I have been in so much pain during sex and my sex drive has dropped tremendously. At one time I couldn't even continue because it was so painful.I am taking the birth control pill and I'm wondering if that may have anything to do with it. But could you help me figure out what is wrong with me so that I can enjoy sex with my husband again.

A. It is not unusual for women not to have orgasms when they first become sexually active. It really does take years of practice - and of course being comfortable with sex. If you suddenly find a change in your sex drive and pain with sex - the two may be related. Yes, birth control pills can be the cause (the Nuva-ring avoids the lower testosterone/sex drive issue) but a problem with your vulvar tissues such as an infection or vulvodynia also needs to be explored. Have you had a GYN exam recently? Can your doctor recommend a different birth control option? Are you on anitdepressants or other medications that could change your libido? Or perhaps you are worried about something else altogether - and your sex life is the first to change as a result?

The fact you were great two years ago means almost certainly you will get to the bottom of it and get better. The best thing is to find a practitioner (sometimes nurse practitioners have more time to spend and work with you on different things) who can take the time to help you.

Q. I live in Albuquerque, New Mexico. I have been sick for the past 9 months and have not found a doctor here to diagnose me. I have had a live blood analysis by a holistic person trained in the use of dark field microscopes. She has determined I have some form of spirochete in my blood. I have been taking herbal supplements and doxicycline with much relief. I am not totally over my symptoms as I have been basically self diagnosing and medicating myself. My question is where can I go to get someone to properly diagnose my infection and get treatment. Any advice, help, support or direction would be greatly appreciated.

A. Did you travel outside New Mexico or was your infection acquired close to home? Have you had the standard Western Blot and other tests for lyme disease (and syphilis still can occur so would presume you were checked for that as well although that is treated wit penicillin drugs and not doxycycline). Most clinical trials did not find a great advantage to long term antibioitics although since doxycycline has helped that may suggest you need doxy for a few months at least. It can be hard on your esophagus so make sure you drink with an empty stomach so it gets absorbed and with lots of water or fluids....and don't lie down after you take it for some hours. Have you seen an infectious disease specialist who is expert in the endemic infections in your area?

Q. I have been to the infectious disease department of my hospital but they have and will only run ELISA testing for lymes which has come back negative twice. I cannot find a doctor who will order further testing for lymes. My condition is getting worse again as I have no more antibiotics. I would like to find a doctor who will run further testing. Do you have any idea where I can go?

A. Unfortunately I am stuck. I would rely on the CDC website information and lab tests that recommend. There are lyme specialists in some cities that may help - and perhaps they could be found in your area. I am sorry I couldn't be of help.>br /> Warm regards and hope things turn around for you.