Women's Health and Family Care in Jackson, Wyoming

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Hours: Monday - Friday 8:00 am - 5:00 pm or by appointment
Location: 555 E Broadway Suite 108 PO Box 14230
Jackson, Wyoming 83002 | Get Directions

Phone: (307) 734-1313

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Back Pain During Pregnancy

Published August 5th, 2015, in the Jackson News and Guide

Giovannina M. Anthony, M.D.

Back Pain During PregnancyOn an average day seeing patients in the office, I hear about a lot of different types of discomfort experienced by pregnant women.  Heartburn, frequent urination, difficulty sleeping, and numbness in the hands and feet are just a few of the common complaints.  By far the most common, however, is back pain during pregnancy.  Especially for women who have never had to deal with back pain prior to pregnancy, the problem often takes them by surprise.

The main cause of back pain in pregnancy is muscle strain.  Why is it so common in pregnant women?  Especially late in pregnancy, one look at a very pregnant woman tells the tale:  the heavy uterus, now way out in front of the torso, forces her to arch backwards, just to remain upright.  This arching is called lordosis.  Her center of gravity, once in the central torso, is now several inches forward.  I often see pregnant women supporting their lower back with both hands as they walk or stand, which exaggerates the pregnant woman’s “waddle” as she walks.  Deep core muscles she never even knew she had are now being recruited to simply stay upright, and she often over-compensates with a dramatic lordosis.  The result:  strained back muscles.

In addition, the abdominal muscles are an important component of spine support.  In pregnancy, the abdominal muscles are stretched out and can weaken.  These changes increase the risk of injury, strain, soreness, and stiffness in the back during and after exercise.

The icing on the cake is the effect of hormones on connective tissue during pregnancy.  To prepare the pelvis for the passage of the baby through the birth canal, a hormone called relaxin literally relaxes the ligaments in the joints of the pelvis.  This loosening allows the joints to become more flexible, but it can also lead to back pain if the joints are too mobile.

What can you do to prevent back pain during pregnancy?  For starters, be aware of how you stand, sit, and move.  Also, I would strongly recommend orthotics in both shoes.  The arch supports will change the geometry of standing and relieve the lower back.  Another tip is to invest in a firm mattress, which provides more support during pregnancy and will also improve sleep patterns.  Perhaps the most effective treatment that never fails to improve back pain is to sleep on your side with one or two pillows between the legs to help prevent the hips from collapsing.

A general rule is to sit in chairs with good back support, so you can lean back, and/or to use a small pillow behind the low part of your back while sitting.  There is a special device called a lumbar support that can be purchased from medical supply stores that is very helpful.  And, do not bend over from the waist to pick things up—squat down, bend your knees, and keep your back straight.

The role of exercise in prevention and treatment of back pain during pregnancy cannot be over emphasized.  Regular exercise strengthens and stretches the muscles that support your legs and back while promoting good posture.  Exercise will not only ease back pain but also help prepare for labor and childbirth.

What kind of exercise is recommended for back pain during pregnancy?  In general, exercise that strengthens and stretches the muscles that support your back and legs while promoting good posture are key.  A great place to start is simply by stretching the hamstrings and hip flexors.  Simply stretching these muscles will release tension in the lower back.  Also, exercises such as pilates will improve core strength, which also helps release and relax deep core muscles throughout the back.

I also recommend prenatal yoga to virtually all of my patients.  Prenatal yoga improves circulation, stretches the appropriate muscles, builds strength, and keeps the body flexible, which is also important to preparing for labor and delivery.  Most yoga studios offer classes in prenatal yoga with an instructor familiar and trained to work with pregnant patients.  For patients who are unable to attend a formal class, prenatal yoga is also available online.  Local prenatal yoga instructors can be found teaching classes online at yogatoday.com, where you can do prenatal yoga in the privacy of your home and at any time.

In addition to the physical benefits of yoga in easing back pain, yoga also provides a powerful stress management tool with rhythmic breathing.  The meditative aspect of yoga also can bring a great sense of calm and peace to a pregnant woman as her life and body go through tremendous changes.  Awareness of the perineum that occurs through yoga practice will also help with the labor, delivery and postpartum experience.

Other tools to help with back pain during pregnancy include prenatal massage and physical therapy.  Generally, I recommend patients pursue exercise with stretching, prenatal yoga, and/or pilates, supported sleep with firm mattress or bolsters/pillows, followed by regular prenatal massage.  If improvement is minimal, referral to an experienced physical therapist may be indicated.

If back pain is worsening or persists for more than a few weeks, your prenatal provider should be contacted.  We would want to make sure that other causes of pain, such as preterm labor and urinary tract infection, are not present.  Fortunately these scenarios are uncommon, and ultimately back pain resolves with delivery of the baby.

The HPV Vaccine: Gardisil 9

The New HPV Vaccine:  Gardisil 9

Published:  Jackson Hole News and Guide, March 2015 

Giovannina M. Anthony, M.D.

In 2006, the FDA approved the first HPV (human papillomavirus) vaccine, designed to prevent cervical, vulvar, and oral cancers caused by the most common and virulent HPV subtypes:  16 and 18.  The vaccine also prevents infection by HPV subtypes 6 and 11, which cause the common but benign genital wart.  Persistent HPV infection leads to cancer of the cervix in 10,000 American women each year.  And genital warts?  The numbers are in the millions, for both women and men.

Cancers of the anus and head and neck are also possible, and can occur in both sexes.  Research on HPV has revealed that subtypes 16 and 18 cause approximately 70% of all of these cancers.  In December 2014, the FDA approved Gardisil 9, which adds protection from five additional high-risk subtypes:  31, 33, 45, 52, and 58.  This is a 20% increase in the level of protection from the first vaccine and means that Gardisil 9 now protects women from over 90% of the abnormalities caused by the highest risk subtypes.

Sometimes patients will say to me, who cares about HPV vaccination?  “I get my pap every year, and pre-cancerous areas on the cervix will be removed before I ever get cancer.”  The problem in this country is what I like to call the “burden of HPV disease.”  Not a day goes by that I don’t call to counsel a patient about HPV, repeat a pap smear (not exactly fun for the patient), burn off genital warts, scrape the inside of the cervix, biopsy, or excise precancerous abnormalities off of the cervix in a larger procedure.  In addition to the stress, anxiety, and discomfort, and multiple time-consuming doctor visits, it costs patients, insurers, and taxpayers billions of dollars each year to manage HPV disease.  None of these patients have cancer, but the means of prevention in non-immunized women are invasive and expensive.  Why would we not want to prevent the spread of HPV disease?

So what exactly is HPV?  It is a virus that is spread by skin-to-skin contact, including sexual intercourse, oral sex, anal sex, and even minimally intimate contact:  i.e., hand to genital contact.  Condoms do not provide complete protection.  Most women and men have become infected with HPV between 15 and 25 years of age.  When patients ask me, “why do I have this?”  I answer them:  everyone has it.  HPV disease is what is called endemic:  so many of us have it, that it simply lives in the population, spreading with intimate contact.  If you are not vaccinated, you cannot avoid HPV.

Fortunately, most people will clear the infection without symptoms and without treatment within two years.  However, in 10-20 percent of women, the cervical infection persists and can recur, and both men and women can harbor the virus for years.  For this reason regular testing is important in detecting cervical abnormalities early.  HPV is classified as either low risk, which causes genital warts, or high risk, which causes cancer.

Because one can pick up HPV without having intercourse, early vaccination is the key to prevention.  All of the currently available HPV vaccines are FDA approved to be given as young as age 9, and as old as age 26.  The earlier the vaccine is given, the more robust an immune response that results.

I hear some parents say that since their child or children are male, they don’t need to be vaccinated.  It is an interesting situation that a parent would vaccinate a boy to protect his future partners, but I believe it is an ethical and appropriate thing to do.  If there was a sexually transmitted virus that girls gave to boys that caused a cancer on their genitals, I don’t think there would be any debate in the United States regarding vaccinating those girls.  This is an unfortunate consequence of gender relations worldwide.  In fact, in many parts of the world, where pap smear screening is unavailable, the HPV vaccine could save thousands of lives.

Another reason to vaccinate both sexes, however, is the fact that HPV causing cancers of the anus and head and neck are on the rise, regardless of sex.  The recent death of Farrah Fawcett from an anal cancer caused by high-risk HPV created a lot more media attention regarding this type of cancer.  Head and neck cancers are more rare, but they are horrific.  Like all HPV-related cancers, these tumors are locally invasive, disfiguring, and devastating.  35% of the anal cancers and over 80% of the head and neck cancers occur in men.

Does the vaccine really work?  The original HPV vaccine has been incredibly effective, and there is no reason to think Gardisil 9 will be different.  Many studies, some of which involved over 15,000 patients, have been discontinued because the vaccine groups showed such a huge benefit that it was no longer ethical to have a non-vaccinated control group.  The protection for both HPV vaccines lasts at least 5 years, but some trials are revealing over ten years of protection, and it may last a lifetime.

A big issue these days is vaccine safety.  The most common side effects are mild redness, tenderness, or swelling near the injection site.  There is no thimerosal (a mercury derivative used as a preservative) in Gardisil 9, nor in the prior Gardisil product.  All medications, including vaccines, have both benefits and risks.  In my opinion, the uncommon risks of this vaccine are far outweighed by the benefits of preventing problems that my patients have to deal with every day.  For now, however, even women who have received the new vaccine still need pap smears, though in general they are performed less frequently than in years past, now that we know how HPV develops.  This new vaccine makes a future where we stop pap smear screening all together a potential reality.

Cancer prevention through vaccination is revolutionary.  Availability of these vaccines is something that men and women in the poorest countries of the world can only dream about.  Parents should at least consider the option of preventing HPV disease in their children, especially now that the prevention rate is upwards of 90%.  Local pediatricians, family medicine providers, and ob/gyns will have more details.

 

 

Local Event: Post Partum Depression

Local Event:  Dr. Anthony to participate on panel discussion regarding POST PARTUM DEPRESSION.

Thursday, May 14th.  6:00 PM at the Teton County Library.  FREE.

“Dark Side of the Full Moon”, a film presented by a collaboration of the JH Perinatal Advocacy Project and Teton County Library. Delve into the unseen world of maternal mental health in the U.S. The filmmakers uncover the history, origins, and mythology surrounding the dark side of motherhood. They attempt to reconstruct the idea of “motherhood,” while forging a path to a system of care to get women the help they need with ease, and without shame, for a quick recovery. An expert panel discussion to follow the screening.

Facebook event page:

https://www.facebook.com/events/1608304066053298/

 

Contraception News

Contraception News: the National Women’s Law Center (NWLC) has published new resources to help patients navigate the Affordable Care Act (ACA), including state-specific guidance and FAQs on enrollment, a comprehensive resource guide on getting coverage for birth control, and guidance on what to do if an employer objects to providing birth control coverage. NWLC also operates the Pill4Us hotline (1-866-PILL4US or pill4us@nwlc.org) which assists women having difficulty accessing contraceptive coverage.

State specific guidance on the Affordable Care Act

What to do if an employer objects to providing birth control coverage

Pill4Us hotline:  email:    pill4us@nwlc.org

Atrophic or Menopausal Vaginitis

“Atrophic Vaginitis” is a very common problem in post-menopausal women.  The cornerstones of care and resolution aim to increase comfort during sexual intercourse and relieve dryness, primarily through rejuvenation of the vaginal tissues and providing moisture.  It requires some effort and discipline, but the following steps will help.

 

 

1.     First, avoid deodorant soaps.  They are harsh irritants and should never be used in the vulvar area.  Examples:  Zest, Lever 2000, Irish Spring, Dial, Ivory, and Dr. Bonner’s. Moisturizing soap such as Dove is preferred and inexpensive.

 

 

2.     Studies show that some women require an emollient only as treatment.  I recommend  Replens, which is available over the counter, or at multiple pharmacy websites, including drugstore.com.  Replens is an emollient that provides moisture to the inside of the vagina, much like a lotion, but is NOT meant to be used as a lubricant.   Emollients are completely hormone-free.

 

 

3.     Lubricants decrease friction, and should be used liberally with sexual activity.  They may be either water-based, such as KY and Astroglide, available in your local drugstore, or oil-based, such as pure coconut oil.  Oils have the advantage of not drying out and becoming sticky, and many women prefer this.  Water-based lubricants however are readily available and do not stain bedding.  It is definitely a matter of personal preference.  Refined coconut oil can be obtained on line at mountainroseherbs.com.

 

 

4.     Sexual activity alone, as often as possible, is vital to maintaining healthy vaginal tissues, preventing stenosis (closure of the vaginal opening), and stimulating the development of new blood vessels and hormone receptors.

 

 

5.     If you don’t already have it on hand, purchase Aquaphor ointment at your local store.  Apply to the vulvar tissues around the vaginal opening after intercourse and liberally throughout the day as needed.  This emollient promotes rapid healing on a cellular level and is also very soothing to traumatized tissue.

 

 

6.     Perineal massage, a technique utilized by pelvic floor physical therapists, may also be required.  This type of massage can help eliminate the expectation of pain with intercourse, causing the pelvic floor muscles to contract.  Once this occurs, the pelvic floor acts as a barrier to penetration and a pain cycle is created which exacerbates the problem.  Your doctor will demonstrate perineal massage so you can involve your partner and incorporate this into your sexual practice.

 

 

7.     Some women will need estrogen therapy directly to the vaginal tissues.  This can be delivered with creams, tablets, or a vaginal ring.  Follow the directions on your prescription for appropriate use of vaginal estrogen.  The course is usually intensive at first, for 14 days, followed by 2 days per week thereafter. 

 

 

 

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Jackson, Wyoming

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555 E Broadway Suite 108
PO Box 14230
Jackson, Wyoming 83002

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or by appointment

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