March is National Colorectal Cancer Awareness Month!

Among cancers that affect both men and women, colorectal cancer—cancer of the colon or rectum—is the second leading cause of cancer-related deaths in the United States. Colorectal cancer also is one of the most commonly diagnosed cancers in the United States. The risk of developing colorectal cancer increases with advancing age. More than 90% of cases occur in people aged 50 or older.

Colorectal cancer screening saves lives. However, many people who are at risk for the disease are not being screened according to national guidelines. It is estimated that as many as 60% of colorectal cancer deaths could be prevented if all men and women aged 50 years or older were screened routinely. In most cases, colorectal cancer develops from precancerous polyps (abnormal growths) in the colon or rectum. Screening tests can find precancerous polyps, so that they can be removed before they turn into cancer. Screening tests also can find colorectal cancer early, when treatment works best. The most effective way to reduce your risk is by having regular colorectal cancer screening tests beginning at age 50.

You should begin screening for colorectal cancer soon after turning 50, then continue getting screened at regular intervals. However, you may need to be tested earlier or more often than other people if:

You or a close relative have had colorectal polyps or colorectal cancer; or

You have inflammatory bowel disease.

If you are aged 50 or older, or think you may be at increased risk for colorectal cancer, speak with your doctor about getting screened.

Several tests are available to screen for colorectal cancer. Some are used alone; others are used in combination with each other. Talk with your doctor about which test or tests are best for you. These screening tests are recommended by the USPSTF:

Colonoscopy (every 10 years).

High-sensitivity fecal occult blood test (FOBT) (every year).

Flexible sigmoidoscopy (every 5 years)

(from the CDC website http://www.cdc.gov/Features/ColorectalAwareness/)

I recommend for my patients colonoscopy every ten years as this is both screening (looking for problems) and treatment (removing polyps, for instance) if needed. Also, if you have a strong family history of colon cancer and/or uterine cancer, we may offer you genetic testing for HNPCC (hereditary non-polyposis colon cancer) which carries an increased risk of both colon and uterine cancer.

Screening for Cervical Cancer

The newest recommendations for screening for cervical cancer from ACOG have changed the way we treat our patients.

Part of these changes reflect what we now know about cervical cancer; almost all cases are caused by HPV and sometimes, HPV will clear on its own. But, that is no excuse not to get your pap smear! Pap smears are the best way (and so easy!) to screen for cervical cancer and to let us know if you might be one of those women who needs more testing to look for abnormal cells.

So, if you are under age 21, we are not recommending pap smears. This is because the likelihood of an HPV infection clearing before it causes cervical cancer is very good. Even if it doesn't clear up on it's own, cervical cancer is so slow to develop, that by the time you start doing paps at age 21, we'll still have plenty of time to catch it and treat it if need be.

Women between the ages of 21 and 29 should have pap smears every other year. There may be good reasons to do pap smears more often, like having an abnormal result or other problems with the cervix.

Women over age 30 can go to having their pap smears every 2-3 years if (and this is a big if!) their last three paps have been normal, they have never had abnormal cells on a biopsy of the cervix, they don't have HIV or otherwise immunocompromised, and don't have a history of DES exposure. Sometimes, we will check an HPV test to reassure ourselves that the risk of developing cervical cancer is low.

Women who have had a hysterectomy (with removal of the cervix!) for reasons other than cancer can also stop having pap smears. Again, unless they have risk factors for cervical cancer like previous abnormal cells, new sexual partners, HIV, DES exposure, or being immunocompromised.

Women over the age of 65 without risk factors (see above) and with three normal pap smears previously can also stop getting pap smears. Remember that new sexual partners is a risk factor!

Now, all this is not to say that women can stop coming to the gynecologist every year. No! Women still need annual exams to screen for sexually transmitted infections, other gyn cancers, discuss birth control, and to review other women's health issues.

Also, remember that an HPV vaccine is available and very effective at preventing and reducing the risk of cervical cancer, abnormal pap smears, and genital warts!

Ovarian Cancer Risk

Ovarian cancer is the deadliest gynecological cancer and affects up to 1 in 70 women in the US. Accordingly, many women are worried about what their risks are of having this kind of cancer. Currently, there are no screening tests for ovarian cancer, but women at high-risk should discuss with their health care providers what options are available to them to reduce their risk.
One of the main problems in diagnosing ovarian cancer are that so many of it’s symptoms are things that we all suffer from occasionally anyway. These include bloating, pelvic or abdominal pain, feeling full quickly, and urinary symptoms like urgency and frequency. The difference is that is normal to feel these symptoms for a day or two here or there, but if they persist almost daily for two to three weeks, you should certainly see your doctor.
The ways we can diagnose ovarian cancer may include a physical exam with a pelvic exam, a vaginal ultrasound, and sometimes a blood test for CA125. CA125 is not useful in all women and often has false positives in women who have not yet gone through menopause. This test is most useful when there is an abnormality on the exam or pelvic ultrasound, if a woman is post-menopausal, or if she is at very high risk of ovarian cancer based on other factors.
While ovarian cancer can affect any woman, there are four categories of risk.

• Average risk: the lifetime risk of developing ovarian cancer is 1 in 70. Women in this category do not have a family history of breast or ovarian cancers, never had problems getting pregnant, and have never taken hormone replacement therapy. For these women, the recommended screening for ovarian cancer is an annual gyn exam with pelvic exam.
• Slightly increased risk: the lifetime risk in this group is 1 in 20. Women in this category may have had problems getting pregnant or taken medications to help get pregnant, have a history of endometriosis, may have taken hormone replacement in menopause, or had breast cancer after age 40. The recommended screening in this group includes an annual gyn exam with pelvic exam. You may also want to discuss with your doctor ways to reduce your risks (see below).
• Moderately increased risk: a lifetime risk of 1 in 10. These women may have had a mother or sister with ovarian cancer, had breast cancer before age 40 or had breast cancer themselves with other members of their family with breast cancer as well, have a strong family history of breast cancer under age 50, have Ashkenazi Jewish heritage, or a close family relative with uterine or colon cancer under age 50. The recommendations for these women include genetic counseling and screening, and possibly testing for the BrCa mutation (a genetic predisposition to breast, ovarian, colon, or uterine cancers). These women should also have an annual gynecological exam with pelvic exam with close follow-up for any problems noted on the exam.
• Very increased risk: lifetime risk of up to 1 in 2. These women may be BrCa1 or BrCa2 positive (gene mutations that increase the risk of breast, ovarian, colon, and uterine cancer), or MLH1, MSH2, or MSH6 positive (gene mutations which increase the risk of colon, uterine, ovarian, and kidney cancers).

Women with the BrCa mutations should have a pelvic exam with a gynecologist 1-2 times a year. Some women will opt to have their ovaries and uterus removed (hysterectomy and bilateral salpingoophorectomy) once they have completed childbearing. Women who wish to avoid surgery should have a vaginal ultrasound and CA125 testing twice a year starting at age 30-35. They should also have an annual mammogram and breast MRI to check for breast cancer, starting at age 25-30.
Women with the MLH or MSH mutations should see their gynecologist 1-2 times a year, as well as have a vaginal ultrasound and CA125 test twice a year. They should also have an endometrial biopsy every year to check for endometrial or uterine cancer. Additionally, they should have colonoscopy every 1-2 years to screen for colon cancer, starting at age 20-25. Some women will also elect to have their uterus and ovaries removed when they have completed childbearing.
Reducing the risk of ovarian cancer can be discussed with your doctor. Birth control pills (and presumably the ring and patch) have been shown to reduce the risk of ovarian cancer by 50% in women who use it for more than 5 years. The longer this form of contraception is used, the more benefits. This is one of the simplest, most effective ways to reduce your risk of ovarian cancer.
For women at very high risk of developing ovarian cancer, removal of the ovaries is an option. Surprisingly, this does not completely eliminate the risk of ovarian cancer, but dose reduce it bu 85-90%. This can also reduce the risk of breast cancer by 40-70% in women who have the surgery before they go through menopause. Surgery is usually only recommended in women who have undergone genetic counseling and testing and have been shown to carry a genetic risk for cancers.
To learn more about ovarian cancer, check out the Women’s Cancer Network at http://www.wcn.org/ or the Gynecologic Cancer Foundation at http://www.thegcf.org/. To learn more about genetic counseling and testing, click on http://www.cancer.gov/cancer-topics/Genetic-Testingfor-Breast-and-Ovarian-Cancer-Risk.

Eating for Two

Eating right can be one of the best things you can do for yourself and your baby before and during your pregnancy. The foods you eat are the main source of nutrients for your growing baby.

If you are planning a pregnancy, see your doctor. She or he will discuss with you your diet, any vitamin supplements you might need (folic acid, for instance) as well as your overall health and how that might affect or be affected by a pregnancy.
A healthy diet is important even before you become pregnant. This helps you and your baby start out with the nutrients you will both need. There’s no magical formula for pregnancy nutrition. The basics of a well-balanced diet with plenty of whole-grains, fresh fruits and vegetables, and lean sources of protein remain the same. Of course, you also want to drink plenty of water – two to three liters a day!
You do need to eat more calories in pregnancy, but it may be less than you think. The number of calories recommended for a non-pregnant woman in 2000 a day. There is no recommended increase in the first trimester (up to about 12 weeks) and only about 300-350 calories more in the second trimester (12-26 weeks). This is equivalent to about a cup of yogurt and a small apple. In the third trimester (after about 26 weeks), the recommendation is about 400 extra calories a day.
Pregnant women also require more folic acid and iron. Folic acid helps prevent birth defects, preterm birth, and growth problems in the baby and iron prevents anemia in the mother. Fortified cereals are a great source of folic acid. Leafy green vegetables, citrus fruits, and dried beans and peas are also all good sources of folic acid. The recommended amount of folic acid in pregnancy is 800-1000mcg. A woman trying for pregnancy should start taking a prenatal vitamin or extra folic acid 3-6 months before she is ready to get pregnant. Some women with certain medical problems or a history of a baby with a birth defect may need more folic acid, so ask your provider if you are unsure.
Another important mineral is calcium, with a goal of 1200-1500mg a day. This is important to help build healthy bones in your growing baby as well to keep your bones strong during pregnancy and breastfeeding. Some studies suggest it might also help reduce the risk of other medical problems in pregnancy, like pre-eclampsia.
Prenatal vitamins are usually good sources of folic acid, iron, calcium, and other important vitamins and minerals, but check the labels and check with your doctor. Also, it’s best to avoid prenatal vitamins or formulations that include things like herbs or extracts since there is little evidence of the safety of these compounds and some have even been shown to cause cramping or problems in pregnancy (even ones that are “pregnancy” herbs!) Of course, the best place to get your vitamins and minerals is in your food.
DHA is an important supplement to help with healthy brain and eye development both in pregnancy and while nursing. DHA is one of the Omega 3 fatty acids and the best way to get enough is with a DHA supplement specifically designed for pregnancy. It’s best to avoid flaxseed oil (due to rare, but documented pregnancy complications) or fish sources (due to concerns about mercury levels).
Weight gain is to be expected in pregnancy, but how much you should gain depends on how much you weigh before you get pregnant. Women of a healthy weight should gain 25-35 pounds while women who are overweight should gain 15-25 pounds. Underweight women usually gain about 25-40 pounds in pregnancy. This increase in weight is needed for many components of your changing body and growing baby. As an example:

• Baby 7 ½ pounds
• Breast growth 2 pounds
• Maternal nutrition stores 7 pounds
• Placenta 1 ½ pounds
• Uterus growth 2 pounds
• Amniotic fluid 2 pounds
• Increase in blood volume 4 pounds
• Increase in body fluids 4 pounds

A few special concerns:

• Vegetarianism
  o If you are a vegetarian, it is safe to continue your diet in pregnancy. Some women choose to add lean meats or fish to help get enough protein and iron, but this is not strictly necessary if you can get enough of these in your diet or with the help of vitamins. Sometimes vegetarians need to take extra iron, vitamin B12, and vitamin D.
• Drinks
  o You should avoid alcohol in pregnancy because frequent use can cause birth defects and mental retardation. A few drinks before you knew you were pregnant rarely cause any problems.
  o Moderate caffeine intake is probably OK (1-2 cups of coffee, sodas, or teas). More than that has been shown to increase the risk of miscarriage. Caffeine also crosses the placenta.
  o Diet drinks and other foods with NutraSweet or Splenda is OK 1-2 servings a day. There is little data about the safety of these, and so it is probably best to reduce your exposure.
  o Avoid unpasteurized juices.
  o Read the labels on herbal teas. Many of the herbs used for teas, when taken in large or medicinal amounts, can potentially stimulate the uterus and induce miscarriage. These include anise, catnip, chamomile, comfrey, ephedra (or ma huang), European mistletoe, hibiscus, horehound, Labrador, lemongrass, licorice root, mugwort, pennyroyal, raspberry leaf, rosemary, sage, sassafras, stinging nettle leaf, vetiver, and yarrow. Also avoid Coca (or mate de coca), kava root, skullcap, valerian, woodruff, and lobelia. Mate tea can contain as much caffeine as coffee.
• Meats
  o Do not eat any raw meats. This includes sushi! The nori (seaweed) that sushi is wrapped in can also contain high levels of mercury, so avoid even vegetarian or cooked sushi.
  o Deli meats are probably OK as long as they are fresh. If they’ve been in the refrigerator for more than a few days, either throw them out or reheat them to steaming.
• Cheese
  o Do not eat unpasteurized or “raw” cheeses (this may include some imported, soft cheeses) – check the labels! Pasteurized soft cheeses are OK.
• Fish
  o Fish (including shellfish) is OK 1-2 servings a week. Avoid shark, swordfish, king mackerel, and tilefish. This is again due to the concern for mercury which is a neurotoxin in developing babies.
  

Morning Sickness

Early pregnancy can be affected by nausea and vomiting, or “morning sickness”. Some women’s “morning sickness” is in the evening and some women are lucky enough not to have it at all. Regardless, if you are feeling sick, one good tip is to never have your stomach too empty and never have your stomach too full. Try to eat a variety of foods, but if one in particular turns you off, it’s fine to wait until this phase of pregnancy passes. Many women have good luck with light or bland foods like crackers, cooked fruit, broiled meats, carrots, apples, popcorn, cereal, dry toast, or flavored gelatin.
Some women find relief from ginger (either real ginger in foods like cookies, ginger ale, etc. or ginger capsules), vitamin B6 (25mg three times a day), or SeaBands (acupressure wrist bands designed for motion sickness). Other women find relief by nibbling on a few saltines before getting out of bed in the morning. Sometimes peppermint can help, too, either as aromatherapy or in candies or gum. Again, real peppermint is better than an artificial flavoring.
If natural therapies aren’t helping, there are also some medications that can help. Nestrex and Emetrol are over-the-counter and safe in pregnancy. There are also prescription medications available that your doctor or midwife should be able to offer you.
Often, prenatal vitamins can aggravate the nausea or even prevent women from taking their vitamins at all. One way to manage this is to take your vitamins at night before bed or with food. If that still doesn’t work, taking just folic acid may be better tolerated. Those pills are often much smaller than the regular prenatal vitamins. A goal should be 800-1000mcg of folic acid a day. Some women can’t even tolerate that, and so skipping a few days or weeks of prenatal vitamins might be the only answer to keep from throwing up.
The good news is that this usually passes after the first trimester. If it doesn’t or it is so severe that you are losing weight, you should talk to your doctor.

Birth Control Implant -- Implanon

Implanon is the latest in implantable contraception. It is a flexible plastic rod about the size of a matchstick that is put under the skin of your arm in an in-office procedure. This is a fantastic option for women who want to avoid having to remember their birth control every day, every week, or every month since it lasts for three years.
Implanon has been used over 4.5 million times worldwide and is more than 99% effective. This is a great solution for women who have problems remembering to take pills, have hectic schedules that prevent them from getting to the pharmacy or taking a birth control method regularly, or who want to avoid having to find that condom or diaphragm when the time is right.
Implanon is a very low-dose hormonal method that contains only progestin, so can be used by women who cannot take or who are sensitive to estrogen. This may include women with histories of clotting disorders, high blood pressure, or migraines. It is also safe for women who are breastfeeding.
The implant is made of a medical material that is safe to leave in the arm for up to three years. At the end of three years, it should be removed. If continued contraception is desired, another one can be placed at the same time as removal. If during the three years, a woman decides the time is right to start trying for a pregnancy, the Implanon can be removed at any time and fertility rapidly returns.
The implant is placed with local anesthesia (like Novacaine) in the doctor’s office. The visit will take about 15 minutes and actually placing it takes about 3 minutes. The best time to have it put in is during your period, but can be placed at any time if it’s more convenient.
The most common side effect that women notice with the Implanon is that their periods change. Usually, this is a reduction in bleeding, but it can also cause periods to be irregular. The number of bleeding or spotting days is similar to that experienced by a woman who is not on contraception. This effect is completely normal and is a sign that Implanon is working the way it should. Less common side effects include acne, change in appetitive, , change in sex drive, ovarian cysts, depression, scarring of the skin over the implant, dizziness, hair loss, headache, nausea, nervousness, pain at the site of the implant, and sore breasts. These side effects are much more rare, and most women adjust to the Implanon quickly and easily.
For more information, discuss with your health care provider, make an appointment with Dr. Swartz, or contact your local Planned Parenthood.

The Doctor's Visit BEFORE You Get Pregnant

We recommend a visit with your doctor when you and your partner have decided to start a family. This visit should include a full physical examination including a Pap smear and cervical cultures, as well as blood tests if these have not recently been done. These blood tests will test you for your immunity to rubella and chicken pox and your blood type. If you are not immune to one or both of these viral infections, you may need to be vaccinated. In this case, it is best to wait a month before trying to conceive.
Optimizing the health of the mother before conception is important for improving pregnancy outcome. This is particularly true for certain women, such as those with medical disorders or who regularly take medications. Preconception care is more important than prenatal care for prevention of birth defects.
This visit may also include a discussion of your medical history, your partner's medical history, your family's genetic history, and optimization of your health. We also will usually discuss healthy lifestyle issues and nutrition. I recommend starting prenatal vitamins with a prenatal DHA supplement (Expecta Lipil for instance) at least 3 months before you start trying for pregnancy.
Many women think that they need to stop their birth control method several months in advance before starting to try to conceive. This is true only for DepoProvera (the shot) and maybe for the Mirena IUD. It is not necessary to stop pills, the ring, the patch, etc. until you are ready for a pregnancy.
As always, if you have questions, talk to your doctor or make an appointment to see me.