Dr. Gail Joseph Answers Common Women’s Health Questions

Dr. Gail Joseph, OB/GYN at Doctors Hospital of Manteca, answers some common questions related to women’s health. Check out her responses for San Joaquin Magazine below.

What is a good age for a woman’s first visit to an OB/GYN and what can she expect?

The American Congress of Obstetricians and Gynecologists recommends that young women begin gynecologic visits between ages 13 and 15. Beginning to see a gynecologist at this age allows for young women to build a healthy relationship with their gynecologist which allows them to have open and meaningful discussion about their health as they age. As most young girls are already menstruating by this age group, this is the ideal time to discuss menstrual cycles and evaluate for any abnormalities which might require further work-up and/or intervention. While girls might not be sexually active at this age, they are usually beginning to be sexually aware. Therefore, it is an ideal time to begin the discussion about healthy sexual behavior and disease prevention. It is also an ideal time to begin discussions which help to cultivate "body positivity" and the idea of healthy body image, which can go a long way towards promoting mental health in today’s very image conscious society.

How do I know if a “Mommy Makeover” is right for me, and what is involved?

The "mommy makeover" has become a very common term in the vernacular these days thanks to the Hollywood Elite and social media influencers who aim to project that image of perfection, even in the post childbearing years. According to the American Society of Plastic Surgeons, the “mommy makeover” is a combination of procedures, all done at the same time, and which usually include a breast augmentation, breast lift, breast reduction, tummy tuck, liposuction, and/or a circumferential abdominoplasty. However, the procedures involved are generally tailored to the patient's individual goals and may even include the infamous Brazilian Butt Lift (BBL), brachioplasty or arm lift, thigh lift, labiaplasty and other vaginal rejuvenation procedures. The decision to have such a procedure is highly personal and is usually centered around a woman's perception of the changes her body has gone through as a result of childbearing and breastfeeding.

Pregnancy often involves a significant amount of weight gain which can occur rapidly for some women. During this time the skin on the abdomen stretches to accommodate a growing uterus. Subsequent to delivery, the skin does not always regain its pre-pregnancy tautness. This can result in noticeably loose and sagging skin on various areas of a woman's body. As well, the breasts increase in size while lactating. Stretching of the skin occurs to accommodate this increase in volume. Once breastfeeding has been discontinued, breasts can often appear to sag due to this reduction in the elasticity of the skin on the breasts. Labor and parturition often involve weakening of the pelvic floor muscles and can result in laxity of the vaginal canal which is most often noticeable during intercourse. Even the tissue of the labia undergo some changes during pregnancy due to significantly increased blood flow and hormones. The skin on the labia will often appear excessive or redundant post childbearing.

Quite often a woman's decision to have a "mommy makeover" is dependent on her and her partner's perception of these changes and how comfortable they are with them. Some women simply want to regain their pre-pregnancy aesthetic after completing their childbearing. Several factors influence who can or should have a mommy makeover. These procedures can be costly but, because they are elective, they are not covered by insurance. The patient will need to secure her own funding for the “mommy makeover.” Patients who opt to have these procedures will also need to have a good family and social support system in place as the recovery can take several weeks, during which time the patient will likely require assistance with basic duties around the house, childcare, and transportation. For some patients there is a significant amount of pain involved and there might be a prolonged need for pain medication. Also, swelling which occurs postoperatively can last for months, therefore calling into question the patient's perception of the success of her procedure. Emotional strength and patience are definitely key to a successful recovery. These extensive surgical procedures are, according to the American Society of Plastic Surgeons, not ideal for patients who smoke. Also, due to increased risk of infection and poor healing, moms who are obese (BMI of 30 or higher), who are diabetic, or who might have underlying health conditions, will need to discuss this decision with their primary care physician as well as their plastic surgeon to decide if they are a good candidate for this kind of surgery. In the long run, all women, but especially ones who fall into any of these classes, will need to have built a solid foundation of healthy habits with respect to diet and exercise, in order to maintain the benefits of their surgery. And, as with any surgical procedure, there is a risk of long-term scarring, pain, and disfigurement.

The ideal candidate for a "mommy makeover" is a healthy non-smoker who has completed her childbearing, has thoroughly researched a board-certified physician, has the financial resources to afford the procedures, has the family/social network in place to assist her post-procedure, has weighed the pros and cons of this kind of surgery, is absolutely certain of her decision, and who leans towards the healthy lifestyle habit required to maintain successful outcomes.

Now that I’ve gone through menopause, how are visits to the OB/GYN different?

Once a woman has entered the climacteric state, i.e. gone through menopause, her visits to the gynecologist should not cease. It is still recommended that she have a yearly visit with the OB/GYN for a complete breast and pelvic exam. While the exam may not change significantly, the topics discussed do change. These visits will likely include a discussion of routine maintenance studies in this age group such as mammograms, colonoscopies, and bone density testing. Some gynecologists use this as an opportunity to assess a woman's vaccination status and ensure that she remains up-to-date. Depending on the woman's age, a fall risk assessment might be part of this visit. And finally, screening for depression and intimate partner violence as well as elder abuse is incorporated into these visits as well. In my practice, discussions at these visits are often dominated by discussion of menopause symptoms and the options available for managing them. As well, women in this age group often struggle with pelvic floor disorders and/or incontinence which can be difficult topics to discuss. Some women in their menopause years also experience changes to their sexual appetite and ability to enjoy intercourse, both of which can be due to a variety of causes. These subjects are often taboo and, as such, might go undiagnosed and untreated for quite a long time. By speaking with the gynecologist and having a yearly pelvic exam these issues can be addressed in a timely manner. Pap smear screening is currently not recommended beyond age 65 in women who do not have a history of severe cervical dysplasia or cancer. Breast health maintenance includes a yearly clinical breast exam, yearly mammogram, and self-breast exams (SBE). Once women get into their climacteric phase they often neglect to perform SBEs, and so a visit to the gynecologist is a great opportunity to reeducate these women about SBE techniques and on the importance of the SBE as a part of the breast health triad.

How often should a woman be tested for STDs?

The U.S. Preventive Services Task Force as well as the CDC consensus guidelines recommend that women 24 and younger be screened frequently for gonorrhea and chlamydia. This includes a clinical assessment of sexual practices and risk factors.

Women 25 and older with risk factors such as having a previous STI, having multiple partners, having a partner with concurrent partners or a partner who has an STI, and women who exchange sex for resources should be screened for gonorrhea and chlamydia yearly, or whenever they have had unprotected sex with a new partner.

HIV testing is recommended at least once from ages 13 to 64, but ideally should be performed anytime there is concern for exposure.

Pregnant women are recommended to be tested for syphilis, HIV, hepatitis B, and hepatitis C starting early in pregnancy. Those at higher risk for infection should be rescreened in the 3rd trimester. Screening in the third trimester depends on state and local guidelines as well as ACOG recommendations. Generally gonorrhea, chlamydia, HIV, and syphilis are rechecked at this point in the pregnancy.

How come Pap smears are not done annually anymore, and doesn’t that place me at higher risk for not having potential cervical cancer caught as quickly?

In 2001 the American Society for Colposcopy and Cervical Pathology finally joined forces with several other professional societies to put forth screening guidelines pertaining to screening for and management of cervical pathology. These guidelines would be updated several times in the coming decades. The rationale behind these guidelines and the frequent updates was to increase access to screening for cervical cancer and to minimize related morbidity. Over time there has been a move from yearly cervical cancer screening to age-related interval screening guidelines. This move was centered on the fact of increased access to the HPV vaccine and its contribution to reducing the prevalence of cervical pathology in high risk populations. As well, a better understanding of how the immune system works to control HPV infections, brought to light the prevalence of premature and unnecessary interventions which held potentially life altering consequences for women. For example, many women who would have otherwise cleared the HPV related cervical abnormalities received loop electrosurgical excisional procedures which resulted in pregnancy losses in the long run. This is the main reason why Pap smears are initiated at age 21 regardless of whether or not the patient is sexually active.

Ultimately, in otherwise healthy, non-smoking women who are low risk for exposure to new strains, the progression from a normal cervix to cancer does take quite a bit of time. As well, in these same women, the immune system works to help tame HPV infections within about 2 years, thus reducing the risk of progression to cervical cancer. So the belief is that, as long as women are being seen yearly for an annual pelvic exam by the gynecologist, the likelihood of missing cervical pathology is significantly reduced. With a visual and digital exam of the cervix the gynecologist will likely intercept any interval changes which might induce screening outside of the recommended guidelines.