Month: September 2012

“Is an IUD right for me?”

This is a question I deal with often, as I counsel frequently on contraceptive methods with my female patients. There are multiple methods, including family planning (“rhythm method”), birth control pills, barrier methods (male and female condoms, diaphragms), the patch, the “shot”, implants, and IUDs.

At my clinic, I place IUDs (intrauterine devices) of the Mirena type, which is a 5 year long, progesterone-releasing method. There are other types of IUDs, such as the copper-T and Paragard that do not contain hormones and last longer than 10 years. IUDs are not only used for birth control, but also potentially to control heavy menstrual bleeding, severe menstrual cramping, and conditions such as ovarian cysts, endometriosis, and other female organ disorders.

The following is the general information I give female patients when they’re considering this method:

We are placing an IUD today, and I hope that you’ve had a chance to review either the brochure or research online about this birth control method. Feel free to ask whatever questions you may have before our procedure.

Benefits

-We hope that you’ll be able to keep the IUD for as long as you want, for up to 5 years. If older than 35years old, it’s a good idea to make sure you include a good amount of vitamin D and Calcium in your diet as the IUD may stop your periods for 5 years, which equals a sort of “early menopause.” These vitamins help protect your bones.

As long as you have not had any ectopic (tubal) pregnancies or recurrent STDs (gonorrhea or Chlamydia), there is little reason notto have an IUD if you want. It does not, however, protect from STDs, so condoms must still be used.

Risks & possible complications

-Anytime ‘outside’ objects are introduced to our ‘insides’, there is always the potential for infection and discomfort. We do our best to keep the procedure sterile (gloves, cleaning solutions, instruments, IUD), but it is possible still. You also should have taken the medicines I have you beforehand to reduce discomfort, which can feel like strong menstrual cramping.

Also, most of the instruments used are metal but not all sharp fortunately. There is the potential for bleeding. The most concerning risk is for the instrument to break through the tissue or muscle of the uterus causing hemorrhage, which is an emergency, for which we call 911.

What to expect after the procedure-

We will make sure you feel ok before leaving Please ask for Tylenol if you feel you need it before discharge. You can expect some vaginal bleeding during the first 24-48 hours afterwards with menstrual discomfort. You can use you Ibuprofen for this every 8 hours as needed. Bed-rest is not required, but I would defer from strenuous activity. Going to work from here is fine.

Some women experience irregular bleeding for up to 3-6months after placement. After than, you’ll join 1 of 3 groups: one-third of women continue irregular bleeding for the duration, the second group continue their normal monthly cycles, and the latter one- third stop having their periods altogether. Everyone responds differently and we don’t know which group you’ll fall into until the IUD is placed. The good news is you can return to have it removed whenever you want.

If you feel back to normal after 24-48hours, resume normal activity, which includes sexual intercourse and tampon use if desired. However, you can also wait to see e at your 1 week follow-up to check the string and make sure thing are stable. Call us here if you have any questions during that week, or problems including fever, severe stomach pain, extremely heavy vaginal bleeding, or foul-smelling vaginal discharge.

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Sneaky skin cancers

I’ve been fooled recently. I’ve been fooled by abnormal skin lesions of patients, and I’m not afraid to admit it. I see a good bit of dermatology in my practice, as I’m usually at the front line of diagnosis for my patients.

Here are three recent cases that surprised me.

The first is of a longstanding patient of mine – an elderly white gentleman with a rash on his scalp that we’d frozen lesions off of before, and treated as a combination of “cradle cap” and actinic keratosis, which is essentially sun damaged skin. He returned for evaluation of one lesion on the scalp that seemed to be growing much larger than the others. It was mountainous, yellow and greasy, just like a severe case of cradle cap, and similar to what some babies have.

However, since it was bothersome to him, we decided to take it off by doing an excisional biopsy. We numbed it up and cut it off and sent it to the pathology lab to grow. It returned showing squamous cell carcinoma in situ. This is a precancerous type of lesion that potentially can become cancer. Squamous cell carcinoma in situ has a high probability of becoming true carcinoma. We sent him to a dermatologist for follow up, and he is doing well.

The second patient is an elderly black gentleman I saw with our physician’s assistant. She brought him to my attention for a fairly normal-looking mole on his forehead. He’d had it for years, but it recently started changing in size, shape and color. He had no family history of skin cancers, but due to the recent changes, we agreed to do an excisional biopsy.

Guess what it turned out to be? Squamous cell carcinoma! Not in situ again but true carcinoma. That was truly surprising, particularly since he is African-American, a group that skin cancer doesn’t normally affect, and he had no family history.

The last one is actually a patient of my colleague that he brought to my attention. This is a young, white gentleman who came in for what he thought was “pink eye.” There was a dark spot beginning in the sclera or the white part of the eye, moving into the inside of the lower eyelid. It wasn’t painful, but it was new and had increased over the last couple of weeks. He had no family or personal history of skin lesions or cancers.

The first person that saw him in our practice thought enough to send him to an eye doctor that biopsied the lesion. When he returned to my colleague, guess what it turned out to be? Melanoma!

I never would have imagined skin cancer beginning in the eye. He had no other lesions on the skin that would have sparked the thought of skin cancer. I was able to see the patient and see the original lesion in the eye that was biopsied. I’ll never forget that case, and I’ll now pay even more attention to everyone’s eyes when I examine them.

The point is, skin lesions can be sneaky, and are more often more than meets the eye nowadays. This is not to say every mole, spot or skin tag is cancer, but if there is significant change in color, shape or size over a matter of months, it needs to be evaluated by your doctor. Don’t ignore your body. It may be trying to tell you something.

Dr. C. Nicole Swiner works at Durham Family Medicine, where she treats newborns to elderly patients. She and her colleagues are accepting new patients and can be found at www.durhamfamilymedicine.net.

Deer ticks, and dog ticks, and mites….oh my!

Tick season seemed to start earlier this year than usual. One of my partners in our practice in March said she awoke one morning with a deer tick, and we knew the season was here. This month alone, June that is, I’ve treated 3 cases of RMSF, or Rocky Mountain Spotted Fever, which is one of the common tick‐related illnesses we treat here. Tick‐borne illness is one of the interesting things I’ve learned about since practicing in North Carolina, as these illnesses are more common in the Southeast. But apparently they are an issue all over the US during this time. The illnesses include the above‐mentioned RMSF, Ehrlichiosis, Tularemia, and Lyme disease.

Lyme disease is actually very rare in North Carolina, because the tick that carries the disease is rarely found here. I had to refresh my memory on the different kinds and flavors of ticks, so that I could identify them on patients more easily.

The usual season for ticks is now, during the spring and summer months. The different types of ticks vary from dog ticks to deer ticks to Lone Star ticks. The American dog tick is generally a reddish‐brown color and becomes large and red after it’s attached itself and fed. Deer ticks are usually smaller and darker than dog ticks. The Lone Star tick is also small and reddish‐brown in color but usually also has a white spot on the back. Clear as mud? If confused like I was, you can go to the CDC website (Center for Disease Control and Prevention) to see pictures.

I also have a hard time identifying which is which, so I’ve posted a picture of types in my examination rooms for patients to point them out. Lone Star ticks are probably the most common type in this area, and they cause symptoms such as fever, headaches, myalgias (body aches), and possibly a round, “bulls‐eye” rash where they have bitten. This is the classic rash called erythema migrans, and it’s very helpful to see when trying to diagnose the illness. Not all tick bites will cause the illnesses if caught early enough. The best way to remove them is with tweezers and picking the whole body off, but most importantly the head. If you don’t know whether you’ve removed the entire body, don’t play around with it, have you doctor look at it and remove the rest as quickly as you see it. Don’t use matches or ointments, because they don’t work well all the time.

Once symptoms have been identified, your doctor may go ahead and start treatment, or do blood work. Labs that are affected by tick‐borne illnesses include white blood cell count, platelet count, liver labs, and sodium. There are also antibody tests for RMSF, Erhlichiosis, and Lyme disease. Once I generally have a good idea that a person has been affected, I usually will start treatment with Doxycycline, which is the most common antibiotic that treats all the common types of tick‐borne illnesses. The medicine is prescribed either for 1 or 2 weeks, depending on the severity of symptoms.

Now, to say a word about Lyme disease in North Carolina‐‐‐it’s present, but not very common. In 2008, the CDC reports 16 cases were reported in North Carolina versus 2000‐3000 cases in the upper north states of Connecticut and Minnesota. Because of its long term effects and consequences, such as arthritis and neurologic effects, Lyme disease is taken seriously, but the other types of tick‐borne illnesses are far more common than Lyme disease here in North Carolina. Be careful this summer!

Be Healthy and Be Blessed, Dr. Swiner

*Reference: www.aafp.org (American Family Physician), www.cdc.gov(Center for

Disease Control and Prevention)