Patient: Hello?
Me: Mrs Patient? It’s Dr TBTAM returning your call.
Patient: Oh dear. I’m on the other line with my insurance company. (Pause) Can I call you back?
Performing the Pelvic Exam
This week’s NEJM online has a video on how to perform a pelvic examination. I thought they did a really nice job. Of course, since I do this all day, I have a few additional tips:
1. Make sure you have the right tool for the job. That means long narrow Pederson specula for postmenopausal ladies and large Graves specula for the more ample women, along with standard sizes of both for most patients.
2. For anxious patients and little old ladies, I apply lidocaine jelly to the introitus a few minutes before the exam (Step out and see another patient while it does it’s job). This is also useful for transvaginal sonos in the same crowd.
3. I use two separate slides (not one as shown in the video) for KOH and wet smears. Putting both of these on the same slide invariably leads to cross contamination by the KOH.
4. I still occasionally use the endobrush for paps, even when doing thin preps, because sometimes the larger cyto-broom does not enter the endocervical canal. Just rinse it in the vial like the cytobrush.
5. Get everything ready, including adjusting the light, before you start. I didn’t like seeing the doc in the video touching everything in the room with the gloved hand she was going to be using for the bimanual. If I find I have to use that hand, I change the glove before doing the bimanual. God knows how many hands have been on that light before yours!
6. Specimens for GC/Chlam PCR testing can be obtained from the vagina as well as the cervical os, and this is useful if blood or excess cervical mucus are present at the endocervix, since these can interfere with the sensitivity of these tests. Urine specimens are also appropriate for screening using PCR.
7. The video recommends asking the patient is she wants a chaperone present. I would not ask – just have one there, especially if you are male. The second pair of hands is helpful as well.
8. If you are going to be seeing older women, you’ve got to get good at the one finger exam. This is where the rectal part of the exam is critical – one finger in the vagina and the other in the rectum, and you’ll get a decent exam in most patients.
Questions?….
Zaftig vs. Hollywood Thin
Dr Deb has a fabulous post on the new Fit Light Yogurt campaign in Brazil, which places ample women in classic Hollywood poses to shame them into losing weight. Problem is, I think it does the opposite – these women look great!
Head on over for more photos and join the discussion, which too is ample…
Grand Rounds
This week’s Grand Rounds is hosted over at Wandering Visitor. It’s a fabulous compilation of the best of the medical blogosphere. This weeks theme is “Things that Inspire Us”, and the format is that of a journal article. Very clever and well done!
Head on over for a little inspiration.
Grand Rounds
This week’s Grand Rounds is hosted over at Wandering Visitor. It’s a fabulous compilation of the best of the medical blogosphere. This weeks theme is “Things that Inspire Us”, and the format is that of a journal article. Very clever and well done!
Head on over for a little inspiration.
Sauteed Broccoli
My good friend W taught me how to make this dish while we were vacationing with her family in Maine last summer. She lives in Rome and this is the way she makes broccoli at home. I’m doing this from memory, so I hope I got the ingredients right. We’ll be visiting W and her family in Rome in a few weeks, so I’ll double check the recipe then. Even if I left something out, this was delish!
Sauteed Broccoli wth Garlic, Red Pepper and Croutons
1 head broccoli
5 cloves garlic, chopped
Day old bread
Olive oil
Salt
Pepper
Red Pepper Flakes (Start with 1/4 tsp, add more if you like it hot)
(Optional: Grated Parmesan Cheese)
Wash broccoli, and cut the florets from the head. (If you want to use stalks, trim them and cut into thin slices for quicker cooking.) Cook broccoli in boiling salted water till crisp-tender, but still bright green. Drain well.
Cut bread into small cubes. (1-2 cups of croutons for a head of broccoli) Toss with olive oil and season with salt and pepper. Toast in large skillet over low medium heat on top of stove, or in a 400 degree oven till browned, turning several times. Set aside.
Heat 2-3 tbsp olive oil in skillet till hot. Add garlic and cook, stirring constantly, just enough to soften but not brown. Add broccoli and cook, stirring and chopping it up into small pieces with the side of the spoon or spatula while it cooks, till it is soft. Season with salt and red pepper flakes while it is cooking. Add croutons, stir and serve. If you are my daughter, sprinkle parmesan cheese on top.
Eight Random Facts Meme
Tagged by Dr Rob on this one. I need to tell you eight random facts about myself. Okay, here goes:
1. The first car I ever owned was a ’64 Valient. 
You know, the one with a slant 6 engine and manual stick shift on the column. My uncle found the car for my Dad, who bought it for me for $150 so I could drive to my after school job at Kresges. The summer I was a day camp counselor, the kids I drove in the car were embarrassed to be seen in it, which made me love it even more. I kept the car till I moved to New York after college, at which point my friend Shari (The one who slept with Robbie)’s boyfriend offered to keep it for me and basically trashed it.
2. When I was 10, I won a spot on a bus trip to Washington, DC with Wee Willy Weber’s Cartoon Club.
The only parts of the trip I remember are the baloney sandwiches Wee Willy’s wife made for us and the catacombs. I think they are under a church somewhere in DC. (The catacombs,I mean, not the baloney sandwiches…)
3. I sing.
Anything and everything. I took voice lessons for 2 years with the most amazing teacher, Nancy Evers, but stopped because I really didn’t have time. I still practice with my tapes before choral rehearsals and I think my voice is even better than when I was taking lessons. If you are reading this – Hi Nancy! I miss you!
If money were no object, I would quit my job tomorrow and do music. Not that I don’t love what I do, because I do love it. But you have only one life, and there are so many other things to be done… Do you think American Idol will ever raise the age limit? Because if they do, I’m there, baby!
4. I had Hepatitis C. (Type 2b)
I took the pegintron-ribavirin treatment a few years ago. The treatment sucked, but it worked.
5. I have bitten my nails my whole life,
but recently realized that sometime in the last few years, I stopped biting them. Why is that? Do you think this means I will stop overeating soon as well?
6. I do this voice…
My sisters and I can do this duck voice – well, R really invented it, and she taught it to the rest of us. I’ve morphed it into a little kid voice. I can stratify my boyfriends by whether or not they liked the little kid voice. (Mr TBTAM likes it.)
I stopped using the voice for a while shortly after giving birth – the enormity of the responsibility made it seem so childish. But of course it came back. Now I find the voice quite helpful whenever my kids are being mean to me, at which point I cry out – “You haffa’ to be nice to me! I’m your MOM!” It generally works, because they really like the little kid voice.
7. I am allergic to cats and most dogs.
I hate this, and it has ruined many an evening at a friend’s house for me. I used to hate my Dad for not taking us places because they had cats (he was also allergic), but now I understand.
8. I hate Disneyworld.
(So sorry to those of you who love it…) I think my feeling was crystallized the day I was standing waiting for the shuttle bus at the Swan Hotel and there was Muzak coming out of the bushes next to the bus stop. My feeling about this matter do not seem to be shared by the medical meeting organizers, and so I have been to Orlando now 4 times.
But enough about me. Tell me about you.
I don’t know who’s left who hasn’t been tagged on this one, so if you haven’t, consider yourself tagged by me and give us the facts, just the facts…
Keeping Your Fertility Options Open
What do you do when you’re 35, have 3 kids and for various reasons have run out of acceptable contraceptive options? You have a surgical sterilization, that’s what.
But here’s the question – who gets snipped, the male or the female member of the couple? I almost always advise that the male should be the one.
It’s not personal, guys. It’s because vasectomy is a brief office procedure performed under local anesthesia, compared to a tubal ligation, which is an intra-abdominal procedure performed under general anesthesia. A no-scalpel vasectomy can be performed in as little as 7 minutes, with exceedingly low rates of complications.
“As a couple,” I usually say, ” “Your safest option is a vasectomy”.
But a patient recently objected to the idea of a vasectomy, because it was really her decision to stop having children. Hubby would have kept on going if she had been willing.
“If anything ever happened to me, I would want him to be able to have more children,” she said.
Now this was a woman who had already had several C-sections. Neither she nor her huband liked the idea of her having another surgical procedure. What to do?
“Have him freeze some sperm before the vasectomy”, I said. “That way he may still be able to father children in the future if anything ever happens to you.”
And that’s what they did.
Sperm Banking Before Vasectomy
Sperm banking before vasectomy is not a guarantee of future fertility, since frozen and thawed sperm may be less viable than fresh sperm. Overall, pregnancy rates using cryo-preserved sperm are about 50% lower than with fresh sperm. Assisted reproductive technologies such as intracytoplasmic sperm injection (ICSI) may improve these odds.
How long can frozen sperm be saved? Well, pregnancies have been reported using thawed sperm that have been frozen up to 21 years!
Sperm banking is not terribly expensive, with costs of about $500 per year. Sperm should be frozen and thawed as a test prior to vasectomy to see if they survive storage. And experts advise banking multiple samples in two separate sperm banks as insurance against lab accidents.
When weighed against the option of vasectomy reversal surgery, hedging your bets by sperm banking before getting snipped seems a reasonable option.
A word of caution, though. Urologists who perorm vasectomy generally advise that vasectomy be reserved for men who are really sure they want no more children.
In other words, if are considering banking some sperm because you’re not sure if you will want children in the future, then consider the possibility that you may not be ready for permanent sterilization.
I am not a Paparazzi
Dear Paul Newman:
When you looked up as you were getting into your car outside of the NDI performance on Monday night, I’m fairly certain that you saw me. And I think you noticed that I was holding my cell phone up in front of me. So I’m pretty sure that you think that I took your picture.
Which means you now think I’m the kind of person who takes pictures of celebrities with their cell phone.
But really, Mr Newman – Do you mind if I call you Paul? – Really, Paul, what I need you to know is that I did NOT take your picture. I swear, I didn’t.
I know you don’t read my blog, but if you did, you would know that if I had taken your picture it would be up there. But it’s not. See?
I am, after all, a New Yorker. And we New Yorkers pride ourselves on the fact that the great ones can walk amongst us unrecognized. They are, after all, no better than we are…That didn’t come out right, did it? What I meant to say was that we just want you to feel comfortable…
So, do you believe me?
I really hope you do. Because if we ever run into each other again, I would hate for you to hate me because you think I’m one of those people who take pictures of you with their cell phones.
Because I didn’t. Really.
Sincerely Yours,
TBTAM
Paul Potts – Dreams Do Come True
This years winner of Britian’s “You’ve Got Talent” (via Pharmagossip).
(Note to self – watch daily for inspiration…)
Trojan’s Ad Needs to Evolve
Trojan has mounted (oops – Freudian slip?) a new ad campaign urging young men to be sexually responsible by using a condom every time they have sex. The mantra : It’s time we evolve. From their website:
Sex itself isn’t an unhealthy thing that needs to be policed or demonized; it’s a natural expression of our humanity. Using protection consistently and correctly is a critical component to managing one’s sexual health.
Trojan claims they are trying to break down the predjudice that condom use automatically mean promiscuity. From today’s NY Times:
“We have to change the perception that carrying a condom for women or men is a sign they’re on the prowl and just want to have sex,” said Linda Kaplan Thaler, chief executive of the Kaplan Thaler Group, the New York advertising agency that created the “Evolve” campaign.
Unfortunately, Trojan seems to be sending that exact message with their ad. Set entirely in a bar, with a cute little ditty of a tune beneath it, the ad shows men, portrayed (literally) as pigs, on the prowl trying to pick up a series of girls, all of whom seem to be alone at the bar. None of the pigs are successful. But then, one pig heads to a vending machine and buys a condom, at which point he is transformed into the cutie that he really is, and gets the girl.
Message? – Carrying condoms will get you laid.
Fox and CBS are refusing to air the ad. I’m not sure why – this ad is no worse than what they are showing 24-7 on their stations already. I say air it and let’s get this conversation going.
Trojan – Bad start, but at least it’s a start. Keep trying – I’ll be watching. And so will millions of young men. See if you can find a way to reach them in a way that doesn’t cheapen women or promote promiscuity. You’ve got some brilliant advertising folks working for you – I’m sure they can help you figure it out …
Help Me Plan My Trip to Italy
We are heading to Italy in July, and all I’ve done so far is make our plane reservations. We are flying into Rome and visiting friends there, but the rest of the trip is up for grabs. We are thinking it would go something like this –
- Rome for a few days
- Train to Florence
- Stay in Florence as a base, take day trips by trian or car to Pisa, Siena, San giomani (where else?)
- Back to Rome for another few days? (We fly back from Rome) To the beach maybe? Someplace else near Rome that is worth seeing?
I’m hoping some of you have done this trip before and can help me out. I don’t trust the rest of those people out there on the web..
Any suggestions? Hotels you loved in Florence? (I need to move on this one yesterday..) Restaurants in Rome or Florence or Tuscany? Places to see (and avoid)? Great web sites that you used for your trip? ?
You should know that I HATE being a tourist and I know that I will have to deal with this in Florence, which, from what I read is like Disneyworld. So any suggestions as to places off the beaten track or how to avoid the crowds will be appreciated. In that vein, are we nuts to even go to Tuscany? Should we head to some other region or city within striking distance of Rome?
Any and all suggestions are welcome.
I promise I will be blogging the trip so I can “pay it back” to the blogsophere.
THANKS, GUYS!
Ovarian Cancer Symptoms
Gilda Radner, who died of ovarian cancer at the age of 42, had symptoms for months before her cancer was finally diagnosed.
The American Cancer Society and the Society for Gynecologic Oncologists have issued a consensus opinion outlining the symptoms of ovarian cancer, and more importantly, urging women and their doctors to consider ovarian cancer in the differential diagnosis when these symptoms present.
What are the symptoms? They are vague and all too common – bloating, pelvic or abdominal pain, early satiety, and urinary sympotms such as urgency and frequency. But, when present and persistent for more than 2 weeks and less than 1 year (or in the case of urinary symptoms, persistent after treatment for a UTI), one must consider ovarian cancer in the differential. And consider it early, because this is one cancer that won’t wait around while you exclude everything else.
For almost 2 decades now, this is exactly how I have been practicing. As I’ve said before, I don’t hesistate a second before performing a pelvic ultrasound in women with any of the symptoms listed in the consensus statement. I happen to be pretty good with a vaginal ultrasound probe, and I have an amazing gynecologic radiologist to whom I can refer.
Despite this, in all these years, after performing or referring for thousands of sonograms (and not a few ca125 tests) in what I believe is an optimally aggressive screening approach for ovarian cancer in symptomatic women, I have yet to diagnose a single case of early ovarian cancer. Of the 5 or so cases (it is, after all, not a common cancer), all but one presented to me at stage 3 or more. That early tumor was a borderline cancer, and she would have done well no matter what I had done.
I wish I could say my aggressive management of symptoms has impacted ovarian cancer mortality. It’s certainly reassured a lot of frightened women and found quite a bit of benign disease. But ultimately, I just don’t think it has made a difference in terms of ovarian cancer outcomes.
Maybe it is because my patients with ovarian cancer ignored their symptoms for too long before coming in to see me. If so, then publicizing this consensus statement may make a difference. I certainly hope that it does. And despite my reservations about my practice’s efficacy, I’m not changing what I do, because at this point, there is nothing else I can do. It’s what I have to do, and what my patients deserve.
What we really need is a good early ovarian cancer screening test for asymptomatic women. (No, it’s not the Ca125 test.)
Or better yet, how about a pill to prevent ovarian cancer? Oh, wait a minute – we already have that. It’s called the Birth Control Pill.
_______________________________________________________________
Here’s the Consensus Statement:
Historically ovarian cancer was called the “silent killer” because symptoms were not thought to develop until the chance of cure was poor. However, recent studies have shown this term is untrue and that the following symptoms are much more likely to occur in women with ovarian cancer than women in the general population. These symptoms include:
- Bloating
- Pelvic or abdominal pain
- Difficulty eating or feeling full quickly
- Urinary symptoms (urgency or frequency)
Women with ovarian cancer report that symptoms are persistent and represent a change from normal for their bodies. The frequency and/or number of such symptoms are key factors in the diagnosis of ovarian cancer. Several studies show that even early stage ovarian cancer can produce these symptoms.
Women who have these symptoms almost daily for more than a few weeks should see their doctor, preferably a gynecologist. Prompt medical evaluation may lead to detection at the earliest possible stage of the disease. Early stage diagnosis is associated with an improved prognosis.
Several other symptoms have been commonly reported by women with ovarian cancer. These symptoms include fatigue, indigestion, back pain, pain with intercourse, constipation and menstrual irregularities. However, these other symptoms are not as useful in identifying ovarian cancer because they are also found in equal frequency in women in the general population who do not have ovarian cancer.
Thinking Blogger Award
Many, many thanks to fellow bloggers Dr Wes and KatieZ , who nominated me for a Thinking Blogger Award. It’s an honor to be a recipient of this award, and I am proud to display it on my sidebar over there.
But the best part is that I get to give the award out to 5 other blogs that make me think. And so, without further ado, I award this prestigious award to (drumroll, please…)
The Well-Timed Period. An incredibly interesting, opinionated and comprehensive blog about anything and everything contraceptive.
Enter the Circle: My friend Linda writes an insightful, brassy and funny blog. She’s also into the whole women’s empowerment thing and runs something called the Moon Lounge, yet remains completely normal.
Bardiac: Of course.
Celebrity Cosmetic Surgery: Just checking to see if you’re still reading. Well, it does make me think I’ll never get plastic surgery…
Aetiology: Everything a science blog should be.
If you’ve been tagged, here are the rules. And thanks to the awardees for your contribution to keeping my brain alive.
