By Dr. Pranita Nirgudkar

Cord blood banking is the collection and cryopreservation of stem cells obtained from the umbilical cord at the time of childbirth. Stem cells are building blocks of our blood and immune system and have the ability to replace or repair any kind of damaged cell in the body.

Two main types of cord blood banks exist for the purpose of storing cord blood for potential future transplantation: public cord blood banks and private cord blood banks.

Let us talk about each of these types:

Public cord blood banks – Public cord blood banks collect and store cord blood units for use by any individual who has a medical indication for hematopoietic stem cell transplantation and for whom a suitably matched unit is available. These banks perform collections at a limited number of hospitals throughout the world. A mother can choose to donate her infant’s umbilical cord blood to a public cord blood bank, only if the infant is delivered at a hospital with access to such a bank. Following collection, each cord blood unit is characterized, and the parameters (e.g., HLA profile, total nucleated cell count) are placed in a public database accessible to health care providers. For a list of hospitals that participate in the public donation program, visit http://www.marrow.org/Get_Involved/Donate_Cord_Blood/How_to_Donate/Participating_Hospitals.aspx#FL

Private cord blood banks – Private cord blood banks are for-profit enterprises that facilitate the collection of cord blood for families who are willing and able to pay for such a service. Typically, families decide to bank their infant's cord blood so that it might serve as a source of hematopoietic stem cells for the child or another member of the family, should the need arise. Private cord blood banks supply the family with a collection kit and generally depend on the mother's obstetrician or midwife to collect the umbilical cord blood upon delivery.  The collected blood is then transported to the company’s stem cell  laboratory, where it is processed , stored and  reserved for future use by the family.  The family pays a  one-time  fee for the collection and processing of the blood and an annual fee thereafter for its storage. Cord blood units that are privately banked for potential use by the donor  have only a remote chance of being used for that  purpose. An estimated 1 in 2700 umbilical cord blood units that are collected and stored privately are eventually used by the child or a family member.  There is a 1-in 4 chance that cord blood will be a perfect match for a sibling, but cord blood is always a perfect match for the donor.

The Woman's Group works with three private cord blood banking companies.  These are: 

• CBR              (visit http://www.cordblood.comfor additional information)
• Cryo-Cell       (visit  http://www.Cryo-Cell.comfor additional information)
• ViaCord         (visit http://www.ViaCord.com for additional information)

For a comprehensive list of private banks please visit http://www.savethecordfoundation.org/banking_list.php#Private

Directed cord blood banking –  Private, as well as public cord blood banks, also provide a service called directed cord blood banking for families who currently have a child or other family member with a potential  stem cell transplant-treatable disease and who are expecting another child. The programs providing such a service either facilitate or perform the cord blood collection and then process, characterize and cryopreserve the unit, which is reserved for exclusive use by the donor's family. These collection and banking services for medically indicated families, either private or public, are most often performed free of charge.

Cord blood collection

Cord blood collection may be performed either prior to delivery of the placenta ("in utero") or following delivery of the placenta ("ex utero").  Regardless of the technique employed, the earlier the blood is collected, the less likely it will clot and the greater the probability of obtaining the maximum volume or blood.

Ideally, at least 40 to 60 mL of blood (in addition to the anticoagulant) should be collected. A volume below 40 mL is unlikely to contain a sufficient number of cells to be usable in transplants. Once collected, the cord blood is stored at room temperature until it is transported to the processing laboratory to preserve cell viability.  A maternal blood sample is also collected at the same time to check for the mother’s  HLA type, HIV, hepatitis B and C, HTLV I/II, RPR, West Nile virus, CMV IgG and sometimes, for Malaria and Chaga’s Disease.

Processing and preservation

After collection, cord blood units are tested, processed, and stored for future use, typically within 48 hours of collection.

Complete characterization of a cord blood unit should include the following assays:

• Unit volume and weight, total nucleated cell count with differential, as well as an assessment of the unit's hematopoietic potential (e.g. CD34+ cell count or colony forming unit count) after processing.
• ABO/Rh blood type and human leukocyte antigen (HLA) class I (-A, -B) and class II (-DRB1) haplotypes.
• Testing for hepatitis B, hepatitis C, HIV-1 and -2, HIV p24, syphilis, cytomegalovirus, and bacterial culture.
• Hemoglobin electrophoresis to screen for the presence of a hemoglobinopathy.
• At public banks, mononuclear cells, plasma, and DNA from the cord blood unit may be stored in an aliquot separate from the main unit for future infectious and/or genetic disease testing.

Shelf-life of units

It is not known how long umbilical cord blood cells remain viable when stored. However, other stem cell sources have been stored for many years and retained viability and engraftment potential.

What expectant parents need to know:

• Given the current uncertainties of this technology, the American Academy of Pediatrics does not recommend that parents routinely store their infant’s umbilical cord blood for future use, unless there is an immediate medically indicated use for a sibling.
• The American College of Obstetricians and Gynecologists states that patients who request information on umbilical cord blood banking should be provided with “balanced and accurate information regarding the advantages and disadvantages of public versus private banking and be informed of the approximately 1 in 2700 chance that an autologous unit of umbilical cord blood will be used for a child or family member.
• Parents should be aware that autologous cord blood cannot be selected if the donor child develops leukemia, as the cord blood will have genetic markers of leukemia.
• The indications for cord blood transplant are limited to certain genetic, hematologic, and malignant disorders. (A complete list is provided in http://www.nmdp.org
• Routine storage of umbilical cord blood as "biologic insurance" against future disease is not recommended.
• Cord blood banked by families is much more likely to be used by the donors' siblings than by the donors.
•  Private storage of umbilical cord blood should be considered if there is a family member with a current or probable future need for transplantation.

If, despite the above information,  parents decide to proceed with cord blood banking through a private agency, it is wise for them to thoroughly investigate available companies.  At a minimum, parents should do the following:

•  Read all contracts thoroughly and know all costs associated with banking through a given company.
• Understand whether the stored cord blood will be available for donor use only, or whether another member of the family, such as a sibling, could utilize the unit, should the need arise (so-called "family use").
•  Confirm that the company is financially and otherwise stable, since the cord blood may be stored for years to decades before being used.
•  Inquire whether the company is accredited by a reputable regulatory agency (e.g., AABB, FACT).
•  Know how long the company has been involved in cord blood storage, how many samples they currently have in storage, whether any units banked through the company have been used for transplantation, and their outcomes.

What is the future?

There are several clinical trials evaluating the use of cord blood stem cell infusions for conditions such as cerebral palsy and diabetes.  In addition, there are studies underway using cord tissue stem cells.  Cord tissue contains mesenchymal stem cells which can form bone, cartilage and tendons. Mesenchymal stem cells are thought to have better regenerative properties than cord blood cells. In clinical trials, they are being studied as possible treatment for spinal cord injuries, brain trauma from stroke, and cartilage damage. The research using cord tissue is at an early stage and medical treatments are not currently available.

Summary

At The Womans' Group, we keep up with the latest developments in the collection and use of cord blood.  We also provide our patients with the latest information available to make an educated decision regarding a financial commitment to collect and preserve their newly born baby's cord blood as a means to potentially treat a family member's disease that may be treatable through implantation of stem cells.  The collection and storage of cord blood should be looked at as one would look at a conditional insurance policy.  One bets on never having to need it, but should the need arise, there is comfort in knowing that coverage may be available.

Don’t you wish that you could get rid of fat in a particular area of your body that does not see to react to diet and exercise?  Are you the type of person that does not like the idea of a surgical procedure to remove fat?

Help is now available at The Woman’s Group.  Our new Vaser MC1 MedContour System is just the solution.  This innovative technology was developed in Italy and has been in use in Europe and the middle East for a few years, but it has just arrived to the United States.  The machine uses focused high intensity ultrasound waves to target a fat deposit area an eliminate it.  The waste created through the process is flushed by the body through the lymphatic system.

How does it work?

Patients interested in treating areas of stubborn fat will undergo a series of 45 minute massage therapies.  The massage has two aspects: the treatment with the high intensity focused ultrasound waves and a  massage to move the waste products generated towards the lymph nodes.  Most patients require three to five sessions, depending on the amount of fat that needs to be treated, to obtain the desired results.  Four days after each treatment, the patient receives a short, five minute lymphatic massage to assist in the elimination of waste products.

Does the treatment hurt?

This treatment is not invasive, therefore it is performed on the surface of the skin of the area being treated.  No incisions are required.  Because the ultrasound waves penetrate the skin layers to get to the fat, heat is generated and the patient feels warmth in the area being treated.  Because of this, the skin will become somewhat red; however, this redness will disappear shortly after the end of the treatment.  Most patients liken this treatment to the feeling one gets from a hot stone massage.

 What results can I expect?

Most patients see as much as one inch reduction after each treatment plus enhanced skin tightness.  In addition, the appearance of cellulite can also improve.  It is not unlikely for additional reductions in girth to take place one day after the treatment.  Depending on the stubbornness of the fat, a patient may need several treatments.

 Are there any side effects?

 Other than your clothes fitting better, there are no side effects.  There is no pain involved and no discomfort after the treatment.

 Will the fat come back?

 Patients that have undergone the treatment have retained their new shape while they maintain normal eating and exercise habits.  We expect that if a patient has a significant increase in weight, the remaining fat cells will enlarge and the patient will see  an increase in girth.

 What areas can be treated?

At this time, this technology has been approved for use anywhere in the body except the face and breasts..  Patients have had great results in treating arms, backs, thighs, flanks and hips.

How many body areas can you treat during a single treatment?

 An area is equivalent to the size of a standard sheet of paper.  If the patient would like to work on the abdomen, this would be the size of the area treated. If the patient is interested in a bi-lateral treatment area such as thighs, arms or love handles, each side treated will be the size of half of a standard sheet of paper. Because it is important that the body be able to effectively process the waste created through the treatment, we only treat one area per treatment.  It is important to note that each treatment is followed by a short 5-minute lymphatic massage four days after the treatment.

 How close can you schedule treatments?

 Treatments can be scheduled as quickly as one week apart.

 How does this technology compare to other technologies available?

 There are a number of FDA-approved technologies in the market aimed at the same problem.  Among these are freezing, infrared light, diode laser, thermo electric and ultrasound.   The Woman’s Group research department studied all of these technologies and chose the MC1 Vaser as the most effective and comfortable to patients.

 How much does a treatment cost?

 The Woman’s Group is offering three treatments for the low introductory price of $500.  If after the first treatment, the patient is not satisfied, we will refund $250.  This price will not be in effect for long, so make your appointment now!

 Where can I find out more about the Vaser MC1 Medcontour Technology?

To see the procedure in action visit www.youtube.com and type "Med Contour" for English and "Cavitacion" for Spanish.

A number of physicians at The Woman's Group are now performing minimally invasive, robotic surgery using the da Vinci® System.  This new method uses only a few tiny incisions.  The benefits of this approach include less pain, fewer complications, less blood loss, lower risk of infection and shorter hospital stays (usually 24 hrs. or less).  All these sum up to a quicker recovery and return to normal activities.

Until recently, surgery for most gynecologic conditions was performed using a large abdominal incision.  While laparoscopic surgery had been effective for many routine procedures, the long-handled, rigid instruments used in laparoscopy were considered ineffective for delicate or complex operations such as hysterectomies.  The da Vinci's System  offers  capabilities to overcome these drawbacks.  Featuring 3D, high definition vision and miniaturized – wristed surgical instruments, the da Vinci system helps doctors  take surgery beyond the limit of their hands.

If your doctor recommends a hysterectomy to treat your condition, you may be a candidate for da Vinci Surgery. For more information, please see http://davincihysterectomy.com

When does menopause begin?

A woman is said to have reached menopause when she has not had a period for a full year.  The average age of menopause is 51, but can be earlier or later in some families of women.  Menopause is preceded by a transition period called perimenopause, which lasts from three to eight years and is characterized by irregular periods, mood instability and hot flashes. It is possible for a woman to move directly into menopause with none of the perimenopause symptoms.

What are the typical symptoms of someone who has entered the menopause phase?

Eighty five percent of women have minor or no symptoms.  The other fifteen percent experience hot flashes, mood disorders, vaginal dryness, insomnia, and/or memory problems.

What are the most common approaches to treating the symptoms that come with menopause?

Mild symptoms are managed with good diet, exercise, black cohosh, progesterone cream, and melatonin to help with sleep.  When symptoms affect a woman's ability to carry on her daily routine, we consider hormone replacement therapy – estrogen and progesterone, for women who have a uterus and estrogen only for women without a uterus.  We may add testosterone if depression and decreased libido are problems. The creams, gels, or patches are the preferred routes of delivery because  they bypass the GI tract and get directly into the bloodstream.  There is currently no evidence that bio-identical hormone preparations, made by compounding pharmacies, should be used. A predisposition for osteoporosis may also influence our decision to recommend hormone replacement therapy.

Do most women experience the same menopause symptoms?

Menopause symptoms can vary from woman to woman.  Most women have very minor or no symptoms.  The rest will have moderate to severe symptoms in a variety of combinations that include hot flashes, night sweats, vaginal dryness, pain during intercourse, depression, memory loss and insomnia.  It is important to note that many other medical conditions can mimic the symptoms of menopause, so patients should undergo a thorough physical exam to rule out other underlying medical conditions.

If I am well into the menopause phase and I have not experienced any symptoms, am I likely to experience them later?

The symptoms of menopause can last for several years after you have stopped having periods, but they usually go away with time.  It is unusual for you to develop symptoms for the first time years after you stop menstruating.

 Osteoporosis may  already be present prior to menopause, but bone loss increases for the first 10 years after menopause, which occurs at an average age of  51 for most women, therefore; we  recommend that women get a baseline bone density study once they have ceased to menstruate for a period of one year.  If a woman has thinning bones or osteopenia, a precursor to osteoporosis, we perform a risk assessment and discuss lifestyle factors that can reduce her risk of progressive bone loss.  If she already has osteoporosis, we immediately start treatment with a bisphosphonate and if she complies with this treatment, her osteoporosis often reverts to normal bone density.  At the very least, we are able to stop any further bone loss.  

 A bone density study will yield a “T” score, used to gauge the presence of this condition.  Also, at the time  that we perform a bone density study, we calculate the patient’s FRAX Score.  The FRAX Score was developed by the World Health Organization to assess the various factors that may predispose someone to fracture even if he/she DOES NOT have osteoporosis.  The FRAX Score was necessary because statistics show that some patients may incur fractures even when their “T” scores are greater than -2.5, which is he cut off for osteoporosis.  If your FRAX Score shows an overall fracture risk of greater than 21% or a hip fracture risk of > 3%, then you should be treated for osteoporosis regardless of your “T” score.

 Some patients cannot take bisphosphonates once per week or once per month because they experience  severe gastroesophageal reflux.  In these cases, there are other treatments available including a yearly intravenous  infusion of the drug  Reclast or an injection every 6 months of the drug Prolia. There are also other drugs and medications currently under  development. 

Osteoporosis surveillance is an important aspect of mid-life care.  To maximize your bone health now, do weight bearing exercises 45minutes to one hour most days, take Calcium and Vitamin D (amount of Calcium depends on daily dietary intake) and discuss other risk factors you may have with your doctor.

The primary causes of spider and varicose veins are heredity and pregnancy.  Each successive pregnancy increases the chance of developing both cosmetic and medical vein problems.

Vein problems during pregnancy usually start in the first trimester because they are closely linked to the hormonal process. Later during pregnancy, the pregnant uterus also puts pressure on pelvic veins contributing to vein problems. Vein symptoms and appearance often improves after childbirth but usually some residual vein damage remains.

Many women first notice veins during the second and subsequent pregnancies, but the vein damage actually started during the first pregnancy and was hidden under the skin! Vein disease is slow to develop and symptoms may be present before you see spider or varicose veins appear.

During pregnancy and, especially after childbirth, the risk of deep venous thrombosis (DVT) in leg veins and of pulmonary embolism (PE) increases. Varicose veins during pregnancy increase the risk of DVT, superficial thrombophlebitis (varicose vein clots) and PE. Labial, groin and buttock varicosities may also develop during pregnancy and are easily treated at The Woman’s Group.

There are 3 reasons for treating and/or preventing varicose veins during pregnancy:

·         Preventing or reducing permanent damage to veins due to the additional stress veins are subjected to during pregnancy.

·         Immediate relief of distressing symptoms including itching, cramping, heaviness, throbbing, burning, swelling, and restless legs.

·         Reducing the risk of DVT, thrombophlebitis and PE.

There are tremendous benefits to be derived from using compression hose, as their use reduces the risk of vein problems during pregnancy while relieving discomfort. There is no better conservative treatment for your veins and quality compression hose are very comfortable. We highly recommend that during pregnancy, you use high quality, custom-measured and properly-fitted compression hose containing no latex rubber.  These hose are now available from The Woman’s Group.

For more information, please visit: http://vein911.com/vein-treatments/pregnancy-veins/

What’s worse than getting your period every month?  Not getting it or not being able to predict its arrival!  Ask any woman whose period  comes at random times, and she will confirm how difficult it is to plan life around an irregular menstrual cycle.  What can cause this?  This blog post will discuss some of the reasons.

“Doctor, my periods are always right on time!  Why did I miss my period this month?”

If this is the first time you have missed your monthly menstrual cycle, it is time to see your gynecologist for an evaluation. 

Pregnancy — you say you’ve been taking your birth control pills every day?  Using condoms every time?  Sometimes, even with careful precautions, pregnancy can occur.  Your gynecologist will test your blood or urine to see if this could be the reason of your missed period. 

Breastfeeding — Are you breast feeding?  Breastfeeding is another time when the ovaries are not producing hormones in a monthly cycle.  When the new mother either slows down or stops breastfeeding, the ovaries begin to produce hormones again.  The first month after your period starts up may bring with it irregular bleeding. 

·          Missed Ovulation — Once in a while, the ovary does not release an egg.  This results in either a missed period, or irregular spotting.  Missing an ovulation can be due to stress, excessive exercise / dieting,  or unknown causes.  If it only happens once or twice, it is not harmful, and the ovary usually begins ovulating again normally the following month.

Hormonal imbalance — A number of different hormonal changes can result in missed periods.  Thyroid disorders are the most common cause and their presence can be detected with a blood test.  Others could include irregularities in the pituitary hormones.  These can also be detected with blood tests.

 Medications — A few types of birth control pills and intrauterine devices (IUDs) cause the lining of the uterus to become very thin.  This is a normal response to the hormones contained within these medications / devices.  When the uterine lining is very thin, when it comes time for a period, there isn’t any blood or tissue to be expelled.  So some women taking these birth control pills or who have IUDs in place don’t get a period at all.

·         Uterine  Polyps or Fibroids — Polyps are the overgrowth of the cells lining the uterine cavity.  Fibroids are non-cancerous growths within the muscle wall of the uterus.  Both polyps and fibroids can cause spotting or bleeding mid-month, and can be evaluated with a pelvic ultrasound. 

 ·         Menopause — Many women experience changes in their menstrual cycle up to 5 years before periods stop permanently.  This is a time called “Perimenopause”, when the ovaries stop producing hormones on a monthly cycle.  These menstrual cycle changes can result in menses coming closer together than usual, sometimes even 2 weeks apart for some women.  Other women skip menstrual cycles altogether.  Hormone level blood tests during this time are not  always reliable and often  gynecologists request that women keep a diary of their bleeding for a more accurate diagnosis. 

“Doctor, my periods have NEVER been regular.  What could be wrong?”

Most pre-teens or teens experience irregular bleeding for the first year or two after they start their period.  If this bleeding pattern continues beyond the first few years after periods start, it is time to see a gynecologist for some testing. 

·        Polycystic  Ovarian Syndrome (PCOS) — This syndrome is characterized by either lack of menstrual bleeding or very irregular menses over many years.  Many women with this syndrome also have increased hair growth over their face, chin, or body, or suffer from acne.  This diagnosis is made with blood hormone testing and a pelvic ultrasound. 

 ·      Other hormonal imbalances — Both a low body mass index (low weight for your height) and a high body mass index (high weight for your height) can cause long-term menstrual irregularities.  In some cases, women that exercise for long periods of time every day—for example, marathon or triathlon trainers —may experience menstrual irregularities over years.   In very rare cases, the source of irregular menses can come from other causes such as adrenal abnormalities.

In summary, you should seek the advice of your gynecologist when experiencing irregularities with your period, as the cause may be a health condition that should be treated.

Still, hormone replacement therapy (HRT) is considered the most effective treatment for these menopausal symptoms.  However, women are now turning to alternatives they think are safe – but may not be.

In Search of "Natural"

Many women assume that "natural" hormones would be better or safer, bu the term "natural" is open to interpretation.  Technically, any product whose principal ingredient has an animal, plant, or mineral source is considered "natural".  It doesn't matter if that substance is ground, put into capsules, and sold over the counter or extracted in a laboratory, manufactured by a pharmaceutical company and made available only via prescription.  For example, many women take soy supplements to ease their symptoms; but soy is also used, along with yams to make the estrogen in the FDA-approved hormone drug by the name of Estrace. But unlike Estrace, soy supplements aren't regulated and aren't tested in humans, so we don't know if they are safe or effective.

Enter "Bio-identical"

Bio-identical hormones are hormones that are identical in molecular structure to the hormones women produce in their bodies. These hormones are not found in this form in nature, but are made, or synthesized, from a plant chemical extract from yams and soy beans. Bio-identical hormones are the identical duplication of the native hormones (Estriol, 17 Beta Estradiol, Estrone, Progesterone, Testosterone and DHEA) found in the body.  Because they are the same, these hormones have the same physiological effect on the female body.

Bio-identical hormone therapy i9s often called "natural hormone therapy" because the hormones act in the body just like the hormones we produce. But here, again, the use of the word "natural" can bring confusion, because a pregnant mare's urine is natural, but Premarin, the drug made from it is not bio-identical to human estrogen.  The same is true for the drug Cenestin, which is made from plants, but is not bio-identical.

The human body cannot distinguish bio-identical hormones from the hormones your body produces. Supporters of bio-identical hormone therapy assert that the advantage comes from being able to monitor estrogen levels more precisely and thus, make treatments more individualized.  Skeptics counter that it hardly matters because no one knows exactly what hormone levels to aim for and that symptoms and not hormone levels should be treated and monitored.

What About Compounded Bio-Identical Hormones?

Much of the confusion about bio-identical hormones comes from the mistaken notion that they must be custom mixed at  a compounding pharmacy.  But custom compounding is necessary only when a clinician wants to prescribe hormones in combinations, doses or preparations, such as lozenges or suppositories, not routinely available, or to prescribe hormones not approved for women, such as testosterone and DHEA. Compounding pharmacies use some of the same ingredients that are made into FDA-approved products, but their products are not FDA-approved or regulated.

Are Bio-Identical Hormones Safer?

The answer is that no one knows. There are no studies that prove that compounded bio-identical hormone therapy have fewer side effects or are more effective than FDA-approved preparations. Also, compounded bio-identical hormones are mixed to order, so there are no tests of their safety, effectiveness nor dosing consistency.

The Bottom Line

All hormone replacement therapy, regardless of whether FDA approved or bio-identical from a compounding pharmacy, carry the risk of breast cancer, heart attack, stroke and blood clots.  Studies have recommended that patients use the lowest dose of hormone therapy for the shortes amount of time to control menopausal symptoms.  As a patient, it is important for you to be proactive and work closely with your clinician to decide what is right for you.

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