You’ll feel comfortable discussing issues that aren’t easy to talk about.
Thorough, high-quality, total care for women that keeps pace with active lifestyles is one of our trademarks. From annual exams, Pap smears and Specialty Services (such as the HPV vaccine) to surgical care, we approach each challenge by first establishing a comfort level that makes it easy to get to the heart of the problem. Then we treat it compassionately using proven state-of-the-art approaches and technologies.
Because we, the practitioners of The Woman's Group, are all women, chances are good that one of us has experienced what our patients are going through. That gives us an unparalleled understanding of the health issues women face.
The following is a list, in alphabetical order, of some of the gynecological conditions and treatments, as well as procedures and surgeries available at The Womans' Group. In each case, we have provided a brief explanation.
- In Office Procedures and Surgeries
- Gynecological Conditions or Problems
- Minimally Invasive Gyn Surgery
In-office Procedures
Colposcopy is a diagnostic procedure in which a colposcope (a dissecting microscope with various magnification lenses) is used to provide an illuminated, magnified view of the cervix, vagina, and vulva. This is often the next step in the evaluation process that follows an abnormal pap smear. During this procedure, vinegar will be applied to the cervix, and the gynecologist will then examine the cervical tissue with the microscope. There are certain changes the cervix undergoes once vinegar is applied that can be suggestive of HPV or other precancerous lesions. At this point, the physician may elect to take a small biopsy from a specific area that appears abnormal. This will help determine the proper treatment and follow up for the patient. The results from any biopsy are usually available to the physician in about 7-10 days. There is usually little or no pain during this procedure. We recommend that the patient take 600mg of Motrin 30 minutes prior to the procedure and refrain from intercourse for 48 hour prior. We advise that the patient abstain from intercourse or anything in the vagina for 2 weeks following the procedure. There is often a brown/mustard/ black discharge that can be present on and off for 2-3 weeks. The patient should call the office if there is a fever greater than 100.4, intense pelvic pain not relieved by Motrin/ Tylenol, or heavy bleeding (soaking a pad in an hour or less). Back to top
Cryotherapy uses a refrigerant gas (carbon dioxide or nitrous oxide) to cool the ectocervix with a metal cryoprobe. The ectocervix must be cooled to -20ºC to cause crystallization of intracellular water and destroy the lesion. This can be achieved by forming an ice ball in the cervical tissue that is at least 5 mm from the tip of the probe. The technique traditionally uses a "freeze and thaw" method by which the cryotherapy is performed for 3 minutes, 3 minutes off and freezing again for another 3 minutes. There is at times cramping during the procedure, so the patient is advised to take 600mg of Motrin prior to the appointment time. The most common complaint after the procedure is a copious watery discharge that can last for up to 4 weeks. We also want you to abstain from intercourse, douching, swimming or tampons for 4 weeks. You should call the office after your procedure if you have a temperature greater than 100.4, heavy vaginal bleeding (soaking a pad in an hour or less), or pain not relieved by Motrin/Tylenol. Back to top
At times it is the recommendation from the gynecologist to undergo an endometrial biopsy if abnormal or heavy bleeding, post-menopausal bleeding, or an abnormal pap smear are present. A suction device is used to perform endometrial sampling. This device consists of a plunger within a sheath. This is a very thin instrument only 3mm in diameter and appears to be a long thin "straw". When the sheath is inserted into the uterus, the plunger is retracted, creating negative pressure that draws tissue into the sampling device. This tissue is then sent to the pathology laboratory for diagnosis. The total time for this procedure is less than 20 seconds. Although some patients experience no pain at all, others will complain of intense menstrual cramping. It is recommended to take 600 mg of Motrin prior to the appointment time. The cramping should resolve before the patient leaves the office. There are no specific restrictions or instructions after having a endometrial biopsy. Pathology from the sample will be available in about 7-10 days. Back to top
- Implanon/ Nexplanon Insertion
The Implanon is a form of birth control that is placed in the patient's non-dominant arm. Traditionally, the physician will clean the arm with Betadine and provide a local anesthetic in the place of insertion. She will later insert the 4cm rod in the patient's arm. A snug bandage will be placed around the arm, which should not be removed for 24 hours. There are no major limitations after insertion except for heavy lifting or weight lifting for 24 hours. The entire appointment time takes about 15 minutes, and the actual insertion takes less than a minute. There are no follow up visits required. Back to top
The two types of intrauterine devices that are placed at TWG are Mirena and Paraguard. The specifics for each device are listed in the contraception topic of this website. Every patient who is having an IUD inserted will need to have cultures of the cervix to rule out a current infection. The actual insertion of the IUD should only take a few minutes. Some patients will experience no pain, while others may experience intense menstrual cramps during the insertion. It is recommended that patients take 600mg of Motrin 30 minutes prior to the appointment time. Once the IUD is placed, the strings attached will be cut typically to a length of 3cm. If the patient continues to have cramping after the procedure, it is recommended to take Tylenol or Motrin every 4-6 hours for the next 24 hours. Heavy bleeding or intense pain not relieved by over the counter medications is not considered normal, and you must call the doctor's office. A follow-up appointment is scheduled 6 weeks after the procedure to check the IUD's placement. Back to top
Loop electrosurgical excision procedure, or LEEP, is used to treat pre-cancerous lesions of the cervix. The patient is encouraged to take 600mg of Motrin prior to her appointment time. Once a speculum is placed into the vagina to provided visibility into the cervix, a local anesthetic is injected. There is usually little pain associated with this injection. At this point, a wire loop attached to an electrosurgical generator is used to remove the abnormal tissue. This typically takes less than 30 seconds. A second portion of the procedure is then done when a wand, also connected to heat, is used to treat the remaining cervical tissue. This process helps with bleeding along with treating any remaining HPV. The patient will be provided with instructions as to post-procedure care, which includes pelvic rest for 6 weeks, including avoidance of intercourse, douching, swimming, tub baths or the use of tampons. It is normal to experience a discharge that may be mustard/brown/black in color, light vaginal bleeding, and/or light cramping. The patient needs to call the office for fevers greater than 100.4, pain not relieved by Tylenol/Motrin, or heavy bleeding (using more than a pad/tampon per hour). Pathology collected from the LEEP will typically be available in 7-10 days. Once the results are reviewed by the physician, the timing for follow up pap smears will be determined. Back to top
There are a times when a patient may need to have a minor office procedure. This can include a variety of skin biopsies, or the removal of a mole. It is common to use an instrument called a punch biopsy to perform this task. When the patient is going to have an area biopsied, there is typically local anesthesia injected into the site. The biopsy is then done. There are times when a small amount of suture may be needed for adequate hemostasis. The results from any biopsy are typically available in about 7-10 days. Back to top
- Saline Infusion Sonography
Saline infusion sonography, or SIS, is a procedure which looks for intrauterine abnormalities. During the procedure a speculum is placed in the vagina, and a thin catheter is gently placed through the cervix. At this point, the speculum is removed, and the transvaginal ultrasound probe is introduced. While the sonogram images are being obtained, the saline is injected through the catheter. This allows for discrete evaluation of the uterine cavity and lining for abnormalities such as fibroids, polyps, or scar tissue. There is usually only minor cramping associated with the procedure, and it is recommended to take 600mg of Motrin prior to the appointment time. Back to top
Urodynamics is a test that determines the cause of incontinence. The test includes two separate visits, the first lasting about 15 minutes and the second from 30 to 45 minutes. On the first visit, the patient will need to arrive with a comfortably full bladder. A urine sample will be taken and the nurse will review instructions on preparation for the second visit. The actual urodynamics test will be conducted on the second visit. During this visit, catheters will be inserted to record the pressure in and around the bladder and to allow for measurement of any leaking that may occur during the filling process. Throughout the test the patient will be asked to describe bladder sensations and to cough as to put pressure on the bladder as to cause a leak. There are no restrictions after having a urodynamic test. Upon completion of the test, the results will be evaluated by the physician, who will discuss with the patient the results and discuss treatment options, if necessary. Back to top
In-office Surgeries
This type of surgery uses a small camera, which is introduced through the cervix to view the cavity of the uterus. It can be used as a diagnostic tool to determine the presence of polyps, fibroids, scar tissue etc. It can also be used to remove polyps or fibroids or place a sterilization device such as Essure. Often, before having this type of surgery, you will be required to take a medication called Cytotec two times the day prior to surgery. This medication softens the cervix allowing for a more comfortable introduction of the hysteroscope. After the procedure, it is common to experience light bleeding or discharge that can last up to 2-3 weeks. If you experience a fever, prolonged nausea and vomiting, severe pain not relieved by Motrin, and bleeding heavier than that associated with a period, you must call your physician. You must abstain from intercourse, douching, the use of tampons or tub baths and swimming for at least 2 weeks following your procedure. Back to top
This is a type of procedure is often performed in conjunction with a hysteroscopy. The cervix is typically dilated to allow instruments to be passed into the uterine cavity. Once inside the cavity, samples of the uterine lining can be obtained, polyps/fibroids removed, or an endometrial ablation performed. Any sample that is removed can be sent to pathology for further analysis. The results are usually available within 7-10 days. Post-procedure restrictions are the same as for hysteroscopy. Back to top
An endometrial ablation is a treatment option for women who have abnormal uterine bleeding. The goal of this procedure is to scar or destroy the lining of the uterus to terminate menstruation or decrease its incidence. This type of surgery can only be done for women who have abnormal bleeding due to benign conditions (non-cancerous) and are not considering future pregnancy. The evaluation of a patient for an ablation includes an ultrasound to measure the size of the uterus cavity as well as a biopsy of the lining of the uterus. The endometrial biopsy (described above) is necessary to exclude any pre-cancerous lesions of the uterus. After these steps are complete, the patient may meet with the physician, and the type of endometrial ablation which is most appropriate can be discussed. The Woman's Group offers Novasure, Thermachoice and Hydrothermal ablations. It is common to perform this procedure in conjunction with a hysteroscopy D&C. This can be done in the office or, at times, as an outpatient at the hospital. After the procedure it is normal to have a thin yellow, peach or bloody discharge that can last for weeks. It also takes time for the healing/scarring to take place within the uterus. It is normal that you may have bleeding or even a period after the procedure for up to 6 months. You should call the office after the procedure if you have a temperature greater than 101, severe abdominal pain, or prolonged/ heavy bleeding. Back to top
- Permanent Sterilization (Essure)
The Essure procedure is a type of permanent sterilization that is done in the office. During the procedure, which takes less than 10 minutes, an Essure-certified doctor slides the small, soft inserts through the natural pathways of your vagina and cervix into your fallopian tubes, so no surgery or incision is required. The very tip of each insert remains visible to your doctor, providing immediate confirmation of proper placement. The flexible Essure inserts are made out of the same silicone-free material used in heart stents, so they bend and conform to the shape of your fallopian tubes while remaining securely in place.Over the next three months, your body works with the Essure inserts to form a natural barrier within each of your fallopian tubes. These barriers prevent sperm from reaching the eggs so that pregnancy cannot occur. During this three-month timeframe, you must continue to use another form of birth control.After three months, it’s time for your Essure Confirmation Test. During this simple test, a special dye is introduced into your uterus and viewed on an x-ray, so your doctor can confirm that your fallopian tubes are completely blocked and the inserts are in place. Once you receive this verification, you can rely on Essure for permanent birth control. Back to top
The Woman's Group offers cosmetic procedures to improve the appearance of the vulva. Some women may notice that one or both labia are large or cosmetically unappealing. These may pose aesthetic problems when wearing tight fitting clothing, working out, or during intercourse. If you feel that this is a problem for you, make an appointment with a physician for evaluation. Often these cosmetic procedures can be done in the office. Back to top
Gynecological Conditions or Problems
The Papanicolaou or pap smear is the screening test for cervical cancer in the United States. A sample is usually collected from the cervix or vagina with a spatula or brush and placed in a liquid based medium for transport. It is then sent to the laboratory for microscopic analysis. Traditionally, it takes between 7-10 days for a pap smear’s results to be available to the physician. There are many different results for the pap smear test that are interpreted based on the patient's age and history. A recommendation is then provided to the patient for the appropriate follow up. Recommendations may include observation, more frequent pap testing, or colposcopy (see in-office procedures).
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- Abnormal Uterine Bleeding
There are many different causes for abnormal bleeding in women. The typical menstrual cycle in adults is approximately 21 to 35 days. There can be more variability in the first 10 years after the period starts and the 10 years before menopause (average age of menopause in the US is 51.5years). Common causes for abnormal bleeding include hormonal irregularities, concurrent medical conditions such as thyroid disorders, structural abnormalities (fibroids and polyps), the use of certain medications, infection, pregnancy, and neoplasm. The typical work-up for abnormal bleeding includes a complete history and physical. At that time it can be determined whether labwork, ultrasound, or a biopsy needs to be done. Back to top
- Bio-Identical Hormone Therapy
Bio-Identical hormone therapy is a menopause treatment that copies the molecular structure of the hormones our bodies produce. These replacement hormones are made from soy and yam extracts and can be processed and metabolized in the body in the same manner as the hormones we produce. Treatment with these replacement hormones reduce the side effects that are common to conventional hormone replacement therapies. Bio-identical hormone therapy is a safe and natural replacement for the hormones that our bodies lack during and after menopause, the absence of which can cause symptoms like hot flashes, night sweats, irritability and weight gain. However, hormone therapy is not the only solution to some of these symptoms and should only be used after natural remedies like diet, stress reduction and exercise fail to produce results.
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We provide a full range of contraceptive choices for our patients. Options include:
Traditional oral contraceptive pills that are taken daily and result in a monthly period. Very low doses are available for patients who would like to limit the amount of hormones they take.
Contraceptive pills that are taken daily, but result in a period every three months.
Contraceptive patch that is worn on a weekly basis. Normal monthly periods are experienced.
A ring ( the Nuva Ring) which is worn vaginally for 21 days. The patient can expect to have a monthly period.
Implanon/Nexplanon, which is a 4cm progesterone based rod that is placed in the patient's arm. This method is approved to provide contraception for 3 years and the most common side effect is irregular vaginal bleeding.
Mirena Intrauterine Device, which is a progesterone based IUD that is approved for 5 years of contraception and that is commonly used to treat patients with heavy bleeding.
Paraguard Intrauterine Device, a non-hormonal device which can be used for up to 10 years.
A Diaphragm, a soft latex or silicone dome with a spring molded into the rim that acts as a cervical barrier.
Many forms of permanent sterilization including laparoscopic tubal ligation and two forms of tubal occlusion using Adiana or Essure. The latter 2 procedures can often be done in the office under sedation. Back to top
An ectopic pregnancy is one where there is abnormal implantation of the embryo outside of the womb (uterus). Development most commonly occurs in the fallopian tubes but can also take place in the ovary or cervix. In the scenario where there is abnormal implantation, the developing fetus cannot survive. Many cases are caused by blockage of the fallopian tube, which impedes the transit of the fertilized egg to the uterus. A history of pelvic infections or past surgery on the tubes can cause this condition, although sometimes the cause is unknown. Symptoms of an ectopic pregnancy include pelvic pain and abnormal bleeding. Both medical and surgical treatments are available for this serious complication of pregnancy. Back to top
Endometriosis is a common condition, where cells that typically line the uterus grow in other areas of the body. Every month, a woman's ovaries produce hormones that tell the cells lining the uterus (womb) to swell and get thicker. The body is able to expel these cells through the process of menstruation. If these cells (called endometrial cells) implant and grow outside the uterus, endometriosis results. The growths are called endometrial tissue implants. Women with endometriosis typically have tissue implants on the ovaries, bowel, rectum, bladder, and on the lining of the pelvic area. They can occur in other areas of the body, too. Unlike the endometrial cells found in the uterus, the tissue implants outside the uterus stay in place during menstruation. They sometimes bleed a little bit. They grow again during the next period. This ongoing process leads to pain and other symptoms. The cause of endometriosis is unknown. One theory is that the endometrial cells shed during menstruation and travel backwards through the fallopian tubes into the pelvis, where they implant and grow. This is called retrograde menstruation. This backward menstrual flow occurs in many women, but researchers think the immune system may be different in women with endometriosis.Endometriosis is common. Sometimes, it may run in the family. Although endometriosis is typically diagnosed between ages 25 to 35, the condition probably begins about the time that regular menstruation begins. The classic symptoms of a womea with endometriosis include cyclical pelvic pain at the time of menstruation. The most common treatments include birth control pills, other hormonal regimens, or surgery. Back to top
- Human Papilloma Virus (HPV)
Human Papilloma Virus, or HPV, is a type of virus that can be transmitted sexually and is very prevalent in the US population with over 100 strains in existence. It has been estimated that 75-80% of adults will, at some point before the age of 50, be infected with HPV. HPV in some cases can lead to genital warts, cervical pre-cancers, or cancers of the cervix, vulva, vagina or anus. There are 2 predominant types of HPV: low risk which is associated with warts and high risk which is often found with an abnormal pap smear. Once contracted, HPV is fought by the body's immune system. We recommend taking a multivitamin with anti-oxidants, exercising regularly, and abstaining from smoking. Your physician may choose other methods to treat HPV in certain cases. There are currently two vaccines available for the prevention of HPV, which are often given to women between the ages of 9 and 26. The Guardasil vaccine offers immunity to HPV types 6 and 11 (low risk) and 16 and 18 (high risk). The Cervarix vaccine offers immunity to types 16 and 18. It is known that types 16 and 18 are responsible for over 70% of cervical cancers in the United States. Back to top
Urinary incontinence is defined as the involuntary loss of urine. This is a very common condition for women and one that is at times difficult or embarrassing to discuss with your physician. There are many reasons for incontinence, but the two most common are the weakening of the urethra (outflow tract of the bladder) or spasm of the bladder muscle. There is quite a bit of information that can be gathered regarding a woman's incontinence through history and a physical exam. In addition,we can perform a urodynamics test in the office to assist our evaluation. The Woman's Group offers many types of therapies including medical, behavioral with physical therapy, and a variety of surgeries to remedy this condition. Back to top
Infertility is defined as the inability to conceive after a year of unprotected regular intercourse. This can be a very stressful situation for a couple, and there are many known causes. When looking at the reasons why a couple is infertile, 40% of them are typically due to female factors, 40% to male factors and 20%, even after work-up, remain unknown. There are a variety of tests that can be done to try to determine the cause of infertility. If a couple meets the criteria for infertility, they should make an appointment with a physician so that an evaluation can be done and an appropriate course of action can be developed. Back to top
The average age of menopause in the united States is 51.5 years. Menopause is defined as the absence of menses for one full year. The cause of menopause is the decline in ovarian function over time and thus the decline of the menstrual hormones. The most common symptoms experienced are hot flashes, night sweats, insomnia, mood swings, and vaginal dryness. These symptoms can occur as a woman's hormone levels change, sometimes years before the periods stop. There are no reliable tests available to predict the timing, onset, or severity of menopause. Typically, the patient is treated based on her symptoms and their severity. There are many different types of medications available, which can be tailored to the particular symptom. It is essential that a woman take an adequate amount of calcium with vitamin D when approaching the menopausal years. The highest rate of bone loss in women takes place during the first 5 years after menopause. Back to top
Pre-menstrual syndrome (PMS) or pre-menstrual dysphoric disorder (PMDD) are common conditions that many women will experience throughout their lives. These conditions can have associated symptoms including bloating, cramping, fatigue, moodiness, sleep disturbance, and depression. PMS can be experienced by many women, but PMDD is a more serious disorder that should be diagnosed and treated by a professional. There are many solutions possible including behavioral modification, exercise, eating healthfully, acquiring good sleep patterns, managing stress, limiting alcohol consumption and refraining from smoking. Hormonal therapy (OCPs) can be used to control many of the symptoms. In addition, anti-depressants may be of benefit to some patients. Back to top
Minimally Invasive Gyn Surgery
There are times when medication and in-office procedures are not sufficient to treat gynecological conditions such as uterine fibroids, ovarian cysts, persistent bleeding or cancer. In these cases, surgery is often required. Traditional gynecological surgery used to involve an abdominal incision ranging from 6 to 12 inches in length. Because the size of such an incision, the patient experienced more pain due to the trauma to surrounding tissues, was more prone to infection and experienced longer recovery times. These days, laparoscopic surgery is a minimally invasive alternative that accomplishes the same results with incisions that are less than 1 inch in length. Through these tiny incisions the surgeon introduces a lighted scope containing a camera and the necessary instruments to accomplish the task. Thanks to the lighted scope, the surgeon can see the target area and the instruments as she guides them to perform the operation. For more complex laparoscopic procedures, the doctors at The Woman’s Group use the DaVinci© Surgical System http://davincihysterectomy.com .This system gives the surgeon the additional range of motion and 3D vision required to perform more intricate surgeries. Minimally invasive surgeries result in many benefits to the patient including less pain, less probability of infection and less recovery time. Among the minimally invasive surgeries performed by doctors at The Womans’ Group are:
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Laparoscopic Assisted Vaginal Hysterectomy
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Laparoscopic Assisted Supra-cervical Hysterectomy
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Total Laparoscopic Hysterectomy
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Operative Laparoscopy, including ovarian cystectomy and salpingo-oohorectomy
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DaVinci© Robotic Assisted Hysterectomy
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DaVinci© Robotic Assisted Laparoscopy
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