Hello Reno Families!

This is Leslie Greenberg.  I am a family physician in Reno, Nevada.  I attended University of Nevada School of Medicine and relocated back to my hometown in 2015.  I trained and practiced medicine in the Midwest (Indiana and Kansas) for 20 years before moving back West.  I consider myself a teacher and educator.  I  have  taught family medicine residents for 20 years.  I currently teach at the family medicine residency program in Reno and also see private patients.  I invite you to read my blog.  If you would like to become a patient, please call 775-682-8200.

Medical Disclaimer

Please remember that medical information provided by myself, in the absence of a visit with a health care professional, must be considered an educational service only.  This blog should not be relied upon as a medical judgement and does not replace a physician’s independent judgement about the appropriateness or risks of a procedure or condition for a given patient.  I will do my best to provide you with information that may help you make your own health care decisions.

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HPV vaccine is REALLY effective!!!

HPV vaccine is REALLY effective!!!

The human papillomavirus vaccine is really effective, especially when given before age 17. 

There was a Swedish study of MORE than 1.6 million patients. The patients who received the vaccine before 17 were most helped. 

Incidence of invasive cervical cancer:

UNVACCINATED was 5.3 per 100,000 person-years.

VACCINATED was 0.73 per 100,000 person-years.

HPV is a vaccine that has been offered for more than 10 years.  Low side-effect profile.  Its use decreases the risk of cancer, just like the hepatitis B vaccine (we give to infants) decreases the risk of liver cancer.  Use of HPV vaccine does not increase risky sexual contact nor has it been shown to move up the timing of sex.

Want more information?  https://www.cdc.gov/hpv/parents/vaccine.html

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Who needs a tonsillectomy?

Who needs a tonsillectomy?

As a family physician, I send patients to ear nose throat surgeons for a tonsillectomy if …

  1. Seven throat infections in one year
  2. Five throat infections per year for 2 consecutive years
  3. Three throat infections per year for 3 consecutive years.
  4. Snoring or obstructed-breathing when asleep especially when associated with bed wetting, asthma, poor school performance or behavior issues.

(These are updated guidelines from The American Academy of Otolaryngology–Head and Neck Surgery)

As a side note, observational studies show that codeine (or any medication containing codeine) should not be given after tonsillectomy due to possible severe complications.

I hope this helps.

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Are you a woman with unwanted facial hair? Treatment is easy!

Are you a woman with unwanted facial hair? Treatment is easy!

Hirsutism is “excessive male-pattern hair growth in a woman.”  Hirsutism is common, as it affects between 5 and 10 percent of women of reproductive age.  Unwanted hair growth is associated with significant emotional distress and depression.

Why do women get hirsutism?  It is usually an indication of an underlying endocrine disorder, with the most common being polycystic ovarian syndrome. 

What to do? First-line treatment for women with unwanted hair (who are not trying to conceive) are combined oral contraceptives!  This is easy and well-tolerated therapy.  If facial hair does not get better after 6 months, then additional medication (an antiandrogen like spironolactone) can be started. 

Will it get better?  Yes!  But, probably will not completely go away… Reasonable expectations should be discussed. Medication is unlikely to completely eliminate already existing hair growth.  With time, hair may become less coarse, not grow as fast, and/or may require less frequent use of shaving, plucking, or waxing.

What can you do?  Talk to your doctor and they can write for combination oral contraception pills.  If you do not have a doctor, there is an online service, Pandiahealth.com , which links you to a physician who can send you in a years-worth of pills to your door. 

I hope this helps.

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Anaphylaxis: Life-threatening allergic reaction. What is this? What to do?

Anaphylaxis: Life-threatening allergic reaction.  What is this?  What to do?

Anaphylaxis is a life-threatening allergic reaction that usually occurs within 2 hours of allergen-exposure. 

This is pretty rare, but important to know the symptoms.  The two peak age ranges for anaphylaxis are in children (aged 2 to 12 years old) and in adults between 50 and 69 years.  Most anaphylactic reactions occur outside of the hospital.  Most common triggers are insect stings, foods, and medications.  Up to 20% of cases there is an unknown trigger.  Risk factors for anaphylaxis are those with older age, cardiovascular disease, peanut and tree nut allergy, and coexisting asthma.  

What makes it anaphylaxis?  And not just an allergic reaction?  Anaphylaxis involves TWO or more organ systems such as difficulty breathing (respiratory), tongue swelling (mucocutaneous), skin rash, reduced blood pressure (cardiovascular), abdominal pain/vomiting (GI).

What to do?  Remove the trigger first!  Epinephrine injected intramuscular (Epi-pen) and supportive care.  It is important that the patient continues to breathe, have a patent airway and have adequate circulation.  Only AFTER epinephrine is given should the adjunctive medications be considered. Do not rely on antihistamines (diphenhydramine) as first-line treatment in severe allergic reactions. Patients should be observed for 12 hours as a recurrence of anaphylaxis without re-exposure to the allergen may occur.

What are adjunctive medications?  H1 (diphenhydramine) and H2 blockers (like cimetidine, famotidine), steroids, albuterol nebulizer, and glucagon given in the vein.   

What to do AFTER an anaphylactic reaction?  Make an emergency action plan.  See an allergist.  Avoid triggers.  Always have an epinephrine auto-injector (epi pen) on hand.

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Hypertriglyceridemia. What is this? Is this important?

Burning Man art

Hypertriglyceridemia. What is this?  Is this important?

Hypertriglyceridemia is when the fasting serum triglyceride is 150 or more. 

Why is this important?  Hypertriglyceridemia is linked with an increase risk of cardiovascular disease.  If the triglycerides are more than 500, the risk of pancreatitis also increases.  Other risk factors for hypertriglyceridemia are metabolic syndrome, type 2 diabetes, and obesity.

How to manage hypertriglyceridemia?  If the level is less than 500, start with increasing exercise and change diet.  Good diets include low-carb and Mediterrean diet and the DASH (Dietary Approaches to Stop Hypertension) diet.   Avoid sugar-sweetened beverages.   Exercise promotes the muscle’s uptake of glucose and can reduce triglyceride levels. Moderate to high-intensity exercise and endurance exercise are especially helpful. Weight loss is important!  Even 5% weight loss is important.

If triglycerides are more than 500, your physician can calculate a 10-year risk of atherosclerotic cardiovascular disease.  If risk of heart attack or stroke (per the ASCVD risk calculator) is borderline (5 to 7.5%) or intermediate risk (7.5 – 20%) consider taking a statin medication.   If statins are not enough, then high-dose icosapent can reduce cardiovascular mortality (but only decreases 1 cardiovascular death over 5 years per 111 patients on the medication). 

Other medications which may help, but have not been studied thoroughly are fibrates, omega-3 fatty acids, and niacin. 

I hope this helps.

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Nevadans: Birth control (a years worth!) delivered to your door! Emergency contraception, too.

The Top 5 Legal Online Supplement & Prescription Services - Online Medical Care

Local news did a highlight about https://www.pandiahealth.com/ last night…


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Did you know that Nevada pharmacies are obligated by law to fill a years-worth of birth control pills at once?

Did you know that Nevada pharmacies are obligated by law to fill a years-worth of birth control pills at once?

Yes!  In 2018 Nevada legislature passed this bill…

NRS 689A.0418. This law requires a pharmacist to dispense up to a

12-month supply of drugs for contraception if:

1. The patient has previously received a three-month supply of the same drug;

2. The patient has previously received a nine-month supply of the same drug or a supply of the same

drug for the balance of the plan year in which the three-month supply was prescribed, whichever was


3. The patient is insured by the same health insurance plan for that year.

What can you do?  Ask your physician to refill your birth control pills for 13 pill packages with no refills.  The physician can cite Nevada NRS689A.0418 in their prescription to remind the pharmacist of the law requiring them to fill a years-worth at once.

Do you want a period monthly?  If so, take the pills as they are in the package (3 weeks of active pills and one week of inactive pills).

Do you want a period less than every month?  If so, take only the 3 weeks of active pills and then skip the placebo pills.  (For example, Then take the three weeks of active pills followed by the three active pills from the next pill pack followed by the three weeks of active pills from the third pack.  Then take the placebo pills and you will have a menstrual period once every 9 weeks).

Do you want to never have a menstrual period?  Take the three weeks of active pills of each pill pack and always skip the placebo pills.  You may have breakthrough vaginal bleeding, but this is not thought to be harmful.

If you do not have a doctor, https://www.pandiahealth.com/ is an online physician-led, woman-led service that can fill your birth control pills for a year.  Physician’s review your risks and which birth control pills may work well. Pandiahealth.com also will send emergency contraception, if wanted. 

I hope this helps.

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How to manage arthritis?! New guidelines.

The American College of Rheumatology and Arthritis Foundation have put out new practice guidelines on how to manage osteoarthritis (OA).

Photo by Elly Fairytale on Pexels.com

Arthritis affects over 300 million people worldwide.  The most common joints affected are knees, hips, and hands.

Treatment suggestions


  1. Exercise
  2. Tai chi
  3. Lose weight!  …even a 5% weight loss helps.
  4. Tibio-femoral knee braces may help decrease knee pain and increase walking speed.
  5. Acupunture and heat or cold interventions may help


  1. NSAIDs (ibuprofen and naproxen) oral or topical (cream)  provide temporary improvement
  2. Corticosteroid injections into the joints help knee and hip OA.

What has been shown to not help?  Transcutaneous electrical nerve stimulation (TENS units) does not improve knee OA.  Bisphosphonates, methotrexate, and hydroxychloroquine do not improve pain or function. Platelet-rich plasma, stem cells, and hyaluronic acid have failed to demonstrate clinical benefit in trials. 

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Do you have difficulty swallowing?

Difficulty swallowing is a common problem.  I have had countless patients with this… and also two family members with this in the past few months. 

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Swallowing is a complex process.  Breathing must be coordinated with swallowing.  Food is chewed (and mixed with saliva) and forms into a bolus such that with the initiating of swallowing the food passes the upper esophageal sphincter and into the esophagus.  While in the esophagus peristalsis occurs to get this bolus of food through the relaxed lower esophageal sphincter and into the stomach. 

Many things can hinder the swallowing process. 

  1. Neurological conditions: Parkinsons, stroke, dementia
  2. Neuromuscular conditions: ALS (Lou Gehrig’s), myasthenia gravis, multiple sclerosis
  3. Structural issues: head and neck cancers, radiation, thyroid enlargement
  4. Oral causes: poor dentition or dentures, dry mouth
  5. Reflux  (this is the  most common!)

What is the work up for difficulty swallowing?  First, see your physician.  You need a good physical exam with a head and neck exam, observation of a swallow, abdominal inspection and palpation, cranial nerve exam, and discussion of nutritional status and fitness.

From there daily reflux medication may be prescribed, or a swallowing study may be ordered, or a referral to a GI physician for esophagogastroduodenoscopy (EGD). 

In the meanwhile, diet modifications is helpful. Eat mindfully. Avoid foods that cause problems. Chew carefully. Cut food into smaller pieces.  Drink liquids during the meal. Eat upright. Chin-tuck with swallowing.

I hope this helps.

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Inguinal hernias. What to do?

Inguinal hernias. What to do?

Just in the US 1.6 million groin hernias are diagnosed every year.  The lifetime prevalence of groin hernias is higher in men (27%!) compared to women at 3%. Most of the time hernias are only on one side of the groin, but in 20% of patients they are on both sides. 

What is a hernia? It is a weak spot or a tear in the abdominal wall. Most patients complain of a bulge in the groin that gets larger over time.  There may be pain or discomfort (or pulling or burning) at the site, but nearly 1/3 of patients have no symptoms. 

What is the best way to diagnose a hernia?  In men, the diagnosis may be obvious on physical exam.  Women often need an ultrasound to confirm a hernia.    Ultrasound is also a good imaging tool in patients with surgical complications after a hernia repair, recurrent hernias or other causes of groin pain. If the ultrasound appears normal, some patients need an MRI to diagnose occult hernias. 

If you have a hernia, there is a risk that the intestines will slip through the abdominal wall defect, fill with air, and then not be able to slip back in.  This increases the risk of bowel perforation, abdominal infections which could lead to death. 

Surgical consultation is the key to managing hernias.  The surgeon will review with you what the options are… most of the time this will mean you will need a surgery to keep the bowel inside the abdomen, and stitching or mesh to fill the abdominal wall defect.  Watchful waiting is NOT suggested if you have symptoms or are a nonpregnant female.

When to go to the hospital?  Intractable abdominal pain needs immediate attention.

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