Dyspareunia is the medical word for persistent or recurrent pain with sexual intercourse. This affects 10 to 20% of American women. Dyspareunia can be deep or superficial. Sexual pain can cause relationship distress, decreased quality of life, anxiety and depression.
What are the risk factors for dyspareunia?
lower socioeconomic status
just had a baby
low sexual satisfaction
history of sexual abuse
What will your doctor do? She will take a thorough history. When did it start? What makes it worse? Is the pain superficial or deep? What has helped in the past? A physical exam should be done to visually examine the external genitalia and to perform an internal vaginal exam. Expect to show your physician where the pain occurs.
What are common reasons of sexual pain? Inadequate lubrication, vaginal atrophy, pelvic floor dysfunction, vaginismus (spasms of the vaginal walls), endometriosis, or vulvodynia.
What is vulvodynia? This is chronic genital pain lasting at least 3 months. Pain can be triggered by touch like when inserting a tampon or attempting sexual intercourse or it can be unprovoked. This can have generalized pain or localized. The pain may feel like burning, aching, tearing or stabbing.
What is vaginismus? Vaginismus is an involuntary contraction of the pelvic floor muscles with attempted vaginal penetration. This often leads to fear or anxiety about penetration causing more pelvic floor constriction. Some patients have incidents before the pain such as traumatic sexual experiences or medical conditions and some have no antecedent risk factors.
What can you do about sexual pain? Make a log of the associated symptoms with sexual pain. See your physician. Be prepared to discuss frankly about your condition and to have a physical exam. Multidisciplinary treatment of this condition may include psychotherapy, sexual therapy, cognitive behavior therapy, vaginal lubricants, sequential vaginal dilators, or botox injections.
What is it? Irritable bowel syndrome (IBS) is a varied group of gastrointestinal conditions that is not fully understood.
What causes IBS? Psychological factors do not cause IBS. But IBS can make anxiety or depression worse. Many with IBS have anxiety related to the unpredictability of gastrointestinal symptoms and their IBS may negatively affect their life.
What are the symptoms of irritable bowel?
Recurrent abdominal pain for more than 6 months, occurring at least 1 day per week with 2 or more of the following symptoms
Pain better or worse with defecation
Change in stool frequency
Abnormal stool frequency (more than 3 times/day or less than 3 times/week)
Abnormal stool form (hard or loose and watery)
Mucus with stool
What is needed to diagnose IBS?
Patients should not have alarm symptoms: blood in stool, abdominal mass, jaundice, enlarged lymph nodes, rectal pain, vomiting, or weight loss, or night sweats.
Your physician may order labwork: CBC, thyroid labs, celiac serology, C-reactive protein or fecal calprotectin. Testing for pathogens in the stool may also be done to rule out infectious diarrhea.
You may be referred to a gastroenterologist for a colonoscopy. Colonoscopy is NOT NEEDED to diagnose irritable bowel syndrome. Biopsies may be taken to rule out inflammatory bowel disease (Crohn’s or ulcerative colitis).
What is the treatment for IBS?
There is no definitive treatment for IBS. Treatment focuses on relieving symptoms (constipation or diarrhea) and making patient’s quality of life better. Healthy eating with more fiber and probiotics may help. Loperamide (Imodium) may firm up loose stools. For those with constipation, there are many treatments: fiber, Miralax, lactulose, Dulcolax, senna. There are also prescription medicines available from the pharmacist for constipation-predominant IBS.
One of the reasons that patients do not fill their prescriptions are due to increasing medication costs.
I have begun asking my patients “Is the cost of any of your medications a burden for you?” This fast screening question at the time of your visit helps greatly. Physicians or medical assistants should review the medicines you currently take.
What can you do?
Have your physician review your medications
Do you still need to take the medication?
Can you change to a less expensive medication or a generic version?
Consider using a 90-day prescription to reduce copayments. As an aside, this may also increase ease of use in that having medications at the house is easier than going to the pharmacy every month.
Look up the medicine online to find the name of the manufacturer. Then, see if there is a discount program with the pharmaceutical manufacturer for that medicine. At times these discount programs are easy to complete and some require your tax return from the year before.
Look online to see if your medication is available at a large chain pharmacy on their “$4/month list.”
Use websites and apps such as singlecare.com or goodrx.com that provide comparative costs between pharmacies and coupons for prescription medications
Consider cutting a stronger medication in ½ (to get the desired strength).
Does your physician’s office have a social worker to help navigate these issues?
At our family medicine residency office, we have a social worker who helps patients who need more intensive support (such as navigating insurance plans, determining eligibility for additional insurance coverage, and applying for pharmaceutical medication assistance programs).
Primary prevention means preventing the FIRST EPISODE of a cardiovascular event (like a stroke or heart attack). Primary prevention is key! Family physicians make treatment decisions based on clinical risk and risk calculators. Try this link to find your risk: ASCVD risk calculator.
What influences the score on the risk calculator? Obesity, high blood pressure, diabetes and tobacco use influence risk scores significantly more than cholesterol values.
Who should get a coronary artery calcium score? Consider measuring this if you are 40-75 years of age (without diabetes and with an LDL less than 190) IF a decision about statin therapy is uncertain. Coronary artery calcium scoring has not been shown to improve patient outcomes.
Evidence supports moderate-dose statins as the BEST therapy in primary prevention for patients at increased risk with a mortality rate of 20-30% in 5 years. Moderate-dose statin drugs are well tolerated with low risk of causing muscle breakdown or diabetes. High-dose statins show similar cardiovascular benefits (although they have increased risk of causing diabetes or other side effects). Ezetimibe sometimes is added to the statin but has not been shown to help much. The goal of statins are to decrease LDL levels by at least 50%.
Who should start on a statin drug for primary prevention? Patients with a 12% 10-year risk, or in diabetics with a 10-year risk of 6-12%, or in those with LDL of 190mg/dL or more. Talk to your physician if your 10-year risk is between 6-12%
What should be done for secondary prevention? Secondary prevention is when a patient has ALREADY had a cardiovascular event (heart attack, stroke, or needed a heart stent). Moderate-dose statins are the mainstay of treatment.
Who should start on a PCSK9 inhibitor? Talk to your cardiologist if your LDL (not your total cholesterol) is 220 or more, per American College of Cardiology/American Heart Association (ACC/AHA) recommendations.
Should you start on an omega-3 fatty acid to reduce cardiovascular disease risk? No, research has not shown Omega-3 fatty acids to help.
What if you start on a statin drug and you have side effects? Talk to your physician and consider stopping the statin. After a washout period, re-challenge with a different statin or a lower dose.
How often should you have labs to check cholesterol after starting on medication? The VA/Department of Defense suggests against routine monitoring whereas the ACC/AHA suggests checking 4-12 weeks after statin initiation or dose adjustment and then rechecking every 3 to 12 months, as needed. Research shows that cholesterol levels are stable for up to 10 years, with most of the change between lab results due to testing variability. Fasting before cholesterol labs are only needed to accurately evaluate high triglycerides.
Do you need your vitamin D level checked? The US Preventive Services Task Force just weighed in on this and gave a “final recommendation statement.”
Sounds impressive, huh? Well, actually the USPSTF has said that to check vitamin D levels is an “I” recommendation. This means that we have insufficient evidence to asses the balance of benefits of checking vitamin D level and harms of screening in asymptomatic adults. Keep in mind that an A recommendation means we SHOULD do it. B we PROBABLY SHOULD do it. C recommendation that we should WEIGHT THE RISKS AND BENEFIT of checking. D recommendation we SHOULD NOT do it. And, then an “I” is insufficient evidence for or against.
Who does NOT need to have vitamin D checked? People who live in the community (versus a nursing home), non-pregnant adults, those with no signs or symptoms of vitamin D deficiency, or for those who do not have a condition requiring vitamin D.
Who may consider having vitamin D checked? Patients who are hospitalized or living in institutions (like nursing homes), those with a bone condition such as osteoporosis, osteomalacia or rickets.
Why should we not check? Because we need more research on WHAT LEVEL of vitamin D people need to be healthy. We do not know the level.
Generally, I suggest to patients that most of us have low or low-normal vitamin D levels. We get vitamin D from the sun (but we are often indoors or outdoors wearing protective clothing) and from foods (fortified milk or salmon) but often we could use more. Vitamin D3 is available over the counter, is inexpensive, and 2000 international units (IU) a day increases our levels.
I warn patients that oftentimes their insurance will not pay for Vitamin D labs and the patient should call her insurer to see what their “out of pocket cost for the vitamin D lab is.” Insurers always know what they pay for… physicians don’t.
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.
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.
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.