Shannon M. Juno, M.D.

This is the yearly gynecological exam where age-appropriate preventative health care is addressed. Pap testing begins at age 21 for all women and continues every 3-5 years until age 65. HPV testing is added to the pap test beginning at age 30. HPV is the primary cause of cervical cancer, and those women who have this very common virus in their system will need closer monitoring and more frequent pap testing than those who do not. For most women who are low-risk for cervical cancer, pap testing can be safely discontinued at age 65 or following a hysterectomy when the cervix is removed surgically. Mammogram testing begins for most women at age 40 and continues annually. Colon cancer screening starts at age 45 or sooner when a strong family history of cancer is present. Routine lab testing for cholesterol, kidney, and liver function, thyroid testing, and complete blood count lab tests are commonly ordered for many women. Bone density testing will begin after menopause and be reassessed every few years. Individualized screening may be indicated for women who have a history of other medical problems or a family history that increases their risk for certain diseases.

Menopause is the time of a woman’s life when she no longer has hormone production from her ovaries. The three main hormones produced by the ovaries are estrogen, progesterone, and testosterone. A woman may enter menopause naturally, and this occurs near age 50 in most women, but it can occur at any time after 40. Hormonal fluctuations that can affect how a woman feels from day to day begin in perimenopause, which can begin up to 10 years before menopause. A woman is considered fully menopausal when she has not had a period for a full 12 months. Surgery to remove the ovaries can lead to an abrupt surgical menopause as well. The common symptoms of menopause are caused by low or absent hormone levels. These symptoms include hot flashes, night sweats, fatigue, insomnia, low libido, anxiety, mood swings, vaginal dryness, mental fogginess, bone loss, weight gain, and skin and hair changes. They can be successfully treated with hormone replacement using traditional pharmaceuticals such as estradiol (estrogen) gels or patches and oral progesterone capsules. Bioidentical hormone creams or pellets are also available to add back all of the missing hormones, including testosterone, which often leads to better mood, better sleep, mental clarity, improved libido, and more energy.

Pap testing is performed to screen for cervical cancer. HPV is a sexually transmitted virus and is the leading cause of cervical cancer, and 80% of people have been exposed to HPV in their lifetime. Some people get rid of the virus, while others are unable to clear it from their system. There is a vaccine available to help the immune system fight the virus. When a pap test returns abnormal, there are many different scenarios that will determine the next course of action. Sometimes the test is repeated in a year. Other times, a detailed evaluation of the cervix with a special microscope called a colposcopy is necessary, and small biopsies of the cervix are taken when this procedure is performed. Precancerous cells of the cervix are called dysplasia, and there are levels of severity based on how likely they will become cancer over time. CIN 1 (mild dysplasia) is likely to resolve over a period of 2 years and can be closely monitored without treatment. CIN 2 (moderate dysplasia), CIN 3 (severe dysplasia), and CIS (carcinoma in situ) are all likely to progress to cancer over time, so those types of lesions are treated by removing the area of the cervix where the cells reside. This type of procedure is called a cervical conization and can be completed in the office (LEEP) or in the operating room (cold knife conization). The goal of surgery is to remove the precancerous cells entirely. Unfortunately, if HPV persists following such a procedure, precancerous cells can form again, so it is very important for women who have had cervical dysplasia to continue regular pap testing to check for recurrent abnormalities. Check out the following website to learn more:

gardasil9.com

Many women suffer from irregular, heavy periods. Causes of period abnormalities include hormone imbalances, polycystic ovarian syndrome, uterine fibroids, and uterine polyps. Medical and surgical options are available to treat period irregularities: oral contraceptive pills and similar hormonal treatments; oral medication called TXA; hormonal IUD; endometrial ablation; fibroid or polyp removal; and hysterectomy.

Fibroids are rubbery growths or tumors that occur in the muscular wall of the uterus. They are almost always benign (non-cancerous), but they can cause heavy periods and uterine cramping. They are usually small but can grow to be quite large, and if this occurs, they can press against nearby organs such as the bladder and cause symptoms such as urinary frequency. Fibroids occur in 40% of women and can often be left alone as long as they are not causing the woman problems. If they cause symptoms, they can be treated with medications such as birth control pills or a specialized medication called Oriahhn to reduce heavy bleeding episodes and cramping. Surgical management options include removing the fibroids (myomectomy), radiofrequency ablation of the fibroids (Acessa), uterine artery embolization, or hysterectomy. Endometrial ablation may also help control periods if the fibroids are small. Progestin IUD has also been shown to effectively reduce menstrual blood loss by 80–90%. Uterine polyps are common, especially in menopausal women. They are soft tissue growths in the lining of the uterus, which is also known as the endometrium. Polyps are usually benign, but they can harbor endometrial cancer in some cases. They typically cause light bleeding between periods or bleeding during menopause. Polyps can be removed using a minor surgical procedure where a camera is inserted through the cervix (hysteroscopy) and a device is used to excise the polyp (myosure). Check out the following websites to learn more: 

gynsurgicalsolutions.com/patients/treatment-options/myosure/ 

oriahhn.com

Prolapse occurs when the supporting tissues of the pelvic floor become relaxed with aging and after childbirth. The vaginal wall, bladder (cystocele), rectum (rectocele), and uterus can move downward in the pelvis, which can cause a bulging of tissue near the vaginal opening. This can cause pressure and make it difficult for some women to empty their bladder or rectum. Pelvic prolapse is a type of hernia where tissues bulge out of areas of the body where they do not belong. It is very common. Prolapse can be left alone if it is not bothersome. Vaginal estrogen therapy can be prescribed to help keep the vaginal walls healthy and strong. A pessary device, which is a silicone ring or cube, can be inserted to hold the prolapse inside, but these must be cleaned regularly and should be removed and reinserted for that purpose. Surgery can be performed to correct prolapse, and a urogynecology specialist is best trained in the newest techniques, which provide long-lasting effects for our patients. If you need surgery to correct pelvic prolapse, Dr. Juno will refer you to the best specialist to treat your particular problem.

PCOS is a hormone imbalance that occurs when your ovaries create excess hormones called androgens. This causes irregular menstrual cycles, missed periods, unpredictable ovulation, excess hair growth on the face, arms, chest, and abdomen, acne, hair thinning, darkening of the skin, and skin tags. Small follicle cysts (fluid-filled sacs with immature eggs) may be visible on your ovaries on ultrasound due to a lack of ovulation. The small cysts are not dangerous; they do not cause pain, and not all women with PCOS have them. PCOS causes infertility because women do not ovulate regularly, and when they do ovulate, the eggs are unhealthy. The treatment for PCOS involves targeting the underlying problems, which often include obesity and insulin resistance. Insulin resistance often occurs when the insulin levels in the blood stream run high due to high-carbohydrate or high-sugar diets. The high insulin levels can cause the ovaries to overproduce androgens and stop ovulation. Insulin resistance can lead to diabetes if left untreated. Low-sugar diets are best for PCOS patients. A variety of medications and supplements can be used to treat insulin resistance and high androgen levels. Some women may opt to use fertility medications to stimulate ovulation if pregnancy is desired.

Ovarian cysts are quite common and most often are normal findings in women who are still menstruating. Every month, when a woman ovulates, she forms at least one cyst on her ovaries. When ovulation occurs, the cyst resolves. At times, these “follicular cysts” can be located in an area of the ovary that causes pain, but most of the time, the woman does not even know the cyst is there. In some cases, there are cysts that are not caused by normal ovarian function, and these cysts may need treatment. There are cysts called endometriomas, which are part of the disease process called endometriosis, and these can cause pain and infertility. Cysts called teratomas form from stem cells in the ovary and can develop hair, fat, and even teeth inside of them. These types of cysts will need to be surgically removed. Cysts called hemorrhagic cysts are quite painful but are also associated with normal ovulation. The reason they are more painful than the typical ovulatory cyst is because instead of clear fluid, they contain blood. Typically, they resolve on their own over a few weeks or months. Other benign cysts that require treatment include cystadenomas, which are simple, fluid-filled balloon-like sacs that grow slowly over time but never burst or go away on their own. The worst type of cyst is uncommon, and that is ovarian cancer. Ovarian cancer occurs more often in older women. A woman with a cyst that is complex in nature (meaning that it contains solid and fluid parts) will need close follow-up. Sometimes blood work can be used to look for markers of ovarian cancer when a complex cyst is present. If there is any concern for ovarian cancer, the cyst will be surgically removed, often by a specialist called a gynecologist.

Ectopic pregnancy is when a pregnancy implants outside of the uterus, and the most common place for this to occur is in the fallopian tube. When this happens, the pregnancy cannot survive. We know that ectopic pregnancy often occurs because the pregnancy was not healthy from the start. The fallopian tube cannot grow to accommodate a pregnancy and eventually will rupture and cause internal bleeding, which can be life-threatening to the mother. Ectopic pregnancy can be diagnosed before that happens if prenatal care is sought early in the pregnancy. A sign of an ectopic pregnancy is bleeding and/or pain in the lower abdomen. Pregnancy hormone levels that are increasing slower than expected can be a sign of an abnormal pregnancy. An abnormal pregnancy can often be seen on ultrasound. Ectopic pregnancy can be treated with a medication called methotrexate, which stops the growth of the abnormal pregnancy cells. It can also be treated surgically, and sometimes removal of the damaged fallopian tube is necessary, but not always.

Endometrial ablation is a procedure that removes the thin layer of tissue that lines the uterus, called the endometrium. This is the layer that sheds or bleeds during a woman’s period. The lining of the uterus is cauterized (burned), and this results in light or nonexistent periods following the procedure. Endometrial ablation is used to treat irregularities in the period that do not respond to medical treatment. This procedure should only be performed on women who have completed childbearing. Permanent contraception in the form of tubal sterilization or partner vasectomy is recommended in patients who have endometrial ablation, as pregnancy following this procedure could be dangerous for the woman. This procedure has been shown to be very effective in controlling heavy periods in most women and avoids major surgery such as hysterectomy. Check out the following website to learn more: 

hologic.com/hologic-products/gynecologic-health/novasure-endometrial-ablation

There are many options for birth control for women, and the decision of which method to use is a personal choice that best fits each particular woman’s lifestyle. A patient’s medical history may make certain forms of birth control more risky, and a full review of your medical problems will help tailor a contraceptive choice to you. For instance, estrogen-containing contraceptives may need to be avoided in women past a certain age if they smoke, have migraine headaches, liver disease, or a blood clotting disorder. 

The available options include: 

Birth Control Pills 

Approximately 91–94% effective, but up to 99% effective when taken properly and on schedule. Birth control patch (weekly), ring (monthly), or injection (every 3 months): up to 98% effective 

Check out these websites to learn more: 

xulane.com 

nuvaring.com 

LARC (Long-Acting Reversible Contraceptive) 

Implants that are inserted in the office and can be removed at any time. Intrauterine device (IUD): A T-shaped device that is inserted into the uterus through the cervix, copper, or progesterone options that offer 3 to 10 years of reversible contraception are 99% effective. 

Check out the following websites to learn more: 

mirena-us.com 

paragard.com 

kyleena-us.com 

liletta.com 

Nexplanon Implant: 

Matchstick-sized device inserted in the upper arm, 99% effective for up to 3 years 

Check out the following website to learn more: 

nexplanon.com 

Permanent Sterilization: 

Removal or occlusion of both fallopian tubes (over 99% effective) 

Male Condoms:  

82% effective 

Laparoscopic Surgery or Tubal Sterilization  

This type of minimally invasive surgery is used for most types of gynecological surgery. The abdomen is entered through small incisions (1 cm or less), where long instruments and a camera are utilized to perform procedures such as tubal sterilization, the removal of ovarian cysts, and even hysterectomy. The procedure uses CO2 gas to help the surgeon visualize all structures clearly. It is performed under anesthesia in an operating suite. Dr. Juno performs laparoscopy in Brenham at Scott and White Hospital. Tubal sterilization is one of the most common laparoscopic procedures performed. In most cases, both fallopian tubes will be completely excised. This provides very effective contraception while also reducing the risk of ovarian cancer. The ovaries are left intact; however, removal of the fallopian tubes reduces the risk of the risk of ovarian cancer because this type of cancer often starts in the tubes themselves. The traditional methods for tubal sterilization involved placing metal clips or rubber bands on the tubes; however, this has fallen out of common practice because the risk of tubal pregnancy following sterilization is higher using those techniques.

Endometriosis occurs in up to 10% of women. In this disease, pieces of the uterine lining implant in areas outside the uterus and cause pain and irregular bleeding for the woman. There is also a form of endometriosis called adenomyosis, where the lining is implanted inside the muscular wall of the uterus. All forms can cause symptoms such as painful and irregular periods, painful intercourse, chronic pelvic pain, and infertility. The disease often runs in families. It is a chronic and recurring problem. Options for treatment involve suppressing menstruation as much as possible. This can be accomplished with extended-cycle contraceptives (such as birth control pills that cause periods to occur only every 3 months or less), progestin containing IUD, contraceptive injection, Orilissa (a medication that creates a temporary menopausal state to avoid hormonal stimulation of the endometriosis implants), surgical ablation or excision using laparoscopy, and hysterectomy.

Pregnancy is an important part of the lives of many women, and becoming pregnant can be challenging for many couples. Your chances of a healthy pregnancy start before conception. Pre-pregnancy testing involves screening for medical problems and optimizing control of illnesses such as diabetes and hypertension. A woman who is actively trying to conceive should be counseled on medications and foods to avoid. A healthy lifestyle can increase the chances of conception. Daily folic acid intake is important prior to and during pregnancy. An infertility workup can be initiated in women who have been trying to conceive for more than a year without success or who have suffered recurrent miscarriage. Irregular cycles with missed periods are a sign that ovulation is not occurring regularly and should be evaluated in women trying to become pregnant. Male fertility can be evaluated with a semen analysis. The female infertility workup is more complex and involves hormonal lab testing, pelvic ultrasound, a specialized x-ray called a hysterosalpingogram, which evaluates whether the fallopian tubes are functional, and sometimes diagnostic laparoscopy if endometriosis or other pelvic abnormalities are suspected.