What Everyone Needs to Know about Vitamin D
Rachel Spieldoch, MD
We all know Vitamin D is important for ongoing bone health. However, most of us are unaware of the many benefits vitamin D has in our bodies. And many of us are frustrated trying to figure out exactly how much vitamin D is enough and how much is too much.
Vitamin D is produced by the skin in the form of vitamin D3. It can also be ingested in the form of vitamin D3 or vitamin D2. This is further metabolized by the liver into the biologically active form 25-OH vitamin D which can be measured with a simple blood test.
Severe vitamin D deficiency can result in calcium malabsorption, hyperparathyroidism, bone loss, and increased risk for fracture. Muscle pain and bone pain can also occur with severe deficiencies. Interestingly, obesity and women of color are risk factors for vitamin D deficiency. Other risk factors include decreased sun exposure, regular use of sunscreen, low dietary intake of vitamin D, liver disease, anti-seizure medications, and osteoporosis or osteopenia. It is important that women with specific risk factors or a previously low level of vitamin D have their levels tested by a physician. Additionally, blood testing of parathyroid hormone as well as calcium may be helpful in select patients.
Current studies show that at least 30% of U.S. adults age 20 or older have vitamin D deficiency. Additionally, vitamin D supplementation of at least 400 IU /day has been associated with a decreased risk for vertebral, nonvertebral and hip fractures.
Observational studies show that vitamin D deficiency may be linked to cardiovascular disease, cancer, diabetes and autoimmune disorders. Additionally, smaller studies suggest that vitamin D deficiency may be linked to breast cancer and melanoma.
Is it possible to get too much Vitamin D? The answer to this is yes. Surprisingly, too much vitamin D has been associated with a higher risk of fracture! Additionally, observational studies suggest that elevated vitamin D levels may be associated with pancreatic cancer and cardiovascular disease.
According to the Institute of Medicine report from 2010, the recommended dose of vitamin D supplementation for healthy adult women up to age 70 y/o is 600 IU/day. After the age of 70, the recommended dose increases to 800- 1000 IU/day. This is the recommended dose for women not receiving any direct sun exposure. If your vitamin D level is low or you have other risk factors, the medical recommendation may differ.
Achieving optimal benefits from vitamin D involves maintaining a balance. It is important to be mindful that too much vitamin D can carry health risks. However, appropriate supplementation and blood levels appear to have profound impacts on preventing disease and maintaining healthy bones.
Congratulations to Dr. Spieldoch!
Rachel Spieldoch, MD and Scottsdale Healthcare have earned the AAGL Center of Excellence in Minimally Invasive Gynecology (COEMIG) designation in July 2013.
The COEMIG program is focused on improving the safety and quality of gynecology patient care and lowering overall costs associated with successful treatment. The program is designed to expand patient awareness of – and access to – minimally invasive gynecologic procedures performed by surgeons and facilities that have demonstrated excellence in these advanced techniques. To earn the COEMIG designation, surgeons and hospitals must partner together and demonstrate a cross-organizational commitment to minimally invasive gynecologic surgical care.
The COEMIG program recognizes surgeons and facilities that demonstrate an unparalleled commitment and ability to consistently deliver safe, effective, evidence-based care.
Earning the Center of Excellence designation signifies our ability to consistently deliver the safest, highest-quality of care to minimally invasive gynecology surgery patients
-Rachel Spieldoch, MD
But most importantly, Dr. Spieldoch believes that her commitment to excellence along with Scottsdale Healthcare improves the health and well-being of our patients.
AAGL Center of Excellence in Minimally Invasive Gynecology, COEMIG™ and the COEMIG™ seal are trademarks of the AAGL. All rights reserved.
Great News About Bioidentical Hormone Pellets
Time released bioidentical hormone pellets have become a popular and successful option for many women suffering from menopausal symptoms such as hot flashes, sleeplessness, vaginal dryness, fatigue and low libido. Not only are bioidentical pellets extremely convenient to the patient, but they offer a slow release of hormones to the body for sustained hormonal benefits. Additionally, many women who have not responded optimally to conventional hormone treatments will feel a sense of renewed vitality from the bioidentical hormone pellets.
However, the cost burden of hormone pellets has been a frustration for many patients who would otherwise benefit from hormone pellets. In an effort to accommodate to patient financial concerns and alleviate some of the cost burdens of hormone pellets, Dr. Spieldoch at McDowell Mountain Gynecology will be billing the insurance company for the costs of the insertion. The patient will remain responsible for the material costs of the hormone pellets.
Ultimately, this means significantly less cost to the patient!
Please ask if you have further questions. I sincerely hope that this helps our patients with their hormonal needs and makes hormone pellets more affordable.
The Q&A’s about Atrophic Vaginitis
What is Atrophic Vaginitis, and what causes it?
Atrophic vaginitis occurs when vaginal tissues thin out and lose elasticity due to the loss of estrogen. This “loss” typically occurs shortly before and during menopause (When menstruation subsides) or after surgical removal of the ovaries. The major estrogen found in women, estradiol, is produced by the ovaries during childbearing years. As ovarian estrogen production slows – symptoms of menopause, including genital or urinary symptoms, may occur.
What are the symptoms?
About 50% of menopausal women will begin to have symptoms of Atrophic Vaginitis within 2-3 years of menopause. Those symptoms may include: vaginal dryness, painful intercourse, vaginal itching, and abnormal vaginal discharge. Also, women may experience urinary symptoms such as painful urination, urinary urgency or frequency of urination. Some women report urinary incontinence or increased urinary tract infections.
How is it treated?
Vaginal estrogen appears to be the most effective treatment for Atrophic Vaginitis. About 90% of patients will have improvement of their symptoms within 3 weeks of initiating treatment. It is important to note that women, who are taking other forms of hormones for menopause, may still experience Atrophic Vaginitis; these women may benefit from addition of vaginal estrogen. Vaginal preparations are available such as conjugated equine estrogens, estradiol or estrone. Synthetic and bio-identical preparations are available. Vaginal estrogen may be delivered via cream, tablet, ring, or pessary.
What are the risks and side-effects?
Vaginal estrogen may have the following rare side effects: vulvar itching or irritation, vaginal discharge, and vaginal bleeding; however, a switch to a different dosage or preparation may reduce or eliminate these problems. Abnormal uterine bleeding has not been shown in studies to be related to the use of vaginal estrogen. Studies show that vaginal estrogen appears to be a safe option for women who have had breast cancer. If you have cancer, you should discuss this with your healthcare provider.
What are some other treatments for Atrophic Vaginitis?
Other treatments include: water soluble lubricants, DHEA, Vitamin E suppositories and herbal preparations such as black cohosh, soy and red clover. Many of the herbal preparations contain plant estrogens thus they may have similar risks as other forms of vaginal estrogen.
Call McDowell Mountain Gynecology at 480-483-9011 and make an appointment with Jill Antell if you are experiencing vaginal dryness and would like to discuss treatment options.
What is all this talk about Robotic Surgery?
Rachel Spieldoch, MD
Surprisingly, nearly two thirds of hysterectomies are still performed in America with open laparotomies. However, it has been proven through multiple studies that minimally invasive surgery with laparoscopy has been shown associated with a faster recovery, lower infection rates, shorter hospitalization stay, decreased blood loss as well as significantly less postoperative pain when compared to traditional abdominal surgery.
In gynecology, laparoscopy has become a valuable tool for performing multiple surgeries including: hysterectomy, ovarian surgery, myomectomy (uterine fibroid removal), endometriosis, and pelvic floor procedures for vaginal prolapse. It has additionally become an adjunct for many surgeries in reproductive endocrinology and infertility as well as in gynecologic oncology. While laparoscopy has many indications in gynecologic surgery, there are limitations which include restrained instrument motion and dexterity, the use of 2-dimensional visualization, as well as significant surgeon fatigue related to ergonomically unfavorable positioning.
The da Vinci robotic system was approved in 2005 by the Food and Drug Administration and has revolutionized minimally invasive surgery. Robotic assisted laparoscopic surgery overcomes many of the limitations found with traditional laparoscopy. This allows for more complex surgical cases to be performed with minimally invasive surgery. In fact, removal of fibroids with robotic surgery allows for removal of larger fibroids and been shown to have even less blood loss than when performed with traditional laparoscopy.
The da Vinci robotic system is comprised of three components. The first component is the surgeon’s console which is located near the patient bedside. The surgeon is seated at the console and controls the robot assisted tools which include the camera and all surgical instruments. The second component is the called the patient-side robot. The surgical instruments are attached to the patient side-robot which are placed carefully within the operative field. Third, the vision cart allows for 3-dimensional imaging. Finally, a surgical assistant is at the patient’s side throughout the procedure for additional aid. In order for all components of the da Vinci robotic system to orchestrate, a well-trained surgical team is required.
As with any surgical advancement and technique, it is crucial to balance available technology with its indications for use and potential advantages. The da Vinci robotic system offers instruments which have full dexterity and range of motion. The 3-dimensional visualization and the ability to quickly zoom into small areas allows for precise tissue manipulation in challenging surgical spaces. This is unique to robotic surgery. As a result, the robotic instruments are superior for delicate tissue manipulation and dissection. This may be of particular use in patients who have had scarring from previous surgeries, endometriosis, malignancy, uterine fibroids or other similar situations. These advancements with robotic surgery gives experienced surgeons the opportunity to offer patients minimally invasive surgery which in any other circumstance would require an open laparotomy and large abdominal incision.
From the surgeon’s perspective, the robotic system also allows the operator to sit comfortably at a console. This helps to avoid physician fatigue due to standing for long hours in uncomfortable positions. Furthermore, the capabilities of the robotic system are astounding with regards to medical communication and teaching! Imaging, such as a recent CT scan or MRI can be seen on the surgeon’s console. This may be helpful when trying to precisely locate an abnormal finding such as uterine fibroids. Additionally, the system allows specialists who are long distances away from the actual surgery to watch the procedure and communicate with the operating surgeon. This aids in providing up-to-date techniques and improved patient care.
It is important that patients consult with their physician regarding the best surgical method to deal with their medical concerns. While minimally invasive robotic surgery has many advantages, it may not be the most appropriate surgical option for everyone. However, one thing is for sure, robotic surgery is continually offering exciting advancements to minimally invasive surgery and it is here to stay!
Evaluation of an Ovarian Cyst
Rachel Spieldoch, MD
One of the most frightening gynecologic malignancies for women is ovarian cancer. While it only affects about 1.7% of the general population, once detected it is often lethal. Early detection of ovarian cancer remains an ongoing challenge for healthcare providers. Many women suffer from recurring ovarian cysts or a significant family history of gynecologic cancers. Even in today’s world of technology, it remains very difficult to screen and diagnose ovarian cancer. Ovarian masses are seen frequently in gynecology. While most represent benign disease, it is important not to miss the premalignant and malignant disease processes.
At this time, there is no “gold standard” screening test for ovarian cancer. Furthermore, symptoms associated with ovarian disease can be vague ranging from bloating or loss of appetite to pain and generalized malaise. There are several known risk factors for ovarian cancer. Age is the most important independent risk factor. The incidence and mortality increase sharply after menopause. The average age for an epithelial ovarian cancer is 60 years old. Up to 10% of ovarian cancers are associated with a genetic mutation such as BRCA1, BRCA2 and Lynch syndrome. Having a known genetic mutation can increase a woman’s risk by 10-45%. Without genetic testing, a strong family history is important for assessing risk. Other risk factors include women who have not had children, early onset of periods, and late menopause. Infertility also seems to have an association with increased risk.
Clinical history and physical exam are always instrumental in effective evaluation. Once this has been performed, pelvic ultrasound is most frequently used to evaluate uterine and adnexal structures. If a patient has been found to have a complex mass or concerning finding, 3D-ultrasound and/or MRI may be helpful. Gynecologic expertise in assessing ovarian masses in relation to clinical evaluation and radiologic findings are very important.
Several blood tests may also be helpful in evaluation. A serum CA-125 is the most widespread blood test used for assessing ovarian disease. However, CA-125 is far from a perfect screening test. The CA-125 is also expressed in many benign and normal female conditions, especially in a premenopausal female. There are many false positives with this test. Furthermore, the CA-125 is only elevated in 50% of early epithelial ovarian cancers and is not elevated at all with other types of less common ovarian malignancies. The OVA-1 test is another blood test which evaluates several serum protein markers that are elevated with ovarian cancer. This test is to be used in addition to complete evaluation for a woman with highly concerning lesions. Additionally, this test is very costly and should not be used for routine screening.
Thus, it remains important for the clinician to distinguish between low, intermediate and high risk ovarian masses. Often, serial repeat ultrasounds and CA-125 levels are used for evaluation of an ovarian mass over a given period of time. If there is interval change or other reasons for concern, surgical intervention may be indicated. Even for benign disease, surgical intervention may be indicated due to pain, mass size, interval growth, risks for ovarian torsion and cyst rupture. Please consult with your doctor if you are having new symptoms or radiologic findings suggestive of ovarian or adnexal disease.
August 2011 Newsletter
Buzz about Breast Cancer Blood Test (BT test)
Rachel Spieldoch, MD
Currently one in every eight women will be diagnosed with breast cancer during her lifetime. Some women may have a genetic disposition such as BRCA1 or BRCA2 but these genetically inherited breast cancers only account for 5-10% of those diagnosed. While mammography is the current gold standard for screening, it is not a perfect test. This may be due to several limitations including differences in breast tissue among women, varied machines, technician and radiologist variability as well as the ability for cancerous cells to present differently in women. Many breast cancers are detected only after they are significantly too advanced for cure. We know that with early detection, breast cancer has a 97% survivability rate.
Many patients have been asking about the new BT test being offered in our clinic for breast cancer. The BT test is formally called a biomarker translation test. It is a multivariate blood-based multi-protein biomarker analysis for the detection of breast cancer. What does this mean? This test essentially looks at several different cancer specific proteins which have been known to have an association with breast cancer. These proteins are associated with many different functions including blood vessel growth, cell death, tumor growth, and inflammation, and immune system responses. Their levels become abnormally expressed with cancer growth.
A recent study for the BT test looked at the validity of the test in diagnosing the risk for breast cancer. The study evaluated women younger than 50 years old and women older than 50 years old. The BT test had a 97% accuracy in women less than 50 years old and an 86% accuracy in women over 50 years old. The BT test has a lower sensitivity and specificity in women over 50 years old. This means that there are more false negative results and false positive results in this age group when compared to women younger than 50 years old. However, the diagnostic usefulness of this test is very impressive.
All women are candidates for the BT test and it is recommended prior to mammography. It is particularly helpful for women with known fibrocystic disease, a family history or known genetic disposition, or a history of increased risk exposure such as prior radiation. Additionally, women with inconclusive mammogram results will benefit from BT testing.
Because this is a relatively new test with limited studies available, it is not indicated to take the place of current mammography. However, the BT test is a very innovative new tool for evaluation. The data is very exciting and suggests that a BT test when used in conjunction with mammography may significantly improve the ability to detect early breast cancer. This in turn, may ultimately decrease the amount of unnecessary breast biopsies as well as allow for women to undergo less invasive surgeries for early disease. Most importantly by detecting breast cancer early, the BT test may ultimately save the lives!