San Diego Health: Ages and Stages of Women’s Health


(pleasant music) – Hi, I’m Susan Taylor with Scripps Health in San Diego, California. Okay, let’s face it, us women, we’re complicated. Our bodies are very complex and go through all kinds of
changes during our lifetime. Some major changes, some subtle changes. From the onset of
adolescence, giving birth, through menopause and beyond. Here talk to about the ages
and stages of women’s health, is Dr. Dale Mitchell, he is
the Chairman of the Department of Obstetrics and Gynecology, for Scripps Clinic in
La Jolla, California. Thanks so much for being with us. – My pleasure. – If you could laundry list them for us, what are the top four
stages of women’s health? – Well, as obstetricians
and gynecologists, I mean, we see newborn girls at birth, and then we kind of pass them off. Our next exposure is usually
late teens, adolescence, into mid-20’s, what I would
consider pre-conception times. – Pre-birth, uh-huh. (Susan laughs) – We take mothers through
their reproductive years, which nowadays, 25 to
even early to mid-40’s. From mid-40’s to 50, the
time leading up to menopause, and then, from 50 on, after menopause. – So, we’ll go back and
delve back into this a little bit more deeply,
each one of these stages. But, how should women
approach these stages? – Well, I think it’s individualized, and depends on the woman,
of course, and their needs. But, as OBGYN’s, you know, we start to get involved
in those late teens, early 20 years, for a number of reasons. I mean, probably, most importantly is to give education on
safe sex, birth control, and probably most importantly, vaccination for HPV, which
is the most common STD. – STD is a sexually transmitted disease.
– Sexually transmitted disease What’s the difference
between an STD and an STI, sexually transmitted infection? – Just, different terminology. – Okay. – But, just takes in that broad spectrum of bacteria and viruses, basically. – So, in 20’s and 30’s you’re
focusing on contraception. What type of birth control
options do women have now? – There’s quite a few out there. You know, the women that
tend to come to see us, tend to be certainly more proactive and want something convenient. So, we initially have conversations, and look at risk factors. But, in general the majority
of the younger women are gonna be healthy and appropriate, for any form of birth control. So, we usually divide it into hormonal birth controls
versus non-hormonal. The non-hormonal are fairly limited. Usually it’s some combination
of natural family planning, trying to predict when a woman’s fertile. And then, maybe using
barriers like condoms. For women that maybe use no birth control, there is the morning after
pill, which is available. The hormone contraceptives, we have a quite a bit of options, now. So, we tend to ask questions about how long do they need birth control, do they need something reversible, how convenient do they want to have it, what side-effect profile
are they looking at. So, everyone knows about
birth control pills, which have been around a long time. So, that’s usually a good starting point. – They’re a lot safer now then
they were 25, 30 years ago. – They are, the dosages have
come down significantly. They’re very safe for the
general population, in general. In addition to birth control pills now, we have things like the
birth control patch, which is worn on the skin, changed weekly. There’s a really neat product that came out of Europe
for quite a few years, called NuvaRings. A vaginal ring that’s
just placed in vaginally, by the woman, once a month. We have an older method
called Depo Provera, which is an injection in
the arm every three months. We now have a new implantable device, that’s a little rod that
goes in like an I.V., under the skin of the arm,
lasts for up to three years. And then, the IUDs have become
much more popular again. Especially, in our Gen-Z
and Millennials, so. – Technology is just
fascinating, isn’t it? – It is. – The evolution of it. And then, when you talk about pre-natal, peri-natal care, for high-risk pregnancies. That’s over what? What constitutes a high-risk pregnancy? – Well, high-risk pregnancies, you know, hopefully some of the factors can be determined prior to conception. So, we do advise women, that they’re planning to get pregnant, that it would be a good
idea to see an obstetrician in advance of conception. Look at risk factors, and discuss a plan of management, especially in the early pregnancy. One thing we like to talk about before conception now too, is to make sure they
institute pre-natal vitamins or a folic acid supplement, that reduces certain birth defect risk. And, also to see if they’re interested in doing what’s called, carrier screening. So, they can now be screened
through blood testing to see if they might carry
some of the more common autosome or recessive disorders. – Such as? – Things you may have heard
of like cystic fibrosis, Fragile X, spinal muscle atrophy. So we look at a panel that
might affect children, and offer this to women prior
to pregnancy, if possible. – And then also, what
about gestational diabetes? Talk a little bit about that. – Yeah, so once a woman
becomes pregnant, most of the risk factors are going
to be determined on how the pregnancy plays out. But some of the more
significant risk factors can be maternal obesity, can be a big problem. Maternal age can be a
problem, especially for 40 year olds and above,
we’ll see more problems. – Such as? – Well, you definitely see
that population’s going to have higher rates
of high blood pressure. They’re going to have more diabetes. They just in general might
tolerate pregnancy less well that the 20-something year old. They have a little higher
C-Section rates and things. So that population can be a
little bit more challenging. – And then, talk about in
the 20s and 30s, you also talk with women about
heavy periods, and also endometriosis, talk a
little bit about that. – Yeah, so that almost might
get into a little bit more of that group leading into menopause. So from the 40s to 50s,
it is not uncommon to see patients for complaints
of heavier periods, maybe more discomfort with periods, less predictable periods. And that population, some
of it can just do with hormone balance and
changes in their bodies, they’re getting a little bit older. But some of the more common
conditions that are benign are things like endometriosis
and fibroids another common thing that might
lead to issues like this in their 40s. – And then what other
screening tests should you have in your 40s and 50s? – Well, if we talk about
screening tests in general, for us, we recommend
cervical cancer screening, or pap smears, begin at age 20, 21. The current recommendations
are they should be done at least every three years from 21 to 30. And then we recommend
continuing screening from age 30 to 65, and that
screening interval should be three to five years. And that is now a combination
of both the pap smear plus screening for HPV,
or human papilloma virus. As far as other screening
tools, like breast cancer screening, that
has become a little more controversial for women
in their 40s, but as OBGYNs, we tend to be a
little more conservative. So I’m still recommending
a baseline mammogram around age 40. I would recommend, at least
every two years from 40 to 50. And then from 50 to 75,
I would recommend yearly screening. – And then talk about
the different types of breast cancer screening. I mean, I know that
there’s digital mammograms, and there’s this
tomosynthesis, and this is for women who have much denser breasts. – Yeah, so I think at
Scripps Health, at least, our radiology department,
for the most part, is 100% digital readings
on mammograms now, which is in addition
to just the radiologist reading the films, there’s
also kind of a cross-check with a digital imaging now. Tomosynthesis just means
you’re doing a standard mammogram, but taking many more pieces or pictures through the breasts. So for women with dense breast disease, maybe at higher risk for breast disease, this would be a good option for them. In general, women with
just dense breasts, and otherwise no risk factors,
they’re a harder group to know what to do with currently. My recommendation is
those women might consider bilateral breast ultrasound in conjunction with mammography once a year. And maybe even like a breast specialist to be part of their care. – And then also in your
40s and 50s, obviously there’s fertility issues,
but talk about also pelvic organ prolapse, what is that? – Yeah, okay. Pelvic organ prolapse,
typically is more common to happen in women that
have had vaginal births. Typically the more births they have, maybe the greater risk. The more difficult the
births have been, the more likely, the bigger the baby, okay? We also have some genetic predisposition. So you’ll see thinner,
fair skinned women tend to have smaller supporting
ligaments to begin with, so they might be at higher
risk than a heavier set dark skinned person. But in general – So what happens when
you have the prolapse, what does that mean? – So there’s kind of three
components to the vaginal canal. We’re talking about
basically the vaginal canal is dropping or coming down,
or even sometimes coming out. So you have an anterior
compartment, which is kind of the support for the bladder base. A posterior compartment,
which is really the rectal. And then there’s the uterus
and cervix itself, for the upper portion of the vagina. So any or all three of
those organs can actually be coming down. – And what are the symptoms of that? – It can vary quite a bit. Sometimes we just pick it
up on pelvic examination. But patients that come
in symptomatic, the most common complaint is that they just feel a heaviness, a fullness. They might literally feel
something coming out. It can sometimes interfere with
comfort during intercourse. – And then in your 60s and
70s, what are the issues that you deal with? – Again, these are women
post-menopause, of course. And maybe many of the issues
a gynecologist might deal with have already started to occur in the 50s. So menopausal symptoms like
hot flashes, mood changes, vaginal dryness. These are all things that
typically come up from the early 50s into the
early 60s, and the most probably common reason why
they come to the gynecologist for care for those things. But we continue to see women, like I said, pelvic examination, pap
smear is still recommended to be done into the mid
60s and older, depending on sexual activity. We also feel we do a
good job of screening for cervical or pelvic or gynecologic cancers, so pelvic examination is still important. – And then what about
also bone density, and dementia, and heart issues and cancer? – Yeah, so most of our
patients, I think by the time they get to their mid
50s into their early 60s, my recommendation is
they probably should also have an internal medicine
specialist, be seeing them as part of their annual physical exam. Many women will start to
transition to an internist versus an OBGYN at that age as well. Obviously they get involved in this type of screening as well. We remind them in their
early 50s to consider colonoscopies, baseline
screening examination. Bone density studies
have also become a little more controversial, but I
recommend them now when a woman has either been in menopause
for 10 years or longer, or by her early 60s, okay? Other than that, it would
be women with, maybe just risk factors. So if there’s a strong family
history of osteoporosis, if a woman has to be on
chronic steroid use, there are several risk factors,
might increase the risk of osteoporosis. – So hold this thought, we’re
going to come back to this. I know there’s all kinds
of attitudes regarding hormone replacement
therapy after you’ve gone through menopause. And I know that there have
been news articles about hormone replacement therapy
maybe increasing risk of cancer, so hold that thought. We’ll come back to that in
just a couple of minutes. You are a big advocate of
minimally invasive gynecologic surgery. Can you explain what
that is and what are the advantages of it? – So MIS or minimally invasive
surgery takes in a big portion of surgical
interventions these days. But the most common thing
for us, gynecologists were actually pioneers in
minimally invasive surgery back in the 50s, when
laparoscopy first came into play, gynecologists were the first
people to adopt these things. And we have continued
to be the trendsetters, honestly for minimally invasive disease. – When you say laparoscopy,
what do you mean by that? – So these are surgeries
that are done through very small incisions in the abdominal wall. Typically a camera’s put
in at the belly button, and then there might be
several other very small ports to actually put instruments
in to work in the pelvis. – So it’s not cutting
the entire abdomen open? – Right, correct. – So way less invasive? – Way less invasive. – Faster healing? – Faster healing, faster
time back to activity, work. Lower complication rates,
less time in the hospital, and markedly less pain. – And getting back into that bathing suit – You got it. – Without a big scar. – Absolutely! – Talk about infertility treatments. What’s available out there? – So that should, of course,
be tailored to the couple, of course. And I treat people different
based upon their age group. I’m certainly going to treat
my 20 year old a little bit different than my 40 year old. So if a 20 year old comes in,
typically without risk factors most of us recommend that
they continue trying for up to a year even before
any intervention is done. If I have a 40 year old
who’s getting towards the end of reproductive age group,
I might take that down to three months or four months
and say, “You know, hey, let’s think about this earlier.” So basic testing typically
involves semen analysis from the spouse. And then some basic
fertility testing includes lab function to look at ovarian function, ultrasound to look at the pelvic anatomy, consideration of injecting
dye into the uterus to make sure that the
fallopian tubes are open. And that entails a good
part of the basic workup. I’d say probably 80% of
the time, just through that simple testing, we can identify something. About half the time it’s a male factor, half the time it’s on the woman’s side. And there are things, obviously,
we can do at that point. For those 20% that we can’t
figure it out at that point, those are the people that
are usually referred on to a reproductive endocrinologist or a fertility sub-specialist. And their main focus these
days is to consider like direct intra-uterine semination
or in-vitro fertilization, where they harvest eggs and
they create embryos in the lab, and put them back into the uterus. – What’s the success rate
of in-vitro fertilization these days? – Depends a lot on your population. So the younger the woman,
the healthier the woman, the higher the chance of success. Once you get into the mid-40s
or later, success rates have now gone down very significantly. There’s a couple simple
tests that are usually done early in the cycle to
assess ovarian function. So we do a test called
follicle stimulating hormone, and something called
anti-mullerian hormone testing. It’s usually done around
day two, three, or four of a cycle. If those labs are normal,
it predicts a very good chance of success with egg
stimulation harvesting. If those numbers are not
good, a much lower rate of success. So that’s why we use our
fertility sub-specialists to determine what’s best for that individual patient or couple. – And what about sterilization? Who gets it and why? – Yeah, I think with all
the methods of birth control we talked a little about
before, sterilization is becoming less common. But when you look at those
couples that know they’ve completed childbearing,
absolutely sure they don’t ever want to be
pregnant again, sterilization is certainly worth discussing. And in the general population,
about half the time males will do it, half the
time females will do it. For the men, it’s vasectomy. For women it’s some type of
tubal blockage, still most common is the tubal
ligation, which is also done through that small
laparoscopic type surgery. – And then go, let’s fast
forward to menopause. You know, women are told,
“Oh, you’re going to be soaking yourself all day long.” “And you won’t be able to sleep.” “And you’re going to have
all these crazy symptoms.” Does that happen for every
woman, or is that kind of a myth out there? I mean, how does menopause
usually present itself? – You know, I tell my patients
it can present from the lucky person who the only
thing that changes is their periods stop, to the
worst where a woman is just miserable with these hot
flashes and other symptoms. The majority of patients
are going to be within those two extremes. There’s a familial
predisposition, so you’ll see if the patient’s mother
had a lot of trouble, they’re more likely to. And for the patients who
start to have symptoms in those years leading up
to menopause, if they’re starting to have symptoms,
they’re typically going to have a little bit more severe symptoms. – So there really is a genetic component? So if your mom went through
menopause and it was really horrible for her, chances
are how much greater that it’s not going to
be easy for you as well? – Yeah, whether it’s genetic
or expectations, I think that is part of it as well. Yeah, definitely, I think
that comes into play. – And what about osteoporosis? If your mom had osteoporosis,
are you more inclined to end up getting osteoporosis? – Yeah, I mean, you know,
most women, they take after their moms to some extent certainly. And there’s obviously genetics there. So if your mom is thinner,
fair skinned, and developed osteoporosis. Certainly, if you have
that same body habitas, you have a little more likelihood. Pre-emptive things you can
do are healthy lifestyle. So non-smoking, alcohol in
moderation, regular exercise, especially weight bearing,
calcium supplementation with vitamin D, and a lot
of it can be prevented by doing that. – All right, we referenced
this a couple of minutes ago. Let’s come back to it. Hormone replacement therapy
has been kind of controversial over the years. Why don’t you talk about what
exactly hormone replacement therapy is and what is the risk
for getting cancer from it? – Sure. So hormone replacement
therapy is, as it says, a hormone therapy for the
average woman that has a uterus in place, the
combination is usually of estrogen and progesterone. These are the same types of
hormones that are usually in birth control pills, but
different in that they’re more estrogen dominant. They’re meant to replace
what is starting to decline in production naturally in the body. Again, my recommendation
is that this should be very individualized, and
something that you should talk with your doctor about. But I do think for women
that are symptomatic, women that are really having
trouble with hot flushes, as a result insomnia,
fatigue the next day, difficulty getting
through their daily work. Those are people that
are usually very good candidates for it. And if you start hormone
therapy, in a typical woman who’s going to be in
her late 40s, early 50s, otherwise in good health,
I think it’s a great option for them. What we try to do is find
a program that has the lowest dose that’s
effective, and then we’ll continue it for as long as necessary. And for the average woman,
that will be several years. But by the time they get
into their late 50s, 60ish, often they’ll find they no
longer have symptoms and can discontinue therapy. – Is there a protection
that comes with hormone replacement therapy? Does it protect certain
organs in the body? – I think it’s controversial. I think it’s a symptom
reliever for the most part. We think that the down side
is that there’s a slight increased risk of breast
cancer as a result. Older women, that might have pre-existing cardio-vascular disease, it
might precipitate a blood clot, can cause heart attack, stroke. But again, for the
younger women it’s still a pretty safe option. – Okay. So we talked about this at the beginning. I just want to go back and
laundry list it so people can remember it. At what age and how often should
you start getting screened for things such as … ? So we’ll just go right
through the list, you tell me. Breast cancer, once again? – Age 40 – Age 40, and then how
often should you get tested? – I think every one to
two years in your 40s, and then 50 to 75, once a year. – And then bone density? – I think again, with risk
factors, you might start at any age, but for the
average woman, I’d say around 60. – And how often should you get it tested? – Depends on the initial test,
and again, your risk factors. Assuming your bone density’s
normal, every three years at that point. – HPV vaccine? – HPV vaccination, I would
highly recommend in early teenage years for both boys and girls. And that’s important to get
the boys vaccinated as well. The younger women, under
age 14 can actually get away with just two vaccines, two injections. The standard, of course, is three. So the younger women can
save one extra sore arm. But I highly recommend it
for any women at any age that’s sexually active. Most insurers will cover
it up until age 27, so you should try to get
it done before that age. – And the HPV vaccine
protects you from what? – Well, HPV stands for human
papilloma virus, again, it’s the most common STD out there. HPV can cause cervical disease,
including cervical cancer. It can also cause warts
of the genital tract. So current vaccine is
Gardasil Nine, it’s the newest thing on the market. And it has crossovers so it
prevents a lot of this disease, or even women exposed to
HPV, tend to clear it faster after they’ve been vaccinated. – How often should you get a pap test? – Pap test should begin at age 21. Every three years from 21 to 30. From 30 to 65, every three
to five years, depending on your preference. And then 65 and beyond would
be individualized based on need, but could be
discontinued for many women at that point. – And then a colorectal screening? – So colonoscopy for average
risk people, still 50 to 55, and good for 10 years. African-American women,
there’s some data saying they might want to take that
down to age 45 now. – Any other screening
that you should get on an annual basis, every couple of years? – No, I just think see
your doctor at least every one to two years. And again, for my patients
that get into their 60s and beyond, I usually
make sure they’re also seeing an internist in addition to OBGYN. – So the big takeaway from
all of this, Doctor, is what? What’s the baseline for
all of this, I guess? – You know, there’s many
stages to a woman’s life, as you said, it’s a complex organism. – Yes, we are! With pride. – I think based upon those
ages of preconception, times of reproduction, times
leading up to menopause, times after menopause,
a woman has markedly different needs. And I think be proactive
about your health. See your doctor on a regular basis. Don’t be afraid to bring
up any issue that’s important to you. So, be open. – No question is unimportant,
every question is important. – You got it. – Dr. Mitchell, thanks so
much for being with us. – My pleasure again. – We appreciate it. If you want more information
about women’s health, please click on the link,
or go to scripps.org/videos. If you want more critical
information about your health, we take care of you from
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to the Scripps Health YouTube Channel, or
follow us on social media, @scrippshealth. I’m Susan Taylor, thanks
so much for joining us. It’s our mission at Scripps
to help you heal, enhance, even save your life. (pleasant music)

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