By Michele Conklin, Author/Writer Grow Magazine

Dr. Jerath was interviewed regarding this topic and this article was originally published in the Spring 2010 issue of Grow, a health publication from Parker Adventist Hospital. 

Approximately one in 10 pregnant women take some sort of  herbal product, potentially risking the health of their pregnancies and babies, according to a study recently published in the American Journal of Obstetrics and Gynecology. 

"Women tend to think that herbal products are safe because they are natural, but there are many that can cause miscarriage, premature birth or fetal defects," says Vandna Jerath, M.D., an obstetrician with Parker Adventist Hospital. 

Herbs have limited regulation and inconsistent standards of purity and quality.  Women should be cautious in using herbs while pregnant and up to three months prior to becoming pregnant, Jerath says. 

 

Typically, herbs that can be eaten in their original plant form or as a vegetable--rather than as concentrated pills, extracts or tonics--are likely safe. Herbs used in small amounts for cooking or seasoning are generally safe.  

 

Very few herbs taken as supplements are considered safe during pregnancy, Jerath says. Some that are likely considered safe—in specific forms--are:

• Peppermint leaf - Helpful in relieving nausea/morning sickness and flatulence
• Ginger root - Helps relieve nausea and vomiting
• Slippery elm bark - Used to help relieve nausea, heartburn, and vaginal irritations (likely safe when the inner bark is taken orally in amounts used in foods)
• Oats & oat straw - Rich in calcium and magnesium; helps relieve anxiety, restlessness, and irritated skin
• Red raspberry leaf – Rich in iron and considered a safe herbal tea when used in the second and third trimester.  Can ease labor pains and increase milk production.

If you're pregnant, always check with your doctor prior to taking an herb. You also can find information online at the National Institutes of Health’s medlineplus.gov.

www.optimawomenshealthcare.com

By Vandna Jerath, MD

To pap or not to pap . . . that is the question?  Cervical cytology also known as the pap smear is the primary reason for a 50% decrease in the incidence of cervical cancer over the past 30 years.  For years we as ob/gyn doctors have been taught to do pap tests early and often. Well, really to do them at least yearly or more often if the patient was high risk.  We were also advised to do them within three years of our adolescent patient becoming sexually active or by age 18-21; whichever came first.  Now, the rules and recommendations have changed . . . and yes, it’s confusing.

ACOG – American College of Obstetricians and Gynecologists of which I am a fellow and consists of over 50,000 of my colleagues came out with some new guidelines for cervical cancer screening in November 2009.  These recommendations came on the heels of the controversial new mammography screening guidelines.  Although, it may seem that these guidelines were highly restrictive in the pursuit of cancer, they were really meant to be more cost-effective and less invasive.  And if we take a deep breath and a step back the cervical cancer screening guidelines actually seem reasonable.

What’s new?  Well, there were three major changes in cervical cancer guidelines by ACOG:

1.       The age at which to start pap smears – should be age 21 regardless of sexual activity.

2.       The pap interval – for those ages 21-29 every two years and for those 30 and over up to every three years is appropriate if they have had three normal paps and are low-risk.  And for those who have had a benign hysterectomy, are low risk and have had three normal paps, routine paps may be discontinued.

3.       The age at which to stop pap smears - seems to be by age 65-70.  Provided that the patient is low-risk and had normal pap smears for the past 10 years, discontinuing pap smears at this age is adequate.

None of these guidelines are meant to replace the annual well woman exam which may still be performed without a pap smear.  The annual exam is still typically required and recommended for a variety reasons.  These reasons may included a woman’s general well-being, family planning, counseling for sexually transmitted diseases/infections (STDs/STIs),  to refill birth control or hormone prescriptions, follow-up on breast examinations, check blood pressure, evaluate pelvic anatomy, and address other gyn conditions.

Cervical cancer occurs in approximately 11,000 women annually in the U.S. and accounts for approximately 4,000 deaths each year.  Risk factors for cervical cancer include early onset of sexual activity, increased number of sexual partners, history of STDs/STIs, high risk HPV, history of abnormal pap smears with moderate or severe dysplasia (pre-cancerous changes of the cervix), smoking, HIV or immunocompromised patients, diethylstilbestrol (DES) exposure, poor nutritional status, obesity, teen pregnancy, low income, and in some cases family history.  Cervical cancer is most common between the ages of 40-55.  Cervical cancer by nature is slow growing and occurs over the course of many years.  It is typically diagnosed in women who have not ever had a pap smear or have not had one within the past five years.

Over 95% cervical cancers are caused by a high risk form of HPV – Human Papilloma Virus and 75% of all sexually active adults will have had some form of HPV in their lifetime.  Also, HPV infection is more common after the onset of sexual activity and more prevalent in the adolescent population.  However, these young women’s immune systems will clear 60-70% of the infections in one year and up to 90% by two years.  Meaning most of these new infections will regress and be unlikely to cause cervical cancer.  The incidence of cervical cancer under the age of 21 is about 1 in 1,000,000.   

So, it makes sense to perhaps wait and test these teens as young adults rather than when they first become sexually active as most will have fought off their HPV infection and lowered their risk for cervical cancer.  If they are tested earlier they are likely to have significantly abnormal pap smears which will result in further testing and procedures that are both invasive and can be harmful to their future fertility.  These procedures can increase their risk factors for incompetent cervix, cervical scarring, cesarean section and preterm birth in the future.

Although HPV can cause pre-cancerous changes and lead to cervical cancer, it does not do so quickly.  Cervical cancer is a slow growing cancer and the disease process takes many years to develop so the two-three year interval on pap smears in a low-risk population seems reasonable. 

As for stopping pap smears altogether on those who have had a hysterectomy or are over 65-70 years, well, I struggle with this guideline the most.  Logically and statistically, I get it and understand why this guideline has been recommended, but anecdotal evidence speaks to me as I have had several patients with either vulvar or vaginal cancer over the years.  It also concerns me that this might possibly be the population that may skip their “annual” exams if no pap smear is needed which may lead to inadequate overall care of the patient.  It may not be cost-effective to perform a pap and highly unlikely that these patients are at risk for cancer, but I do feel this is an informed decision that the patient will need to make in conjunction with her doctor.

There are still several factors which will ultimately impact these cervical cancer guidelines.  One is the use of the HPV vaccines, Gardasil or Cevarix.  Gardasil is FDA recommended for girls ages 11 and 12 and approved for girls/women ages 9-26.  It has also recently been FDA approved for boys/men as well.  Gardasil has been tested extensively and approximately 40 million girls/women worldwide have been vaccinated.  It is considered safe and protective against HPV types 16 & 18 which are the cause of 70% of cervical cancer and types 6 & 11 which are the cause of 90% of genital warts.  Cervarix has been distributed to about 7 million girls/women worldwide and is FDA approved for ages 10-25.  Ideally, either vaccine should be given prior to onset of sexual activity and is thus, most protective.  Some protective benefits may occur in previously sexually active women if they are not already infected with HPV or these particular types of HPV as well.  Studies are underway to test the benefits, if any, of the HPV vaccine in women older than 26 years of age.  The full impact of the HPV vaccine on cervical cancer will likely not be known for 15 years, but for now vaccinated women will still follow the same new screening guidelines.

Another question that remains is whether to do HPV tests on all patients.  Most of us use HPV testing in patients with abnormal pap smears, mainly ASCUS, but the benefits of using it routinely remains to be seen and is still uncertain.  ACOG recommends that HPV testing not be done on patients under 30 years of age due to the high likelihood of transient positive results.  But, HPV testing may be done as co-testing along with a pap on those low risk patients over 30 years old.  And if the pap and HPV testing are both negative, ACOG advises that the patient not be rescreened prior to three years.

Now, back to the original question – to pap or not to pap?  Cervical cancer, although slow growing, can be a deadly disease and must be taken seriously.  The new guidelines and decreased intervals of pap smears may be adequate to diagnose cervical cancer, but both the doctor and patient must feel comfortable.  For a low risk patient, it is important that the doctor communicates these changes and discusses these guidelines with the patient and involves her in the process and course of action.  Although reasonable, these screening guidelines must be individualized based upon the patient’s history and needs and discussed with her.  Additionally, it is essential that each woman still undergo a well-woman annual exam with or without a pap smear for her overall health and wellness.

 

Vandna Jerath, MD

Optima Women's Healthcare

www.optimawomenshealthcare.com

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By Vandna Jerath, MD

I believe the doctor-patient relationship is about being a team.  It is only through teamwork and the sanctity of that bond that we can achieve success.  I define that success as empowered healthcare that leads to a positive outcome for you. That outcome may include alleviating fear and anxiety, resolution of symptoms, improvement of any condition, a cure of a disease, definitive surgery, becoming pregnant, or birth of a baby. I believe my role is to recognize your condition and needs and provide you with knowledge, experience, resources, and options.  It is not only an inherent right, but also a necessity that every patient should be actively involved and educated regarding her healthcare condition, options, and treatment plan. I also firmly believe that once a patient is provided with this knowledge, she maintains the autonomy to make her decisions regarding the course of her healthcare.  I do not believe it is my duty or purpose to make a decision for you, but simply to communicate effectively, empower you with knowledge and expertise (based upon my education and experience), maintain empathy and compassion for your individual needs, guide you down the best path possible, and ultimately respect your choice and wishes.  In this capacity the doctor-patient relationship leads to not only success, but also fulfillment and contentment for us both.

Many doctors have been burdened by overwhelming numbers of patients, rising malpractice costs, challenges of running a medical practice,and sleep deprivation that they have forgotten why they went into medicine.  The essence of our fulfillment comes from the doctor-patient relationship. My best days are those where I see patients who are amazing women, havethe opportunity to help them with their healthcare challenges and personal struggles, and reap the benefits of their life experiences and gratitude.  Sure - not every day is like this, but when the day is like this, it is truly AMAZING and I only look forward to the next day with renewed hope and optimism.

I have so many wonderful memories and experiences from my past eleven years in practice and have learned so much from my patients.  It is through them that I gained knowledge, experience, wisdom, strength, insight and friendship over the years.  As I was closing up my practice in Westminster, CO, several patients sent me notes or came to visit to give me a personal thank you and hug.  Several shared with me what a lasting impact I have had on their life.  Those gestures were not only appreciated, but will be treasured.  Some of my favorite patients (yes – we do have favorites) have pledged to continue their care with me in Parker, CO and in some cases may drive over an hour to see me.  I am truly honored and humbled by theircommitment to me and confidence in me. It is this type of doctor-patient bond that transcends any frustrations or challenges in medicine and makes it all worth it! 

I look forward to opening my new practice in January 2010 to continue my current doctor-patient relationships as well as to develop new ones.

 

Vandna Jerath, MD

Ob/Gyn Physician

www.optimawomenshealthcare.com

 

 

By Vandna Jerath, MD

WELCOME!

I'm an obstetrician/gynecologist and  as I develop my new ob/gyn practice in Parker, Colorado I thought I would take some time to write about current or relative topics that impact women's healthcare.   

I was in private practice for 11 years in Westminster, Colorado and decided to make a monumental change by relocating to Parker, CO.  Why did I make this move?  Well, for many reasons and like most doctors it is harder and harder to  make a reasonable living while adequately caring for patients in a  safe, positive, technically advanced, compassionate, and thriving environment.  I felt that this transition would offer a better path for these conditions and opportunities as well as provide better momentum, growth, and sustainability. 

I'll be back soon to begin talking about some important topics in women's health, medicine, and  healthcare reform today!  Thanks!

Vandna Jerath MD
www.optimawomenshealthcare.com