A TEXAS TOP DOC GYNECOLOGY PROVIDER

• Preventing unintended pregnancy
• Decreasing cramping pain with periods
• Decreasing blood flow and clots during periods
• Decreasing risk for uterine and colon cancer
• Decreasing risk for ovarian cancer by up to 75%
• Helping with mood changes during the menstrual cycle
• Controlling the timing of cycles
• Decreasing facial and body acne

Risks of Birth Control Pills

• Increased risk of blood clots and stroke

Birth Control Pills

• do not cause or increase risk for breast cancer
• do not cause abortion
• prevent ovulation, when taken correctly
• do not prevent all cyst formation on ovaries
• do not encourage sexual activity

All birth control pills are similar. All do the same job, but different formulations may work better for some individuals. When starting birth control pills, you may experience nausea or abnormal bleeding during the first 3-6 months of use until your body gets used to the medication. If these symptoms do not resolve after 6 months, call our office and we can consider a different pill that will work better for you. If you skip a pill or take a pill late, you may experience breakthrough bleeding or bleeding in the middle of your cycle. This does not indicate an underlying problem and can be resolved by taking your pill at the same time each day.

Some women will not experience any periods at all during pill use. This is also very safe and represents a good balance of estrogen and progesterone to prevent period bleeding. However, if you have bled on a pill before and suddenly stop having periods, it is usually recommended you take a pregnancy test. All birth control pills can be safely used in a continuous manner for 3 to 4 months. This method of use would therefore produce a period only every 3 or 4 months.

To use the pill in a continuous manner do the following:
Start pill pack on day 1-3 of menses.
When you reach the green or inactive pills, do not take these pills.
Instead, start a new pack with an active pill.
You can do this for 3-4 months, thus inhibiting a period for that time.
After 3-4 months, then take the green pills for 5 days to stimulate a period.
Then, restart the process all over again.

Please note that there can be risks associated with taking any kind of hormone. For this reason, if we start you on a birth control prescription, the initial script will be for 3-4 cycles. We require a follow-up visit towards the end of this trial period, to ensure that the hormones we have prescribed are not having any adverse affect on your body, (ie: elevated blood pressure, headaches, etc). Once we verify your health and satisfaction, we will provide the script for the remainder of the year. If you are unhappy with your current pill, we can schedule you to come in and discuss all options available.

HORMONES/IUD

The simplest treatment is the use of hormones such as birth control pills or progesterone pills. However, many women are unable to use this option due to side effects or other medical conditions that inhibit hormonal use, as well as some women, do not want to take a birth control pill.

HYSTERECTOMY

A hysterectomy is the removal of the uterus and cervix but not necessarily the removal of the ovaries. da vinci Laparoscopic total Hysterectomy is the most common way that Dr. Jukes chooses to remove a patient’s uterus and cervix. This surgery usually takes 45-60 minutes to perform and you would stay in the hospital for 10-23 hours.

After a hysterectomy, you may never require another pap smear in the future, as long as you have never had a history of abnormal pap smears. The case for keeping the ovaries is that hormones produced by the ovaries help keep bones strong, prevent heart disease, and prevent menopausal symptoms. However, if a woman keeps her ovaries, there is a risk for ovarian cancer or ovarian diseases that may require surgery in the future. Some reasons for removing the ovaries are endometriosis, family history of ovarian cancer, pain associated with recurrent ovarian cysts, ovarian tumors, hormonal or menstrual migraines or post-menopausal or near menopausal women.

ABNORMAL PAP SMEAR

If you receive a phone call from us informing you that your pap smear is abnormal, the following will help you understand your abnormality and what we will do to treat you. Below is a basic understanding of categories of pap smears from normal to more abnormal. Please do not panic as you DO NOT have cervical cancer.

• Normal Pap Smear
• Atypical Squamous Cells of Undetermined Significance without Human Papilloma Virus (ASCUS, neg HPV) / Variant of Normal Pap
• Atypical Squamous Cells of Undetermined Significance with Human Papilloma Virus (ASCUS, pos HPV)
• Atypical Glandular Cells of Undetermined Significance
• Low-Grade Squamous Intraepithelial Lesion (LGSIL)
• Carcinoma In Situ (CIS)
• Cervical Cancer
• ASCUS, favor HGSIL

Any of the above pap smears that are underlined will require a procedure called a colposcopy to evaluate your cervix. A colposcopy will help Dr. Jukes determine if the abnormality requires any further treatment or whether she will only have to follow you with additional pap smears through the year.

MENOPAUSE & ESTROGEN

Some of the most frequently asked questions in our practice revolve around hormone treatment. Menopause is defined as cessation of periods for more than 12 months in women over the age of 40. Menopause is not defined as “having hot flashes.” Laboratory tests or hormonal levels are unnecessary in women with a uterus and not on birth control pills to diagnose menopause.

Once you are menopausal, the decision to use estrogen and/or progesterone is up to you based on your symptoms. If your symptoms are unbearable and inhibiting your enjoyment of life, we recommend the use of hormone replacement therapy.

Symptoms of menopause that are reduced or eliminated with hormone use are:

• Hot Flashes
• Vaginal Dryness
• Painful Sexual Intercourse
• Mood Changes
• Skin and Hair Changes

You should not use hormones in menopause if:

• You have had Breast Cancer
• You have had Uterine Cancer
• You have had Blood Clots
• You have had a Stroke
• You have significant Heart Disease
• You have abnormal vaginal bleeding

In our opinion, the risks of hormone replacement have been overblown in the media. We all take risks every day to improve our lifestyles. For example, we drive our cars every day although we have a 1 in 12 chance of being involved in an auto accident every year. By using hormone replacement, there is a 1 in 1000 risk of developing breast cancer at the age of 40 per year or a 1 in 250 chance of developing breast cancer at the age of 60 per year.

Most women would not give up the use of their car because of the great benefits they receive from being able to drive. The same is true for hormone replacement. If you feel dramatically better on hormone replacement, the small risks can be reasonable for the great benefits you receive.

If estrogens can improve your life and make the quality of life better for you, the benefits outweigh the risks. If, however, your menopausal symptoms are tolerable for you, then we would recommend not using these medications. The only way to know how you will feel on or off of hormones is to try one way or the other. If you are currently on hormones, you can come off by slowly weaning off of them.

Recommended weaning schedule:

• For one month take a half of a pill per day, then you can stop
• For one month take a half of a pill every other day, then you can stop
• For one month take a half of a pill every third day, then you can stop

We do recommend that you take the smallest amount of hormone for the shortest period of time to control your menopausal symptoms. Estrogen and progesterone, in most studies, slightly increase your risk for breast cancer. Estrogen alone, in the most recent studies, did not show an increase in breast cancer risk. All estrogens do increase risks for blood clots and stroke and this increases with age and it is our preference that women stop hormone use by age 60, other than vaginal use.

If you have any further questions about your hormones, we would be happy to address them at your annual visit.

MENOPAUSE / PERIMENOPAUSE

Perimenopause is the process of change that leads up to menopause. It can start as early as your late 30s or as late as your early 50s. How long perimenopause lasts varies, but it usually lasts from 2 to 8 years. Menopause is the point in a woman’s life when she has not had a menstrual period for 1 year. For most women, menopause happens around age 50, but every woman’s body has its own timeline. Some women stop having periods in their mid-40s. Others continue well into their 50s.  Some women have only a few mild symptoms. Others have severe symptoms that disrupt their sleep and daily lives.

Symptoms can include: irregular periods, hot flashes, trouble sleeping, emotional changes headaches, heart palpitations, problems with remembering or thinking clearly and vaginal dryness. If you have any questions or concerns, please contact Dr. Jukes. Our office can provide treatment options to make this transition easier and more comfortable.

ENDOMETRIOSIS

The lining of the uterus, called the endometrium, responds to changes that take place during a woman’s monthly menstrual cycle. The cycle often is about 28 days. First, the endometrium grows and thickens to prepare for a possible pregnancy. If pregnancy does not occur, the endometrium then thins and is shed by bleeding.  With endometriosis, tissue like the endometrium is found in other areas in the body.  It looks and acts like tissue in the uterus.  It most often appears in places within the pelvis such as the ovaries, fallopian tubes, outer surfaces of the uterus, bowel walls, bladder and ureters, and rectum.  Endometrial tissue may attach to organs in the pelvis or to the peritoneum.

The main symptom of endometriosis is pelvic pain. Such pain may occur with sex, during bowel movements or urination, or just before, or during your menstrual cycle. Menstrual bleeding may occur more than once a month. Endometriosis may also cause infertility, though the severity of the disease does not determine this.

Endometriosis can be mild, moderate or severe. The extent of the disease can be confirmed by looking directly into the body.  Using the minimally invasive daVinci robotic system, Dr. Jukes can determine the extent of the disease and remove the endometriosis as well as the scarred tissue around it. A helpful website is www.killercramps.org.

URINARY INCONTINENCE

Urinary incontinence, the loss of bladder control, is a common and often embarrassing problem. The severity of urinary incontinence ranges from occasionally leaking urine when you cough or sneeze to having an urge to urinate that’s so sudden and strong you don’t get to a toilet in time. If urinary incontinence affects your day-to-day activities, don’t hesitate to contact our office. We offer in-office Urodynamics testing which allows us to measure the pressure and volume of your bladder as it fills and the flow rate as it empties. Test results help Dr. Jukes to provide treatment options. In most cases, simple lifestyle changes or medical treatments such as Pelvic Floor Therapy can ease your discomfort or stop urinary incontinence.

UTERINE FIBROIDS

A Uterine Fibroid is a common type of benign (non-cancerous) tumor that develops within the uterine wall.  Uterine fibroids occur in one-third of all women and are actually the leading reason for hysterectomy (removal of the uterus) in the U.S.  Uterine fibroids may grow as a single tumor or in clusters. If you have been diagnosed with uterine fibroids, Dr. Jukes offers minimally invasive surgery for their removal with the daVinci robot.

Fibroids are most common in women aged 30-40 years, but they can occur at any age.  Fibroids occur more often in African-American women than in Caucasian women.  They also seem to occur at a younger age and grow more quickly in African American women.

Symptoms may include longer, more painful menstruation with heavy bleeding, pain in the abdomen or during sex, pressure with difficulty urinating, constipation, abdominal cramps, enlarged uterus and abdomen, and difficulty conceiving. Fibroids may also cause no symptoms at all.

A common alternative to hysterectomy for fibroids is myomectomy, the surgical removal of fibroid tumors and a procedure considered standard-of-care for removing fibroids and preserving the uterus.  It therefore, may be recommended for women who wish to become pregnant.  If fibroids located within or projecting into the endometrial cavity/lining, then D&C, Hysteroscopic Myomectomy can be performed via a transvaginal approach using versapoint electro surgery and saline.  If you have been diagnosed with uterine fibroids, Dr. Jukes offers minimally invasive surgery for their removal with the da Vinci robot.

PELVIC FLOOR REHABILIATION

Pelvic Floor Rehabilitation, or PFR, uses a process called biofeedback to assist patients in identifying the muscles of the pelvic floor. PFR is useful in treating many conditions that affect women, such as urinary incontinence, pelvic relaxation, pelvic pain, and painful intercourse. Most commonly it is used for urinary incontinence in women who have weak pelvic floor muscles. Exercises are introduced and practiced in weekly sessions with our Nurse Practitioner, Kelli Porter. The course of treatment varies dependent on the needs of the individual. Your improvement will be tracked week to week.

LEEP

The Leep procedure is usually recommended when your annual Pap smear indicates the presence of abnormal cervical cells, or cervical dysplasia. This may be an early warning that cancer may occur. The loop electrosurgical excision procedure, or LEEP procedure, is one of several procedures that Dr. Jukes has available to help diagnose and treat abnormal cervical cells. Abnormal cells can be removed which allow new healthy cells to grow. It has a 90-95% cure rate for cervical dysplasia.  The LEEP procedure takes about 5-10 minutes and is performed in our office under local anesthesia.

COLPOSCOPY

The Colposcopy is a procedure that Dr. Jukes and her Nurse Practitioner perform in the office. While performing an additional pap smear, they will look at your cervix with a special microscope after applying vinegar solution over the cervix. The vinegar solution causes any significant abnormalities to appear white.

If any significant lesions are visualized, a biopsy of the area may be taken for evaluation in the lab. DO NOT worry about this biopsy. Most women do not even feel it being done. Your cervix does not have nerve endings like your skin. We will then use medicine that will stop any bleeding at the biopsy site. This can cause some cramping like menstrual cramps. If you want to take some Ibuprofen prior to your procedure, this can help with the cramping.

The results from the colposcopy will take about 1-2 weeks to receive. Unless the results require that we do further procedures, we will usually see you back for a pap smear in 3-6 months.

PARAGARD IUD

The ParaGard  intrauterine contraceptive device is a simple T-shaped piece of soft, ultra-flexible plastic, wrapped in copper and designed to fit comfortably in the uterus.  ParaGard is hormone-free, and can be left in place for up to 10 years.  This device can be easily inserted in-office by Dr. Jukes, usually while on your menses.  Because insertion can be uncomfortable, we recommend taking 600mg of Motrin prior to insertion.

NEXPLANON

Nexplanon is one of the most effective birth control methods available.  Nexplanon is a long-acting, prescription contraceptive that is a flexible rod, about the size of a small matchstick.  It is placed under the skin of your arm in our office.  It is estrogen free, containing only progestin, and is effective for 3 years eliminating the need for daily, weekly or monthly birth control dosing.  Nexplanon is reversible, and can be removed at any time, easily in our office.