A primer on emergency contraception pills

Thoughtful woman sitting on floor using laptop in living roomYou’ve heard about emergency contraception pills but do you really understand exactly what they do?

First, the simplest way we describe these pills to our patients is to call them emergency contraception that prevents pregnancy after unprotected sex. They are not traditional birth control. And they do not cause abortion because they work before a pregnancy occurs.

According to the American College of Obstetricians and Gynecologists, fertilization, the union of an egg and a sperm, occurs in the fallopian tube. During the next few days the fused egg and sperm move through the fallopian tube to the lining of the uterus, where it implants as a cluster of cells that will become the fetus and placenta. Emergency contraception pills do not work at this point. Read more…

Tuesday, August 19th, 2014 at 12:00

Your daughter’s all-important first visit to our office

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“When should my daughter first see a gynecologist?” is a question our patients often ask during their visits to us, followed by an almost always immediate second question: “What kinds of things do you do to calm the nerves of the first visit?”

The optimum time for a first visit to our office is between ages 13 and 15. As for the second answer, because it can be scary for your daughter as young girls often feel embarrassed or nervous discussing their bodies, we make the visit as pleasant and comfortable as possible, and consider this a get-to-know-you session, where we begin building relationships and talk about health, education and prevention.
In most cases young girls visit our nurse practitioner Laury Berkwitt, who specializes in women’s health, is a mother of two, and is passionate about caring for young women and adolescents. She knows how to speak to young girls and is able to get them to open up, talk and ask questions. Read more…

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Child’s obesity linked to how much – or how little – mom gained during pregnancy

home_pregnancy (2)If you gain too much or too little weight while pregnant, a new study has found that your child has a greater risk of being overweight or obese. The study caught our attention since weight  – “How much or how little should I gain?” – is one of the first questions many of our patients ask us.

The researchers studied 4,145 women and their children, ages 2 to 5, all members of Kaiser Permanente health care plans in Northern California. The women participants were racially diverse and all had a normal body mass index (BMI) before pregnancy, which according to guidelines established by the Institute of Medicine (IOM) means they should gain between 25 and 35 pounds during pregnancy. Read more…

Friday, June 13th, 2014 at 12:32

In the News: The Dangers of Power Morcellation for Uterine Fibroid Removal

The FDA speaks out

Earlier this month, the U.S. Food and Drug Administration issued a memorandum that discouraged surgeons from using a common procedure called power morcellation to remove uterine fibroids. Power morcellation uses a medical device to divide uterine fibroids into smaller pieces that can be removed through a small incision in the abdomen, such as during laparoscopic surgery.

Why was the FDA announcement necessary?

New data from the Center for Devices and Radiological Health show that power morcellation can spread undetected cancers more often than previously realized. According to the data, one in 350 women who undergo a hysterectomy to treat fibroids or who have fibroids removed have undiagnosed uterine sarcoma — a type of cancer that can be aggressive. If power morcellation is performed in women with this kind of uterine cancer, the procedure can spread the cancer around the abdomen and pelvis.

The agency’s review occurred following wide media coverage of Dr. Amy Reed, a 41-year-old Boston anesthesiologist who underwent a power morcellation hysterectomy in October 2013 to treat what she was told were likely benign uterine fibroids. Follow-up tests found that Reed had uterine leiomyosarcoma, a very aggressive tumor. Imaging tests showed that the cancerous tissue had been spread throughout her abdominal cavity, giving her stage 4 cancer.

The FDA stopped short of ordering the devices needed for this procedure off the market because, according to a spokesperson, “there still may be individual patients who benefit from the procedure.”

Uterine fibroids: A bit of background information

Most women will develop uterine fibroids at some point in their lives. Most uterine fibroids do not cause problems. However, uterine fibroids can cause unpleasant or even painful symptoms, such as:

• heavy or prolonged menstrual bleeding,
• pelvic pressure or pain, and
• frequent urination

Between 500,000 and 600,000 women undergo hysterectomies in the United States every year. Up to 40 percent of these procedures are to treat painful fibroids.

What do I think?

I’ve had concerns about power morcellation for some time: I think it’s an expensive and dangerous technique that does not improve surgical outcome. While I’m in full support of the FDA’s safety advisory, I think they should have gone even further and taken the devices off the market until a solution is found. Fortunately, there are some good alternatives to power morcellation, including a small lower abdominal incision, manual extraction though a laparoscopy incision, and manual morcellation via posterior colpotomy (an incision in the back of the vagina). I believe that posterior colpotomy is the best option in many cases because it is safe and associated with minimal postoperative pain and excellent cosmetic outcomes.

If you’re considering treatment for uterine fibroids, be sure to discuss with your physician all the available treatment options, including the benefits and risks. If you’re in the area, give me a call to set up an appointment.

Additional information on uterine fibroids

Extensive information on uterine fibroids can be found at:

FDA Safety Communication: Laparoscopic Uterine Morcellation, April 2014
National Institutes of Health: Uterine Fibroids Fact Sheet, March 2013
John M. Garofalo, M.D.: Uterine Fibroids

About the practice

Dr. John Garofalo, M.D., is a gynecologist located in Fairfield County, Connecticut. He has more than 20 years of practice and surgical experience covering many facets of obstetrics and gynecology.
Laury Berwitt is a nurse practitioner specializing in women’s health in Fairfield County, Connecticut. Laury has a passion for providing quality women’s health care in a safe and comfortable manner by creating a trusting patient-practitioner relationship. She has been in practice for 10 years, caring for women of all ages.

For more information, go to www.garofaloobyn.com. John Garofalo, MD and Laury Berkwitt, APRN can be reached for personal consultations by calling 203.803.1098.

Mammograms: Making Sense of Conflicting News

In the past few months there’s been a lot of conflicting information about mammograms in the press. Not surprisingly, we get asked a lot of questions by our patients: Are mammograms useful? At what age should I start getting tested? What are the risks? What if I test positive?

Recent News: A Quick Summary

A few months ago, there was a cost analysis of whether women should start regular mammograms starting at age 40 or age 50. Why was this a concern? Because the American Cancer Society recommends that women start mammogram screening every year starting when they turn 40, while the U.S. Preventive Service’s Task Force recommends that women get a mammogram every other year starting at age 50.

A few weeks later, a Canadian study reported that mammograms did not reduce breast cancer deaths. This study was criticized by U.S. radiologists as being flawed and misleading.

The Latest Word

Even more recently, the American Medical Association published the results of studies that attempted to put all the previous research into perspective. For the first study, researchers at Harvard examined all the research done on mammograms since 1960. They concluded that while mammograms have benefits, these benefits have been “oversold,” while the potential harms have been minimized.

Who Should Get Screened, And When?

The researchers also found that annual mammograms can reduce the risk of dying from breast cancer by about 19 percent; but the benefit varies based on a woman’s age and her underlying cancer risk. For example, breast cancer becomes much more common as a woman ages. Here are the statistics:

chart

As for women age 75 and older, the study found that there have been no tests to see whether women of this age benefit from regular mammograms. This means that there’s no way to know how much regular mammograms might extend the life of a woman in this age range.

The Risk of Overdiagnosis

The Harvard study also evaluated overdiagnosis, in which women are treated for a cancer that would never have been life-threatening. The researchers found that about 19 percent of women who are diagnosed with breast cancer as a result of a mammogram undergo unnecessary surgery, chemotherapy or radiation.

So What’s the Bottom Line?

The researchers concluded that mammography is a useful but not perfect screening test. So if you’re trying to make a decision about mammography, be sure to discuss the risks, benefits, uncertainties, alternatives, and your own health history and preferences.

About the practice

Dr. John Garofalo, M.D., is a gynecologist located in Fairfield County, Connecticut. He has more than 20 years of practice and surgical experience covering many facets of obstetrics and gynecology.

Laury Berwitt is a nurse practitioner specializing in women’s health in Fairfield County, Connecticut. Laury has a passion for providing quality women’s health care in a safe and comfortable manner by creating a trusting patient-practitioner relationship. She has been in practice for 10 years, caring for women of all ages.

Laury and Dr. Garofalo offer mammography and related consultation services as part of well woman care.

For more information, go to www.garofaloobyn.com. John Garofalo, MD and Laury Berkwitt, APRN can be reached for personal consultations by calling 203.803.1098.

Vaccines During Pregnancy: Are They Safe?

There’s been a lot of conflicting information lately about vaccines during pregnancy. And not surprisingly, we hear a lot of questions on this topic at our medical practice. The short answer to the “are vaccines safe” question is that certain vaccines are strongly recommended during pregnancy, and that the known benefits of these vaccines are generally believed to outweigh any potential concerns.

Here are a few of the more common questions we’ve heard, along with our answers.

What is a vaccine and how does it work?

Most vaccines are solutions that contain a weakened, killed or similar version of a virus or organism that causes a particular disease. Vaccines take advantage of the fact that immune systems can “remember” infectious organisms and viruses.

Vaccines are generally injected into the deltoid muscle (the outer part of the upper arm). Vaccines are formulated so that they cannot get you sick, but they can prepare your immune system to fight that particular disease. In other words, vaccination can provide immunity without you having to experience the disease or its symptoms.

Should pregnant women get vaccinated?

Certain vaccinations can protect you from various infections and illnesses during and even after pregnancy. This protection is passed to your unborn child, helping to protect your child during pregnancy and even for the first few months after birth. This is particularly important for infections such as pertussis (whooping cough), which is highly contagious and can be particularly deadly for unborn newborn children and infants.  Vaccinations can also protect you from getting a serious disease that could affect future pregnancies.

However, not all vaccinations are safe during pregnancy. Vaccines that should generally be avoided during pregnancy include:

  • Varicella (chickenpox)
  • Human papillomavirus (HPV)
  • Measles
  • Mumps
  • Rubella

In addition, vaccines that contain weakened but live viruses — such as the nasal spray vaccine — are generally avoided for pregnant women (although they are considered safe for postpartum or breastfeeding women). Instead, pregnant women are usually given vaccines that contain inactivated (killed) or synthetic versions of the virus or infection-causing agent.

Your healthcare provider can help explain the vaccinations you should consider before, during and after your pregnancy.

Should pregnant women get a seasonal flu vaccine?

Inactivated seasonal and H1N1 influenza “flu” vaccines are recommended for most pregnant women. Pregnant women have a higher risk for serious complications from influenza than non-pregnant women of reproductive age. Flu  vaccine can protect pregnant women and their unborn babies, and also protect the baby after birth. In fact, the Centers for Disease Control and Prevention ¬— a federal agency that protects public health and safety through the control and prevention of disease, injury and disability — classifies pregnant women as a group that is more eligible to receive flu vaccines when the vaccine is in short supply.

What vaccines are safe during pregnancy?

Other than flu vaccines, the only vaccines recommended for routine use during pregnancy are primary or booster Tdap (tetanus, diphtheria and acellular pertussis) vaccinations. One dose of Tdap vaccine is recommended during each pregnancy, regardless of when you had your last Tdap or tetanus-diphtheria (Td) vaccination.

If you’re traveling abroad or if you’re at increased risk of certain infections, your healthcare provider may recommend other vaccines during pregnancy, such as hepatitis A, hepatitis B and meningococcal or pneumococcal vaccines.

When during my pregnancy should I be vaccinated?

Ideally, all women who are pregnant or might be pregnant during the influenza season should receive the inactivated influenza vaccine in October or the first half of November (prior to the influenza season), regardless of their stage of pregnancy. Vaccination after this period can still be beneficial because peak influenza activity usually occurs in January or February, but may occur as late as May.

Other immunizations during pregnancy may be delayed until the second or third trimester, to minimize concerns about complications. However, certain routine immunizations such as tetanus vaccines may be given during the first trimester if there are special risks to the unimmunized pregnant woman, fetus, or newborn.

Can a vaccine when I’m pregnant cause my child to become autistic?

Some researchers claim a connection between autism and childhood vaccines —particularly measles vaccine and thimerosal, a mercury preservative used in vaccines. However, the overwhelming majority of evidence does not support an association between immunizations and autism. The Advisory Committee on Immunization Practices (ACIP) does not recommend avoidance of thimerosal-containing vaccines for any group, including pregnant women.

Additional information on vaccines

Extensive information on vaccines and immunization can be found at:
www.immunizationforwomen.org
www.cdc.gov/vaccines
www.cdc.gov/vaccines/pubs/ACIP-list.htm

About the practice

Dr. John Garofalo, M.D., is a gynecologist located in Fairfield County, Connecticut. He has more than 20 years of practice and surgical experience covering many facets of obstetrics and gynecology.

Laury Berwitt is a nurse practitioner specializing in women’s health in Fairfield County, Connecticut. Laury has a passion for providing quality women’s health care in a safe and comfortable manner by creating a trusting patient-practitioner relationship. She has been in practice for 10 years, caring for women of all ages.

Laury and Dr. Garofalo offer and wholeheartedly recommend influenza and Tdap vaccinations during pregnancy.

For more information, go to www.garofaloobyn.com. John Garofalo, MD and Laury Berkwitt, APRN can be reached for personal consultations by calling 203.803.1098.

 

da Vinci Surgery In The News: How Safe Is It?

A few days ago, I saw a local newspaper article that described a botched robotic surgery from 2009. The article went on to claim that new surgical technologies such as the da Vinci® Surgical System are not always properly evaluated by physicians and hospitals in terms of their potential harm to patients. Perhaps most alarming, the article noted that there are questions about the experience and expertise of many of the surgeons who use the equipment.

I always encourage my patients to be fully informed about the advantages and potential risks of any procedure they’re considering. From my perspective, the recent media coverage provides an excellent opportunity to explain robotic surgery and review what you can do to help prevent the kind of complications mentioned in the article. Finally, at the end of this blog you’ll find a description of my practice and what my patients can expect if they choose robotic surgery.

What is the da Vinci Surgical System?

As I explain on my website, the da Vinci Surgical System uses small incisions to allow surgical access for miniaturized surgical instruments and a high-definition 3D camera. Seated at a da Vinci console, the surgeon views a magnified, high-resolution 3D image of the surgical site. State-of-the-art computer technologies convert the surgeon’s hand movements into precise micro-movements of the da Vinci instruments. Introduced more than five years ago, the da Vinci Surgical System has been used successfully in tens of thousands of procedures.

As a minimally invasive technique, robotic surgery typically offers the benefits of less pain and bleeding, faster recovery and fewer potential complications compared to traditional “open” surgery. It also allows higher levels of precision and complexity than non-robotic laparoscopic procedures. However, as with any kind of surgical treatment, there are risks associated with robotic surgery. These risks include injury to tissues or organs; bleeding; infection, and internal scarring.

Questions for you to ask before you agree to robotic surgery:

COEMIG certification?
If you’re considering any gynecologic surgery, including one that uses robotic technology, be sure to ask if your surgeon and his or her hospital are COEMIG-certified. COEMIG stands for “Center of Excellence in Minimally Invasive Gynecology.” According to the American Association of Gynecologic Laparoscopists (AAGL), which created the COEMIG program, COEMIG certification is only given to surgeons and facilities that uphold an “unparalleled commitment and ability to consistently deliver safe, effective, evidence-based care.” COEMIG standards are frequently upgraded as surgical processes improve. Certification is not merely a one-time achievement; it must be maintained. Designees are regularly monitored by a special medical review agency.

Experience with robotic and laparoscopic surgery?
If you’re considering gyn surgery, be sure that your surgeon is not only COMIEG-certified but highly experienced in laparoscopic and robotic surgery. Remember that a surgeon cannot safely go from “open” hysterectomy to complex robotic surgery overnight. So ask: How much experience does your surgeon and his or her hospital have with robotic surgery? How many years of experience and how many surgeries? Likewise, how much experience does the surgeon have with non-robotic laparoscopic surgery? What is the surgeon’s record of successes and complications from robotic surgeries?

Don’t be afraid to speak up and ask. These questions can help reduce surgical risks while providing reassurance that your provider and healthcare facility are committed to your health and safety.

About Dr. John Garofalo, M.D.

Dr. John Garofalo, M.D., is a gynecologist located in Fairfield County, Connecticut. Dr. Garofalo was the first gynecologist in lower Fairfield County to be certified on the da Vinci Surgical System more than four years ago. He has performed hundreds of procedures with the da Vinci Surgical System, with a complication rate of less than 1%. He also has more than 10 years of experience performing complex non-robotic laparoscopic surgeries.

Dr. Garofalo is certified to use the da Vinci Surgical System for diagnosis and/or treatments associated with the following conditions and procedures:

About Garofalo OB/GYN & Associates

Dr. Garofalo’s practice, Garofalo OB/GYN & Associates, has been designated as a Center of Excellence in Minimally Invasive Gynecology (COEMIG) by the American Association of Gynecologic Laparoscopists (AAGL). According to the Surgical Review Corporation (SRC), which administers the program on behalf of AAGL, more than 650 providers around the world currently participate in the COEMIG program, which was launched in 2010.

For more information on Dr. Garofalo and his medical practice, go to www.garofaloobgyn.com. Dr. Garofalo can be reached for a personal consultation at 203.803.1098.

AAGL Awards Garofalo OB/GYN with COEMIG Designation

AAGL COEMIG Seal_Light2 (2)“I would like to share my news of Garofalo OB/GYN & Associates being designated as an AAGL Center of Excellence in Minimally Invasive Gynecology (COEMIG).”

The COEMIG program is focused on improving the safety and quality of gynecologic patient care and lowering the 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.

The COEMIG program ensures the safest, highest quality care is delivered to minimally invasive gynecologic surgery patients worldwide, regardless of where they choose to have their procedure performed.

By designating the individual surgeon and facility together, patients are able to distinguish providers who have met the requirements for delivering high-quality perioperative care from those who have not. Insurance companies will also be able to use the designation to identify those committed to excellence.

AAGL only designates this high banner of quality to surgeons and facilities that uphold an unparalleled commitment and ability to consistently deliver safe, effective, evidence- based care. The program is structured to help minimally invasive gynecologic surgery providers continuously improve care quality and patient safety.

For more information about the AAGL, visit www.aagl.org. And for more information on the Surgical Review Corporation, visit www.surgicalreview.org.

Friday, September 13th, 2013 at 10:30

SILS – Single Incision Laparoscopy Surgery on Norwalk Hospital’s Health Talk

health talkcrYesterday, I appeared on “Health Talk” to discuss SILS - Single Incision Laparoscopy Surgery.

In a nutshell, instead of a six-inch incision required by traditional surgery (or even the three to four smaller half-inch incisions utilized in standard laparoscopic surgery), SILS surgery is accomplished through a single small incision in the belly button.

The following operations can be performed by SILS:

  • Removal of uterus (hysterectomy)
  • Removal of ovary (oophorectomy)
  • Removal of gallbladder (cholecystectomy)
  • Removal of appendix (appendicectomy)
  • Repair of paraumbilical or incisional hernia
  • Diagnostic laparoscopy with biopsy

Beginning Sunday, May 19, each evening at 8 and 10 pm, you can view this very infomative segment. Health Talk is Norwalk Hospital’s TV show which broadcasts on Cablevision Local Programming Channel 84.

If you have questions about SILS or need more information, call my office at 203-855-3535.

Monday, May 20th, 2013 at 22:23

Angelina Jolie and the Importance of BRCA1 Testing

angelinacrEarlier this week, Angelina Jolie publicly shared her decision to have a preventive double mastectomy and removal of her ovaries in order to reduce her chances of getting breast cancer and ovarian cancer. According to news reports, Angelina made these decisions after learning that she carried a mutated gene known as BRCA1 which significantly increased her chances of getting breast cancer and ovarian cancer. Angelina’s mother passed away at the age of 56 after a seven-year struggle with cancer. Angelina is in her late 30s.

Here at Garofalo Ob/Gyn, we’ve already had several patients ask about what this means to them, and whether they should undergo genetic screening for the BRCA1 mutation. We’ll do our best to answer some of these questions here.

What are BRCA1 (and BRCA2) genes?

Genes are molecular instructions that hold the information for the human body to build and pass along bodily characteristics such as blood type and eye color. When genes are improperly formed, it’s called a mutation. Mutations can occur during a lifetime or they can be hereditary — inherited from a parent.

Everyone has BRCA1 and BRCA2 genes. (The BR comes comes from “breast” and the CA comes from “cancer.”) In normal cells, these genes play a role in protecting the body against the development of cancer. But individuals with mutations in either of these genes have increased cancer risks, most notably for breast cancer and — for women — ovarian cancer.

What is BRCA testing and what does a positive result mean?

BRCA testing is a genetic blood test that checks the sequence of the BRCA1 and/or BRCA2 genes. It takes about three weeks to get results. A positive result means that the person has a genetic mutation that increases the risk of cancer. Specifically, a positive BRCA1 result for a woman can mean a 60%-80% lifetime risk of breast cancer and a 30%-45% lifetime risk of ovarian cancer. A positive BRCA2 result for a woman can mean a 50%-70% lifetime risk of breast cancer and a 10%-20% lifetime risk of ovarian cancer. For men, the mutation can mean a higher likelihood of prostate cancer, testicular cancer, pancreatic cancer and male breast cancer.

How much does BRCA testing cost?

BRCA testing is usually covered by insurance if certain criteria are met. For example, testing can be less expensive once a mutation has been identified within your family.

What can be done if I have the BRCA1 or BRCA2 mutation?

This is the kind of question that should be discussed with a genetic counselor. The answer may depend on many factors, including your age, health and family history. Since ovarian cancer screening tends to be unreliable, ovarian removal is recommended for BRCA1 and BRCA2 carriers, ideally between the ages of 35 and 40. On the other hand, regular breast screening is good at picking up breast cancers early, and it may be a reliable alternative to mastectomy.

Dr. Garofalo is very experienced in risk-reduction bilateral salpingo-oophorectomy (the surgical removal of both ovaries and the Fallopian tubes) for women who are BRCA1 or BRCA2 positive. This surgery can be done laparoscopically or with the da Vinci Surgical System, as an outpatient procedure with rapid recovery.

 

Do I need to be tested for BRCA1 and BRCA2?

Here at Garofalo Ob/Gyn, we can help determine whether if and when genetic testing is appropriate by exploring your personal and family history. For example, people of Ashkenazi Jewish ancestry are more likely than other groups to have the mutation, as are people with Norwegian, Dutch and Icelandic ancestry.

It’s important to remember that these mutations are relatively uncommon, and that not everyone with one of these mutations develops cancer. However, we encourage all of our patients to be aware of their health conditions and of the risks they may face.

If you have more questions about genetic mutations and cancer risk, just let us know.

About the practice

Laury Berwitt is a nurse practitioner specializing in women’s health in Fairfield County, Connecticut. Laury has a passion for providing quality women’s health care in a safe and comfortable manner by creating a trusting patient-practitioner relationship. She has been in practice for 10 years, caring for women of all ages.

Dr. John Garofalo, M.D., is a gynecologist located in Fairfield County, Connecticut. He has more than 20 years of practice and surgical experience covering many facets of obstetrics and gynecology.

For more information, go to www.garofaloobyn.com. John Garofalo, MD and Laury Berkwitt, APRN can be reached for personal consultations by calling 203.803.1098.

Thursday, May 16th, 2013 at 22:23