national center for women's health

8/14/2019 National Center for Women's Health

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National Center forWomen's Health

Pope Paul VI Institute

6901 Mercy Road

Omaha, Nebraska 68106

(402) 390-6600

Fax: (402) 390-9851

[email protected]


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http://www.popepaulvi.com/ncfwh-evaltreat.htm

Evaluation and Treatment Programs

Infertility

Prematurity Prevention

PMS

Abnormal Uterine Bleeding

Ovarian Cysts

Repeated Miscarriage

Dysmenorrhea and Pelvic Pain

Endometriosis

Postpartum Depression

Progesterone Support in Pregnancy

Perimenopausal/Menopausal Care

Polycystic Ovarian Disease

Reversal of Tubal Ligation

Getting Help

NCWH Home

Contact us:Pope Paul VI Institute

6901 Mercy Road

Omaha, Nebraska 68106

(402) 390-6600

Fax: (402) 390-9851

e-mail: [email protected]


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Evaluation and Treatment Programs

National Center for Women's Health

The National Center for Women's Health not only offers general obstetrics, gynecology andgynecologic surgery, but also specializes in the provision of care for patients with the followingconditions:

Infertility evaluation and treatment Prematurity Prevention Program Premenstrual syndrome Abnormal uterine bleeding Recurrent ovarian cysts Repeated miscarriages

Dysmenorrhea and pelvic pain Surgical treatment of endometriosis Postpartum depression Progesterone support in pregnancy Perimenopausal/menopausal care Polycystic ovarian disease Reversal of tubal ligation

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Infertility Program

The Pope Paul VI Institute Infertility Program, one of the few that exists in the United States, is adisease-based approach which recognizes that "all infertility (or other reproductive problems) arecaused by some type of organic or functional disease process." Unlike the current medical approachwhich typically involves limited evaluation, patients at the Pope Paul VI Institute will receive acomplete evaluation and a sound explanation as to why they are having problems achieving ormaintaining a pregnancy. The organic or functional causes of infertility can be relatively easilydiagnosed and treated.

Causes of Infertility (Organic or Functional)

Endometriosis Pelvic adhesions Polycystic ovarian disease Obstructions of the fallopian tubes Hormonal dysfunctions Ovulation-related problems Previous chlamydia infections Hypothalamic amenorrhea

Infertility and related problems (such as repetitive miscarriage and tubal pregnancy) are best treatedwith a comprehensive approach to diagnosis and treatment. A typical evaluation includes serialhormone evaluation, a follicular ultrasound series, laparoscopy, hysteroscopy, and selective

hysterosalpingogram. A seminal fluid analysis is recommended for the man if this has not been done.After evaluation, the physician conducts a comprehensive planning session with the couple duringwhich the couple is shown the videotape of their laparoscopy and the various causes of thereproductive problem and the treatment plan for those difficulties are explained. Because it is adisease-based approach, the disease that caused the reproductive problem for the woman (and/or herhusband) can be either eliminated or satisfactorily treated.


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EffectivenessBy identifying and treating the underlying diseases that cause infertility, the Institute harnesses thebody's ability to work more effectively as opposed to "driving" the reproductive system, "pushing"the system, or trying to "replace" the system. The effectiveness of the program varies dependingupon the type of disease that occurs. In some cases, the Institute's effectiveness is greater than 80percent in assisting a couple to successfully achieve a pregnancy. In many common infertility

problems, the success rate will be 50 to 75 percent. In some more uncommon infertility problems, thesuccess rate will be lower than that but almost always higher than the rates expected from programsdriven by the artificial reproductive technologies (in vitro fertilization, artificial insemination, etc.).While the infertility program of the Pope Paul VI Institute is one of the most successful in the UnitedStates, a pregnancy can never be guaranteed.

NaProTechnology-DrivenThe new medical science of NaProTechnology is geared toward the evaluation, study and treatmentof reproductive and gynecologic problems. It allows for evaluation and treatment that arecooperative with the reproductive system (which in this case is working abnormally). Thus,pregnancy can occur with a normal act of sexual intercourse. The system is natural and is acceptableto everyone. The treatments carry a very low incidence of multiple births and a low incidence ofsubsequent tubal pregnancy and miscarriage--both are common problems associated with the

programs of the artificial reproductive technologies.

NaProTRACKING the Menstrual CycleMost infertility treatment programs in the country are based on artificial reproductive technologies(such as in vitro fertilization, artificial insemination, selective abortion, etc.). In contrast, theNaProTechnology-driven system of the National Center for Women's Health is morally acceptable toall people. For example, in vitro fertilization is a highly abortive technology that often forces womento make abortion-related decisions, which they do not want to do. When quadruplets or quintupletsresult because multiple embryos were injected into the uterus, the proposed solution is "selectivereduction," which is nothing more than an abortion. These are decisions that most people do notwish to make and seem inconsistent for a treatment program that is trying to generate new life whiledestroying new life. Because a NaProTechnology approach treats the underlying diseases eithermedically or surgically, all pregnancies occur as the result of a normal act of intercourse. The basic

integrity of the unity which occurs with the natural achievement of pregnancy is not compromisedwith the program found at the Pope Paul VI Institute.

Because the woman is charting her cycles, very accurate hormonal evaluations can be accomplishedand the various biological markers and their role in the infertility problem can be assessed. It is themost effective means currently available (including comparisons to urine test kits for ovulation) fordetermining the point in the menstrual cycle when a woman is fertile.


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To learn how to NaProTRACK your cycles, enter Creighton Model FertilityCare System.

AffordableInfertility treatment is often not covered by insurance programs. Artificial reproductive technologyprograms run more than $10,000 per menstrual cycle and up to $150,000-$200,000 (or more) persuccessful pregnancy.

At the Pope Paul VI Institute, evaluation likely includes NaProTRACKING the menstrual cycle, ahormone profile, a follicular ultrasound evaluation, a selective hysterosalpingogram, and a diagnosticlaparoscopy. Test results might indicate the need for more treatment, including surgical intervention.However, the overall cost of the program at the Pope Paul VI Institute is only a fraction of the cost ofa program that revolves around the artificial reproductive technologies.

Many couples come to Omaha for a 7-10 day stay to accomplish a complete infertility evaluation. Thenurses will help you through this process and are available for any questions.


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Prematurity Prevention Program

Prematurity, one of the major complications of pregnancy, affects approximately 10 percent of allpregnancies. Premature birth carries a significant risk of complications. In most circumstances, thebest incubator for the baby is the mother's womb. Modern medicine has not been able to duplicatethe womb's ability to care for the baby's growth and development needs.

Premature birth also necessitates prolonged hospital stays for the baby, thus affecting the baby'searly infancy environment. While neonatal intensive care units are capable and the baby's survival isgood (especially after the 28th week), having a baby in intensive care decreases the ability of theparents to bond with the newborn and their ability to provide the newborn with the needed love andaffection. Moreover, intensive care nursery is expensive.

For these reasons, a pregnancy should be maintained as long as possible (so long as everything else isnormal). The Pope Paul VI Institute has introduced a Prematurity Prevention Program based on 20years of research. While the national preterm birth rate is approximately 10 percent, theprematurity birth rate at the Pope Paul VI Institute is less than 4 percent. This is the result of anaggressive and pro-active management program.

Identifying Risk FactorsThe most important factor in treating prematurity is identification of conditions associated withincreased risk for premature birth. The Prematurity Prevention Program cannot eliminate the riskbut does lower the risk of premature labor and subsequent birth. Risk factors include:

Previous prematurity Exposure to Diethylstilbestrol (DES) Cervical incompetence (congenital, acquired, or family history) Previous repetitive miscarriages Placenta previa Malformations of the uterus or large uterine fibroids Cervical cone biopsy Multiple pregnancy (twins, triplets, etc.) Persistent uterine irritability Excessive amniotic fluid (polyhydramnios) Severe kidney or urinary tract infections Age less than 18 years or greater than 35 years Smoker Infertility or other reproductive disorders Low grade uterine infection

Self-Monitoring Your Uterine ContractionsSelf-monitoring of uterine contractions is important in prematurity prevention. The Pope Paul VIInstitute has developed a uterine contraction self-monitoring protocol, which is critical to pregnancyhealth maintenance. The woman self-evaluates her contractions, cramping, backaches, pelvicpressure, intestinal cramping, vaginal discharges, and vaginal bleeding. She looks for a change thatoccurs from day to day in the baseline of the general symptom pattern. This information is thenshared with the physician.

Ultrasound MonitoringUltrasounds are performed at 6 to 8 weeks, 14 weeks, and 18 to 22 weeks to evaluate patients at highrisk of preterm birth. Changes in the cervix, which have been undetected by the obstetrician till now,can be detected many weeks prior to the onset of preterm labor. Detection of dramatic changesallows for implementation of treatment options.


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Treatment Approaches for the Prevention of Preterm BirthFor patients that exhibit increased uterine contractions during the course of their pregnancy andexhibit those signs that are suggestive of an increased risk for preterm labor, the physician willimplement a number of treatment options. These treatment options may include the following:

Bed rest Hydration Urinalysis Progesterone therapy Tocolytic agents Cervical cerclage Pulsed antibiotic therapy

A Team ApproachPreterm birth can be prevented in the majority of circumstances. At the same time, accomplishingsuch a goal is a team effort. It is extremely important that you, the patient, recognize the part youplay on this team. Your self monitoring of uterine contractions in pregnancy is critical to pregnancyhealth maintenance and should be a part of your obstetrical management. It has been the physician'sexperience that this is more effective than electronic monitoring of uterine contractions. Thephysicians and nurses are also part of the team. Good communication is the key.

Listening is the Important SkillPerhaps the most important feature in preventing preterm labor and birth is the skill of listening.The pregnant woman must listen to her body as it speaks to her in various ways. Of equalimportance, the medical team must listen to the patient as she communicates those signs andsymptoms to them. These are the keys to understanding and preventing preterm labor. Theprematurity prevention program of the Pope Paul VI Institute has been established with the idea oflistening to the patient, interpreting her observations, and implementing successful strategies for theprevention of preterm birth.

Finding Help

If you are at high risk for preterm labor or have previously had a preterm delivery, you can obtainhelp at the Pope Paul VI Institute. An appointment with the physicians at the Pope Paul VI Institutecan be made by calling (402) 390-6600. You may also call for a long-distance telephone consultationwith a registered nurse. Indicate that you are at risk for pre-term labor.


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Premenstrual Syndrome

Premenstrual syndrome (PMS) is a medical condition with a combination of emotional and physicalsymptoms that can disrupt your health, work, and personal life. The symptoms can occur on aregular basis during the premenstrual phase of the menstrual cycle (7 to 10 days prior to the onset ofmenstruation). It can be a very debilitating condition.

PMS symptoms are very real. There are 150-200 different symptoms associated with PMS. Commonsymptoms are bloating, fatigue, irritability, depression, teariness, breast tenderness, carbohydratecraving, weight gain, headache, and insomnia. These begin to occur at least four days prior tomenstruation.

It is important to distinguish symptoms which are present premenstrually and those that are presentall of the time, e.g. symptoms associated with depression.

EvaluationYour physician will ask you to begin charting your cycles using CREIGHTON MODELFertilityCare System. After you have two months of charting, the doctor will recommend ahormone evaluation which will be timed in cooperation with your charting. By timing the hormoneevaluation based on the information provided by your chart, your physician will be able to determinethe extent to which progesterone and estrogen levels are deficient. Premenstrual syndrome hasgenerally been considered to be a progesterone deficiency condition. Studies have also shown thatdecreased levels of beta-endorphins may be present. In many patients with PMS, a relative degree ofhypothyroidism is also present.

Medical TreatmentIn some cases your doctor may prescribe medication to reduce your symptoms. These include:

1. Human chorionic gonadotropin (HCG) given in injection form2. Progesterone supplementation3. Naltrexone

If thyroid levels are high or low, a small amount of thyroid medication may be recommended.A drug used by the Pope Paul VI Institute Physicians in treating PMS is naltrexone. In patients withlow beta-endorphin levels, naltrexone acts to lower the tissue levels of beta-endorphin and allows formore normal ovarian function. This is especially helpful if anxiety is a major PMS component.

Effectiveness of TreatmentBased on research at the Pope Paul VI Institute for the Study of Human Reproduction, theoverwhelming majority of patients treated according to our protocols feel significant improvement.


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Abnormal Uterine Bleeding

Each month, the endometrium--the lining of the uterus--builds up and sheds. An average menstrualcycle lasts about 28 days, counting from the first day (day 1) of one period through the last daybefore the beginning of the next. However, a normal cycle may be shorter or longer than this rangingfrom 21 to 35 days. The menstrual period is the time during the cycle when bleeding occurs and may

last from 3 to 7 days.

Abnormal bleeding is bleeding that is not regular, lasts longer, or is heavier than usual. Thisinformation describes abnormal uterine bleeding and explains its causes and treatments.

Causes of Abnormal BleedingFor the first few years after menstrual periods begin, they are often irregular. In older women,menstrual periods usually become more irregular with the approach of menopause (when the ovariesno longer function and menstrual periods end), and become lighter or heavier. The irregularity of awoman's periods is due to infrequent ovulation ,which is common during these times of life.Menstrual cycles that persist in being longer than 35 days or shorter than 23 days are not normaland should be checked by a doctor.

Abnormal bleeding may be the result of a hormonal imbalance. This imbalance can make bleedinglonger or shorter than usual, or periods may be more or less frequent.

Besides lack of ovulation and other hormone imbalances, irregular cycles may occur because ofweight loss or gain, heavy exercise, stress, illness, or use of drugs. Pregnancy can also cause missedperiods or abnormal bleeding. If you think you might be pregnant, you should see your doctor.

Other causes of abnormal of heavy bleeding are:

Problems with blood clotting Infection of the uterus or cervix Miscarriage (when a pregnancy is lost before the fetus is able to survive outside the uterus) Ectopic pregnancy (pregnancy occurring outside the uterus, most often in one of the

fallopian tubes)

Uterine fibroids (non-cancerous growths that form on the inside of the uterus, on its outersurface, or within the uterine wall itself)

Abnormal growth and thickening of the lining of the uterus Polyps (non-cancerous growths) or tumors of the lining of the uterus Certain types of cancer, such as cancer of the uterus, cervix, or vagina Problems linked to certain birth control methods, such as intrauterine device (IUD) or birth

control pills

Other hormonal problems, such as thyroid diseaseSome vaginal bleeding is not from the uterus and may come from other areas.

DiagnosisTo diagnose abnormal uterine bleeding, your doctor will ask you about your medical history and willgive you a physical exam. It is helpful for you to chart the dates and length of your periods by usingthe CREIGHTON MODEL FertilityCareTM System. This is an excellent and accurate means ofmonitoring the abnormal bleeding. The tests used to diagnose abnormal uterine bleeding may bebased on that charting and the symptoms you are having.


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Your doctor may perform a biopsy, in which a small amount of the tissue lining the uterus isremoved and looked at under microscope. Cultures of the cervix and vagina may be performed tocheck for infection.

Tests to determine the cause may include:

Ultrasound Laparoscopy Dilation and curettage (D&C) Hysterosalpingography

Some of these procedures can be performed in a doctor's office, while others may be done in ahospital with anesthesia.

TreatmentTreatment for abnormal uterine bleeding will be based on the diagnosis. It may involve surgery ortaking hormones, iron, or other drugs. When hormones are indicated, they are given cooperativelywith the woman's cycle, based on her NaProTRACKING.


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Ovarian Cysts (Recurrent or Otherwise)

Many women suffer from the recurrence of ovarian cysts. These can become quite painful and whenthey present themselves, it is common for the physician to recommend either birth control pills fortheir treatment or surgical intervention sometimes leading to removal of the ovary. In both cases,these treatments are generally unnecessary.

It is helpful to understand the basic workings of the development of the two major types of ovariancysts:

Persistent follicular cysts Persistent luteal cysts (luteinized unruptured follicle).

With the beginning of the menstrual cycle, the ovary generally does not have any cysts on it or theyare very small or left over from the previous cycle. However, as ovulation approaches, there is a cystthat develops on the ovary called the follicle. The egg is located inside the follicle. At the time ofovulation, the follicle ruptures and the egg is released. The follicle then becomes a corpus luteum,which produces progesterone and estrogen. These two hormones prevent the further cysticdevelopment on the ovary. When these two hormones are no longer produced (approximately 13days following ovulation), then menstruation occurs and the process starts all over again.

Persistent Follicular CystsWith a persistent follicular cyst (which is the least common of the two functional cysts), the growthand development of the follicle is abnormal probably because of outside stress and its hormonaleffects. The follicle may grow to a certain size but does not grow any further and stays a follicle.Sometimes this can go on for several weeks. When it does this, it can cause a considerable amount ofdiscomfort and pain and the woman may present to the doctor with pelvic pain (often on one side orthe other). Pelvic ultrasound will reveal the presence of a cyst. To know whether or not it is afollicular cyst by ultrasound, one also needs to evaluate the lining of the uterus (the endometrium). Ifit is in the proliferative phase (the preovulatory phase) by ultrasound examination, then, bydefinition, this is a follicular cyst.

To prevent these on a long-term basis, the cyclic administration of progesterone in a cooperativefashion with the menstrual cycle can be used.

Persistent Luteal CystsWith the persistent luteal cyst (or the luteinized unruptured follicle), the follicle grows and developsto a certain point where it would normally rupture and release the egg. However, at that point, itdoes not rupture and does become luteinized (that is, it causes a corpus luteum to be formed withoutthe follicle rupturing). Progesterone is then produced and eventually the cycle comes to an end. Inthis case, the unruptured folicle remains on the ovary as a cystic structure and usually increases insize as a woman gets closer and closer to her menstrual flow. This cystic structure can reach 5 to 6cm in size and become very painful and it is not uncommon then to present her physician with acuteabdominal pain. The persistent luteal cyst is far and away the most common of the two functional

cysts.

TreatmentsBecause both of these types of ovarian cysts are related to abnormal hormone function as theprimary cause, one can realize that surgical intervention or treatment of these is generally nothelpful. In particular, it does not help in the recurrence of these cysts. It may help, of course, in themanagement of the initial situation but it does not help recurrence of these because surgery does notget to the basic problem that causes these ovarian cysts. Nonetheless, surgical management is oftenrecommended.


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The management of these problems is primarily hormonal. Many physicians will recommend the useof birth control pills for this hormonal management, however, that also does not get to theunderlying problems.

At the Pope Paul VI Institute, we recommend that the patient learn how to NaProTRACK hermenstrual cycles. This allows her to record the various biological markers that key the events of the

menstrual cycle. She can do this by learning the CREIGHTON MODEL FertilityCare System.With a persistent follicular cyst she will have a prolonged preovulatory phase; with a luteal cyst shemay have a prolonged postovulatory phase. In either case, when the patient presents with pelvic painand an ovarian cyst, an evaluation of the recordings of the biomarkers can be connected with thesymptoms that the patient has an ovarian cyst, a reasonably exacting diagnosis can be made.

In both cases, treatment with natural progesterone is the answer! The progesterone can be givencooperatively with the woman's cycle.


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Repeated Miscarriage

Miscarriage, often called spontaneous abortion by doctors, is the loss of a pregnancy before 20 weeks.It occurs in about 15-20% of all pregnancies. Most happen in the first three months. Three of moremiscarriages in a row may be called repeated miscarriage (or habitual abortion). Women who haverepeated miscarriages need special tests to try to find the reason for them.

After several miscarriages, you may wonder whether you will ever be able to have a healthy baby. Behopeful. The chances of having a successful pregnancy are good even after more than onemiscarriage. The approach of the doctors at the Pope Paul VI Institute is to diagnose what is wrong,to correct it, and then to support any future pregnancies with hormonal support as soon as thepregnancy is diagnosed.

CausesOften, the reasons for repeated miscarriage is not known. Sometimes, however, it has a definitecause. Examples of known causes include:

Hormone imbalance

Illnesses in the mother Disorders of the immune system Abnormalities of the uterus Environmental and lifestyle factors Chromosomal problems

If you have had more than one miscarriage, each may have had a different cause.

DiagnosisBecause repeated miscarriage has many possible causes, your doctor will need a great deal orinformation to diagnose the problem. You will be asked about your medical history and pastpregnancies, as well as your lifestyle. A complete physical exam, including a pelvic exam, is alsoimportant.

The doctors at the Pope Paul VI Institute will ask you to begin charting your cycles using theCreighton Model FertilityCareTM System. By using your chart as a tool, our diagnostic proceduresand treatment can be performed and administered more effectively. It allows you and your physicianto work in cooperation with your natural cycle. At times cycle abnormalities will become evident inyour charting. This information is invaluable to your physician.

Procedures that might also be done include:Laparoscopy and hysteroscopy: This is a surgical procedure in which a slender, light-transmittinginstrument, the laparoscope, is used to view the pelvic organs. The hysteroscope is used to view theinside of the uterus.Blood tests: Blood is drawn and tested for hormone or immune system abnormalities.

Ultrasound: In this procedure, sound waves are used to view the internal organs and visualizeabnormalities of the pelvic organs.Hysterosalpingography: This is an x-ray of the uterus and fallopian tubes. It is usually taken afterthe organs are injected with a small amount of fluid.Endometrial biopsy: In this procedure, a sample of the tissue that lines the uterus is taken and lookedat under microscope.

Special Care for Future PregnanciesSometimes the problem that caused the miscarriages can be treated. Surgery may be effective forsome problems of the uterus and cervix. Treatment with antibiotics can cure infections. Hormone


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treatment may be very helpful both before the baby is conceived and during the pregnancy. Thephysicians at the Pope Paul VI Institute believe in immediate support with progesterone and possiblyhuman chorionic gonadotropin depending on the woman's history.

What You Can DoIf you have had repeated miscarriages, future pregnancies should be planned, diagnosed early and

watched carefully. You can improve your chances of having a successful pregnancy in the future bydoing the following things:

1. Have a complete medical workup before you try to get pregnant again. It may be that thecause of the miscarriages can be found and treated by your doctor.

2. If you think that you might be pregnant, see your doctor right away. The sooner you seekprenatal care, the sooner you can receive any special care that you may need.

3. Follow your doctor's instructions. He or she will tell you what you need to do to keepyourself and your baby as healthy as possible.

Coping with Repeated MiscarriageThe loss of a pregnancy--no matter how early or how late--can result in feelings of grief ordiscouragement that may overwhelm you. For many women, the emotional healing takes longer than

the physical healing that follows a miscarriage. Reach out to those closest to you and ask for theircomfort and support. Talk to your doctor. Counseling can help both you and your partner if youthink that you cannot deal with your feelings alone.

Finally...Even if you have had repeated miscarriages, you still have a good chance to have a successfulpregnancy. Future pregnancies will need prompt, early evaluation. Your doctor will check yourpregnancy closely and provide any special care you may need as your baby grows.


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Dysmenorrhea and Pelvic Pain

Dysmenorrhea refers to cramps which may occur beginning a few days prior to menstruation andcontinue for several days during the menstrual flow. These cramps are due to the actual contractionof the muscle of the uterus as it expulses the lining of the uterus at the time of menstruation.

Menstrual cramps can be very severe and immobilizing. They can cause one to miss work, school,etc. It can be associated with nausea, vomiting and rectal pain.

Almost always, this pain is due to some type of underlying organic disease which does lend itself tospecific treatment strategies which are very often successful.

Causes

Infection Endometriosis Pelvic adhesions Cervical stenosis

EvaluationEvaluation may include:

Thorough history and pelvic examination Cultures of the cervix and/or uterus Pelvic ultrasound Diagnostic laparoscopy NaProTRACKING of your menstrual cycles

It is helpful in evaluating your pain to NaProTRACK your menstrual cycles. By learning a system

for recording the events of your menstrual cycle, you can keep a careful record of your pain.

Treatment

Oral medications called prostaglandin inhibitors (such as Advil, Aleve, Motrin, Naprosyn,Anaprox, Cataflam) are often the beginning treatment

If these are not helpful, then a diagnostic laparoscopy with laser vaporization of theendometrial implants.

Very often, the birth control pill (BCP) is prescribed for dysmenorrhea. The disadvantage to usingthe pill to treat this is that it is not diagnosing or correcting the problem. It is masking or suppressingthe symptoms. You also have to deal with the annoying and harmful side effects that the BCP causes.

More importantly, so many of these changes in the menstrual cycle from the pill have the ability toaffect fertility long term. Therefore, in order to have the best chance at preserving fertility andavoiding infertility, it would be best to avoid the birth control pill as a solution to cyclic pain.


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Endometriosis

Endometriosis is a condition in which tissue that looks and acts like endometrial tissue is found inplaces other than the lining of the uterus, such as ovaries, tubes, bowels, outer surface of the uterusand other pelvic structures. Endometriosis may also develop on body tissues located anywhere in theabdomen. These tissues respond to the cycle of changes brought on by the female hormones just asthe endometrium normally responds in the uterus. Endometriosis can cause pelvic pain,dysmenorrhea, and infertility.

DiagnosisAn accurate diagnosis can be obtained only by a procedure called laparoscopy. This is an out-patientsurgery done under general anesthetic, with a slender light-transmitting telescope that is insertedthrough a tiny cut made in the lower abdomen. This enables the doctor to view the pelvic organs andto actually see if endometriosis is present.

TreatmentDifferent types of treatment may be needed for endometriosis:

Laser LaparoscopySpots of endometriosis can be removed from their abnormal locations by laser at the time ofthe diagnostic surgery. This procedure is often recommended for mild and moderateendometriosis. About 50-70% of patients can be treated by laser laparoscopy and can avoidmajor surgery. Removal by cautery is not recommended as there is an extremely highrecurrence rate.

Laparotomy (major surgery)In cases of severe endometriosis, it may be necessary to have major abdominal surgery. Alaser is used in this procedure. With this procedure, you will be in the hospital for a few daysand will need 4-6 weeks to recover fully. With surgical treatment, the actual chances ofrecurrence are low and, when there is recurrence, it is minimal.

Hormone TherapyHormone therapy is sometimes recommended as a treatment for endometriosis. Thehormones treat the illness by stopping ovulation and have many side effects. They do notcorrect the problem.

The decision to have surgical treatment...Many physicians use artificial reproductive technology and do not treat women with infertility bydiagnosing and treating their endometriosis. These physicians have not developed the surgical skills

necessary to meticulously remove the disease. Dr. Hilgers has been doing this type of surgery for over30 years and offers expertise in finding and removing spots of endometriosis. He has foundendometriosis in 95% of patients who, in a prior laparoscopy by another physician, were told thatthey did not have endometriosis.


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Postpartum Depression

Postpartum depression is a major depressive disorder which generally begins within the first fourweeks following delivery. The symptoms are typically very distressing to the patient and to herfamily. Changing reproductive hormones and the withdrawal of naturally occurring progesteronefollowing delivery may be a causative factor. Traditional treatment involves psychiatric evaluation

and possible antidepressant therapy.

Symptoms

Depression Fatigue Changes in appetite Changes in sleep Thoughts of suicide Anxiety

At the Pope Paul VI Institute, the physicians have developed an assessment tool and a treatment

protocol for postpartum depression. The patient's symptoms are evaluated. If indicated, the patientis given a dose of natural progesterone. She makes frequent contact with the physician in an ongoingassessment and additional doses are given as needed.

The effect of the treatment is often quite immediate and the patient reports feeling significantlybetter. So often, physicians treat this condition with antidepressants. These medications take asignificant time to work and also have side effects that many patients find to be hard to tolerate. Ifyou are interested in this service, please call the nurses. Indicate that you are needing help forpostpartum depression.


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Progesterone Support in Pregnancy

Studies have shown that progesterone support can be helpful in those patients with previousinfertility or miscarriage. In additional individuals who can be considered candidates forprogesterone evaluation and subsequent supplementation would be those who have had a previousabruptio placentae, previous stillbirth, pregnancy-induced hypertension, previous prematurity,previous premature rupture of the membranes, previous or current intrauterine growth retardation,hyper-irritability of the uterus, congenital uterine anomaly, or patients with cervical cerclage.

Key principles to the use of progesterone in pregnancy are that natural progesterone can be used andthat it be started as early as possible in the pregnancy. During the course of the pregnancy,progesterone levels are drawn every two weeks and progesterone is supplemented based on theprogesterone level. Through research done at the Pope Paul VI Institute, the physician havedeveloped a graph identifying average level of serum progesterone during the course of thepregnancy. A treatment protocol has been established based on this graph.

Progesterone can be taken by several routes: intramuscularly, vaginally, or orally. Intramusculardosing provides the best absorption and is generally recommended.

The Institute offers the service of progesterone monitoring to women who are seeing other physiciansfor all other aspects of their prenatal care. The woman has her blood drawn every two weeks and theserum is sent to the National Reproductive Hormone Laboratory for assay. Dr. Hilgers will theninterpret the level and dose the progesterone supplementation accordingly.

If you are interested in this service, please call the nurses and ask for information on getting started(402) 390-6600.


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Menopausal Symptoms and Estrogen Replacement

During the menopausal period, a woman is often aware of a variety of different symptoms that canbe extremely annoying to her.

Symptoms

Hot flashes Irregularity in the menstrual cycle Vaginal dryness Discomfort with intercourse Irritability Bloating Weight gain Carbohydrate craving Depression Headaches Fatigue and insomnia

TreatmentIn managing the menopausal symptoms, many physicians recommend estrogen replacement therapy.This causes some perplexing difficulties. For example, if a woman takes estrogen only, the risk ofboth endometrial and breast cancer goes up. Thus, if a woman takes an estrogen for replacementtherapy, she also needs to take progesterone to block or inhibit the effects of the estrogen. In thisway, the incidence of endometrial and breast cancer can be normalized.

There are a variety of different approaches to estrogen replacement therapy. There are manydifferent estrogen products available and a number of different progesterone substitutes. Thephysicians at the Pope Paul VI Institute recommend natural estrogen and progesterone supplements.These medications are bioidentical to what a woman's own body produces. There are advantages tothe use of natural hormones. These are available by presciption through a compounding pharmacist.

The question of how long a woman should be on these hormones is a complicated one and one thatneeds to be discussed with the woman and her physician.


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Polycystic Ovarian Disease

Polycystic ovarian disease (PCOD) is a condition that is often associated with infertility. The ovariesdo not function normally and ovulate only irregularly. The ovaries have multiple cysts that formunder the capsule of the ovary. The ovaries are often enlarged. Some 60 percent of women withPCOD will also have endometriosis.

Symptoms

Amenorrhea Long and irregular menstrual cycles Obesity Hirsuitism (excessive hair growth) Hypertension Infertility

A complete evaluation includes a thorough hormone profile, a pelvic ultrasound examination, and alaparoscopy.

Treatment

Medical treatment:Treatment for PCOD is aimed at several factors. A decrease in the production of the malehormones is one aim of treatment. This can be accomplished by giving cortisone-likemedication. Fertility treatment can be accomplished by inducing or stimulating ovulationwith medications. In order to reduce the incidence of endometrial cancer associated withlong and irregular cycles, some type of progesterone withdrawal needs to be implemented ona long-term basis.

Surgical treatment:An ovarian wedge resection is a surgical procedure in which a wedge of tissue is removedfrom the ovary and the ovary is subsequently reduced in size and repaired. While this is anolder operation, it has been recently resurrected because of significant improvement in ourability to prevent adhesion formation. It is extremely effective in lowering the male hormoneproduction and regulating the menstrual cycles, thus improving fertility. The woman willoften go back into regular cycles following this surgery. The pregnancy rate after thisprocedure is about twice what it is with Clomid.


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Reversal of Tubal Ligation

Women who have had previous tubal ligations can often have their tubal ligation reversed. This is amicrosurgical procedure. The area where the ligation occurred is excised and the tubes aremicrosurgically reconnected. Success of this procedure depends upon the type of tubal ligation thatwas performed and on the expertise of the microsurgeon. Dr. Hilgers has over thirty years of

experience in performing microsurgery. Fortunately, most tubal ligations fall into the category ofbeing able to be reversed. Unfortunately, most insurance companies do not pay for this procedure.

Getting Help

If you live in or near Omaha, Nebraska:

For help with one of the above conditions, make an appointment with the director of the PopePaul VI Institute, Thomas W. Hilgers, MD. Just call the appointments desk at the Pope Paul VIInstitute at (402) 390-6600.

An initial appointment interview, which includes a medical history, will be conducted and a

personalized and organized evaluation plan will be established. This will lead to an individualizedtreatment program.

To expedite this program, enroll in a Creighton Model FertilityCare System (CrMS) program tolearn how to NaProTRACK the menstrual cycle. After two months or two menstrual cycles havebeen tracked in this fashion, you can see the physician and the process can move quickly. Usuallyafter two cycles of NaProTRACKING, it only takes two additional months to complete theevaluation.

If you are outside of 150-mile radius of the Omaha metropolitan area:

You can learn the CrMS by attending classes locally or in a location near your hometown. To find orlocate a teacher in your area, visit www.fertilitycare.org, or contact Pope Paul VI Institute at (402)392-0842 or the American Academy of FertilityCare Professionals, 615 S. New Ballas Rd., St. Louis,MO 63141, (314) 569-6495.

Once two cycles or two months of NaProTRACKING have been completed, then a good photocopyof that chart can be sent to:

Thomas W. Hilgers, MD, Director c/o Terri GreenPope Paul VI Institute6901 Mercy RoadOmaha, NE 68106-2604

Please include a cover letter, outlining your history and your reason for consultation.

FeesFor a fee of $25, Dr. Hilgers will review the NaProTRACKING of your menstrual cycle along withyour basic medical history as outlined in your letter. A personal response will be written to you withregard to this evaluation.

If medical records are to be reviewed in addition to the NaProTRACKING, then the fee is $50.

If there is a videotape of a previous laparoscopy to be reviewed, the total fee would then be $75.


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ConclusionIf there are any question with regard to your reproductive problems, do not hesitate to write to Dr.Thomas W. Hilgers at the above address. The staff of Pope Paul VI Institute look forward to helpingyou with your women's health care needs.

national center for women's health

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