Genitourinary Syndrome of Menopause (GSM)

Let’s talk about the big “M” word, Menopause.  It is the elephant in the room and by 2030 17% of the population will be >65yrs old.  Menopause should be of great concern to clinicians and patients because it doesn’t just cause hot flashes, night sweats and mood swings.  It is associated with osteoporosis (bone loss), premature aging, dementia, depression, changes in lipid profile which can increase the chance of heart attacks and stroke…and as if the previously mentioned symptoms are not bad enough, your sex life will completely change too.  Lack of estrogen production from the ovaries leads to the Sahara desert in our vaginas.  Yes, ladies, laugh all you want but it is true.  This is why many menopausal women no longer want to have sex….it hurts like hell.

Imagine losing the elasticity and lubrication in the vagina.  It no longer can comply to your partner, that means the tissue will break rather than stretch and contract.  This results in burning pain, predisposition to infections and a strong desire to wear a chastity belt.  We all know that men continue to produce testosterone until they die….so unless your man has issues with erectile dysfunction or medical issues that lower their testosterone levels, their strong desire to have sex does not respect Menopause.  This is where problems arise, ladies!!!!

I have so many patients that were happily married for years, had a great sex life and now suddenly find themselves in the midst of a divorce when Menopause pays them a visit.  When we get to the root of the problem, usually it was because the sex stopped.  I know that I may be oversimplifying the issue and certainly this may not be the only thing that leads to a divorce but I can tell you that losing that level of intimacy always leads to problems.

It’s not your fault, mother nature just gave us the short end of the stick.  Even worse that losing estrogen is losing testosterone.  Not only is there a “Do Not Enter” sign on your vagina but that strong desire to eat your man alive also goes away.  Because testosterone helps build muscle, we also start gaining weight and our six pack becomes a marsh mellow field.  Lack of libido is an issue that many women do not address with their physician because they are either too embarrassed or shy to bring it up. The great news is that you can do something about it.

Talk to your physician and if they give you the  “deer in the headlights look”, seek a consultation with a physician that specializes in hormone therapy and sexual health. If you are a good candidate for hormone replacement therapy, you can replenish all the hormones that you have lost to menopause. Bio identical hormone therapy is on the rise.  Women are becoming more progressive and proactive about aging, sex and vaginal health.

Hormonal pellet therapy will be something that our office will be offering soon. The beauty of pellet therapy is that the hormones are injected underneath the skin and the effects can last 3 to 4 months. This eliminates the use of messy creams or daily oral therapy. We will be having an upcoming women’s seminar on July 18, 2018 where we will be discussing hormone therapy, Mona Lisa laser therapy, acupuncture, micro needling with PRP, permanent cosmetics, skin care and Hydra facials. Aging does not have to be a slow death.  You can slay the menopausal dragon. Sex can be great again and your vagina will thank you for it.  You will leave your partners exhausted and in love. I will keep you posted with event details. 

Adventure Combat Ops – Zombie Apocalypse Las Vegas

My Troops

Our office anniversary is April 1, 2013.  Many of you may not know this but every year, I close the office on this day and take my staff to celebrate.  Sometimes people show up at our office and think that we are playing an April Fool’s Joke because they wouldn’t put it past us.

April 1 is the day when I show my girls how grateful I am for taking a chance on me and helping me build my dream.  In 2016, we had a long weekend and April 1 happened to fall on a Friday.  The wheels in my brain started to turn and I thought it would be great if we could all get away for the weekend.  I flew my girls to Las Vegas and they had no idea what was in store for them.

A couple of them were legitimately terrified of what I would make them do. Some of them thought that we would go skydiving, mud wrestling, white water rafting or have to do spontaneous stand up comedy in front of a large crowd.  Instead, I found this great team-building activity that was a completely immersive zombie apocalypse.

Megan’s rifle is as big as her
Anette and Maribel ready to fight

We were all given assault rifles, combat gear and thrown into this huge warehouse full of dilapidated houses, crashed cars, and fog so thick you could not see 1 foot in front of you. The commander was talking to us in a pressured speech so that we understood the gravity of the situation as helicopters and alarms were heard overhead.  We were given assignments that needed to be completed in order to help the human race free itself of these flesh eating zombies. The set came complete with the most horrific music, seizure producing lights, dark corners and zombie clowns. As if having the clown isn’t terrifying enough you have to make it a zombie.

Sneaky smile

We were taught reconnaissance and how to clear the room so that our buddies can enter safely. In the process, zombies would pop out of the closet, underneath the bed, the refrigerator, or start climbing into the house through the windows. We had to protect each other by shooting the zombies before they caught us. I was so impressed  at how well my staff protected each other. I remember Patty, our ultrasonographer, coming to my rescue and yelling, “I got you, Dr. R”  as she was blasting away at a zombie that almost bit me.   Without disclosing her age, let’s just imagine someone who is “mature and wise” and likely would not play these games going Rambo on every zombie that crossed her path.

Determined to protect this crew

Once we collected all of the important disc drives, computers, maps and documents, we were trapped, the only way out was for one of us to sacrifice themselves to zombies while the others would get out.  Without hesitation, I offered to do this for my team and ran into an abandoned school bus so that the zombies would follow me and my team would survive to save the world.  Being in the bus with zombies crawling in through the windows and each door was liberating, I was no longer scared.  I closed my eyes and knew that I had served a greater purpose.  I succumbed to my fate.   It was truly an amazing experience and one that if faced with in the real world, I think would play out the same.

Love these girls and our commander likely going commando

Watch the video, Adventure Combat Ops-Las Vegas

What's up Doc?

I am beyond excited to introduce Dr. Sonia Rebeles to our patients.  I had been searching for a doctor that would complement my practice philosophy for a long time.  I received many great applicants but none that captured my heart and soul until now.  Dr. Rebeles responded to my very quirky and unusual job posting.  Those of you who know me well, wouldn’t be surprised to know that the job listing was a little like this:  Do not apply if your staff will be having tequila shots and celebrating 4th of July early when you announce your departure.  Do apply if there will be mass chaos and mourning if you leave your current job.  She called me laughing and we immediately connected.  I felt like I was talking to my long lost sister and I knew she was the right pick.

Hailing from the Lone Star State and with humble beginnings, she was determined to succeed.  She is Board Certified in Obstetrics and Gynecology.  She had her own practice in Texas but decided to move to California to be close to her sisters.  She  worked for two years in Beverly Hills before deciding to join our practice.  Her area of expertise is in minimally invasive benign gynecologic surgery including robot-assisted (daVinci) surgery and single site surgery.


Dr. Rebeles received her Bachelor of Arts degree from Stanford University in Human Biology and her medical degree from the University of Texas Health Science Center at San Antonio. She completed residency training at Texas Tech University Health Sciences Center at El Paso where she subsequently served as an Assistant Professor in Obstetrics and Gynecology and Director of the Minimally Invasive Surgical Skills Laboratory.

In Seattle, WA, she obtained additional post-residency fellowship training in minimally invasive surgery, where she refined both traditional laparoscopic and robot-assisted (daVinci) surgical techniques using some of the earliest models of robot-assisted surgery. She is one of few female surgical proctors of robotic surgery and has taught many physicians the fundamentals of minimally invasive gynecologic surgery throughout her career.

Dr. Rebeles is a Fellow of the American Congress of Obstetricians and Gynecologists (FACOG), and is an active member of the Alpha Omega Alpha Honor Medical Society, and the American Association of Gynecologic Laparoscopists. Her interests include irregular, heavy or painful menstrual bleeding, fibroids, endometriosis, pelvic pain, and urinary incontinence. Using a combination of compassionate and empathetic care, evidence-based medicine, sound knowledge of pelvic anatomy, and the incorporation of state-of-the art surgical technology, Dr. Rebeles is committed to offering women innovative treatment options for multiple gynecologic problems.

The new 21st Century Mona Lisa and Lasers

Da Vinci's Mona Lisa
Da Vinci’s Mona Lisa

Perhaps the most visited, talked about and parodied work of art in the world is Leonardo da Vinci’s, Mona Lisa.  Medicine is fascinated with Leo.  First, we named a surgical Robot after him and now, an amazing laser called the Mona Lisa Touch.

It is the new talk of the town in the US but has been in Europe for almost 10 years.  It only recently gained FDA approval in December 2014. The FDA is like the bouncer with a chip on his shoulder at the most coveted night club, giving you the stare-down because you are wearing your Skechers, “Shape-ups” and you should be wearing your  “Louboutins”.  The fact that Mona Lisa got in the club despite her 16th century wardrobe was a big deal and her dance moves have been revolutionary.

The Mona Lisa laser is the only non-hormonal option for women suffering from vaginal dryness, painful intercourse and mild stress incontinence (leaking of urine while jumping, running, coughing, sneezing, laughing too hard).  This is revolutionary because in the past, women who did not or could not take hormones really had no other option but to suffer in silence.

austin powersThe Mona Lisa Touch is not the type of laser beam that Austin Powers wanted to use on his shark’s heads.  It is very gentle, relatively benign and it will not attack you. It can be done in the office with no anesthesia and completed in just 3 sessions, 6 weeks apart.  Those of you who are fascinated with Madonna’s fountain of youth and wonder how a 57 yr old can look like this:

Madonna

should know that her secret is the fractional CO2 laser. Without getting too technical discussing reflectors, couplers, kilowatts and power; the laser is special becauses it causes small columns of injury to the skin which then trigger a healing response in our bodies. New collagen, elastin and fibrin are deposited at the site of injury to plump up our skin and make us look more youthful.

The applications for the C02 laser in Gynecology are many.  We use the C02 laser to treat endometriosis, cut through tissue, vaporize warts and other HPV lesions. We also use it to “rejuvenate” the vaginal wall and external genital labia.

I am the biggest skeptic when it comes to gimmicks. I have to admit that when the Mona Lisa Touch received FDA approval, my interests peaked because I knew that there were clinical trials proving its efficacy.  I have yet to regret purchasing this laser for my patients.

I have many breast cancer survivors who are not candidates for hormone replacement therapy.  Their only option is the laser.  Despite a cancer diagnosis, patients want to lead normal lives which includes being able to have sex without pain. There is no shame in wanting this…it is a primal need for many and in my humble opinion, an essential part of every relationship.

We are lucky that we can now talk about these things.  Women in the 16th Century probably had to “grin and bear it”.  It doesn’t have to be the Sahara Desert or sand paper, ladies, your vagina will thank you for the rejuvenation. Who needs People Magazine or the Louvre to be glorified.  With the Mona Lisa Touch your partner will certainly be in awe of you and your new-found laser. Welcome to the 21st Century!

A Rare Form of Ectopic Pregnancy… Cornual Pregnancy

Location for ectopic pregnancies
Locations for Ectopic Pregnancies

An ectopic pregnancy is a pregnancy that occurs outside of the uterine cavity 98% of ectopic pregnancies occur within the fallopian tube. There is a rare type of  ectopic pregnancy  that occurs at the junction between the fallopian tube and the uterus. These are called interstitial or cornual pregnancies  and can be extremely dangerous, often times leading to  rupture at the site of implantation and internal hemorrhage.   Recently, I had a patient who unfortunately developed a cornual ectopic pregnancy one year after having a myomectomy (removal of fibroids).  In her situation,  the site where the fibroid was removed was at the  junction between the fallopian tube and the uterus.  The pregnancy implanted at this site and unfortunately the patient ended up needing a hysterectomy to protect her life.   There was no way we could salvage the pregnancy  or her uterus without causing severe bleeding.  The pathology specimen showed  that the pregnancy had not only developed at the cornua but it had also started to invade the muscle which would have led to an accreta (placenta gets imbedded in the muscle and at the time of delivery does not detach and causes severe  hemorrhaging.

Uterus with Cornual Pregnancy
Uterus with Cornual Pregnancy
Uterus Removed with Ectopic Pregnancy seen on the Right Corner.  Fibroids also visible.
Uterus removed with fetus seen on the left corner. Fibroids also visible.

Hot Off The Press!

Empowering Women Through Knowledge (left: Jessica, Cynthia, Maribel, me, Teresa & Annette)
Empowering Women Through Knowledge (left: Jessica, Cynthia, Maribel, me, Teresa & Annette)

These are my girls, my office staff, my backbone…the pump that keeps our machine well-oiled.  I am missing a couple of my employees: PAs (Sylvia & Wendy), RNP (Megan) and front office (Rosie)…don’t worry you will meet them soon.

I love this picture so much. It tells a story about empowering women.  Women that believed in my vision, giving up secure jobs to follow me.  I had no idea that my dream of opening up my own office could ever come to fruition.  Somehow, these girls knew before I did and pushed me to take the leap of faith.  I have to give credit where credit is due.  My office would not exist today if it weren’t for these lovely ladies. They are my superheros.  I could not have done this without them.  Thank you team, HER, Inc.,

Tune in for more updates on our office.  We have only been open for two years and are bursting at the seams.  We have outgrown our office space.  We are building a bigger and better suite on the 4th floor of our same building.  We will keep you posted on our move which hopefully will happen in October 2016.