Important Information About HPV and YOUR PAP

Infection with the Human Papilloma Virus (HPV) is very common in both women and men. There are more than 100 types of this virus and some of these have been linked to genital warts and cancer of the cervix. There is a vaccine that prevents the two types of the HPV that cause the most cases of cancer and the two types that cause most genital warts. This link explains:

• What is HPV

• The link between HPV and cancer

• Who should get the vaccine and why

Please visit: http://www.acog.org/Patients

The Link You Need to Have

American College of Obstetricians and Gynecologists
This official web site of the American College of Obstetricians and Gynecologists provides patients education and much more. http://www.acog.org

If you would like to find more patient education on a variety of Women’s Health topics, please visit the ACOG Patient Education Pamphlets page at: http://www.acog.org/Patients

Bio-Identical Hormone Replacement Therapy

Bio-Identical Hormone Replacement Therapy (BIHRT) is a customized formula of hormone replacement therapy made based on your blood hormone levels. This is a plant based bio-identical hormone combination made to resemble what you ovaries make. Your doctor and YOU, the patient, work as a team to get the best balance of hormones to meet your needs this would include checking blood hormone levels regularly until the most effective dose is found. Many women feel this is a more “natural” way to replace their hormones and prefer this approach. Not only does it address your symptoms of menopause, but it has many hidden benefits that may add longevity and a better quality of life. It is important to understand that BIHRT may have the same risks as other prescription HRT. It is not covered by insurance and the cost may vary depending on the formula that best fits your need and the amount of follow-up needed to adjust your doses.

For your added convenience, we now offer a variety of options for consultations and monitoring, and conveniently located labs for blood drawing.

If you would like more information and for a personal consultations about your options on how to approach Bio-identical Hormones, please contact us to make an appointment.

Alternatives to Hysterectomy: New Technologies, New Options


One in five women has heavy bleeding at some point during her childbearing years. Heavy bleeding is most common for women between the ages of 40 and 50, as they approach menopause. It also can be caused by hormonal changes or certain medical conditions. Although there are other causes of heavy bleeding, such as fibroids, polyps, and cancers, ablation is usually not used to treat these problems. Some ablation techniques may be used with fibroids. Blood loss from heavy bleeding can lead to anemia (lack of iron in the blood). It also can affect you daily activities. In most cases, we can treat the bleeding with medications. However, if the bleeding cannot be controlled, ablation may be used.

Ablation destroys a thin layer of the lining of the uterus called the endo-metrium. This stops all menstrual flow in many women. After ablation, some women still have light bleeding or spotting. A few women may have regular periods. This is because the ovaries and uterus are not removed. If ablation does not control heavy bleeding, further treatment or surgery may be required. Most women are not able to get pregnant after ablation. Therefore, if you may want to become pregnant, you should not have an endometrial ablation. Although pregnancy is not likely after ablation, you should keep using some form of birth-control until after menopause. You also may want to think about sterilization as an option to prevent pregnancy. Ablation does not affect sexual response. A woman who has had an ablation still has all of her reproductive organs in place, and therefore should continue having routine pap tests and pelvic exams.

For more information please visit www.uterus1.com.

Minimally Invasive Surgery

Minimally invasive surgery (MIS) is performed using scopes rather than large incisions. A laparoscope is used to perform the particular minimally invasive surgery. Currently, robotic-assisted surgery is making laparoscopic surgery safer and more effective.

A Laparoscope is a narrow scope with multiple lenses used to look inside the abdomen or pelvis. The scope has a video camera attachment so that the surgeon can view the abdominal and pelvic cavity without a large incision. The picture of the internal structures is projected onto a video monitor like a TV. Other instruments can be inserted through two to three accessory ports. The incisions are ¼ to 1 inch or smaller. Because there are only a few small incisions rather than a single large incision, the patient is usually able to go home the day of the operation.

Minimally invasive surgery reduces the healing time to days or weeks instead of weeks and months. Because of the tiny incisions, or possibly no incisions, the woman is able to go home the same day, and will have a much faster recovery compared to traditional abdominal surgery. Laparoscopic-robotic assisted surgery is less painful and has a faster recovery than traditional abdominal surgery. However, there is always the risk of complications in any surgical procedure, whether it is abdominal surgery or minimally invasive surgery.

It is possible to offer a patient a less invasive, less painful procedure in the vast majority of cases. Some of these procedures include, but are not limited to:

Robotic Assisted Surgeries
•Abnormal uterine bleeding
•Removal of fibroid tumors
•Excision of endometriosis
•Management of pelvic pain
•Infertility surgery
•Ovarian cysts

For more information about MIS, please contact the office to schedule a consultation with Dr. Hage.

Cord Blood Banking


Expectant parents are faced with many important decisions from the moment they find out that they are pregnant. It is a time of excitement and joy. It is also a time of uncertainty when newly expecting parents have to help ensure the best for their unborn child. One of the latest possibilities parents are now considering is the ability to have their physician collect cord blood, enriched with life-enhancing stem cells, easily and painlessly from the baby’s umbilical cord at birth.


Blood is collected from the umbilical cord attached to the placenta after the baby is born. The blood is then packaged in a collection kit provided by the cord blood bank, and then transported to the cord blood facility for processing and storage, where it remains as “insurance” for possible future use. Collected, processed, and stored by a reputable facility, parents are now provided with the potential ability to safeguard their baby’s future health, as well as the health of their family.


Stem cells taken from cord blood form the body’s immune system foundation and manufacture blood and disease-fighting immune cells and while cord blood stem cells can be used without a perfect genetic match. When used by the baby, it is always a 100 percent match. There is also a 25 percent chance it will be an exact match for one of the baby’s siblings. Cord blood stem cells can be used to treat a variety of cancers, such as Hodgkin’s disease, as well as genetic diseases like sickle cell anemia. Other uses include treatment of immune system disorders and more recently, these and other similar conditions have been treated with stored stem cells. Previously, these conditions were successfully treated with bone marrow donations; however, there needs to be an exact match, a waiting period and a very high cost. These issues are avoided with stored umbilical cord blood; There is simply no waiting time necessary and it is available when needed.


The reality of the future lies in the advances in medicine today and without a doubt, the use of stem cells taken from stored cord blood as treatment for so many conditions is truly one of the foremost medical marvels of our time. Medical and scientific researchers in a multitude of disciplines believe that at some point, it may be helpful in regenerating organs and nerves. Expectant parents in ever growing numbers have embraced the fact that cord blood storage is an easy way to prepare for the much-anticipated medical breakthroughs and discoveries of tomorrow. It could be compared to a life insurance policy: You may never use it, but if you or your family need it, it could be a great investment.

Here are some of the cord blood banking facilities that we have used:

• FamilyCord www.cryobank.com
• PacifiCord www.pacificord.com
• Cord Blood Registry www.cordblood.com

Human Papilloma Virus (HPV) Testing

Since the 1940’s, when the Pap smear was first introduced, the death rate for cervical cancer in the US has declined by nearly 70 percent. However, more the 15,000 new cases if invasive cervical cancer are diagnosed and nearly 5,000 women die of the disease each year. Prevention of cervical cancer is possible by finding out if you have a virus called the human papilloma virus (HPV). Certain “high-risk” types of HPV are known to cause most cases of cervical cancer.


Cervical cancer is almost 100% curable when it is diagnosed early and treated promptly. The Pap smear is one of the methods for identifying abnormalities in the cervix that could develop into cancer. Unfortunately, many studies have shown that the Pap smear can fail to detect an abnormality early enough to prevent cervical cancer. The first Pap smear should be done by age 21, or earlier if you become sexually active. Most women are advised to have a Pap smear once a year.


The HPV Test, when combined with the Pap smear, improves screening for pre-cancerous changes of the cervix, if you have HPV. The HPV test is approved by the FDA and uses advanced technology to detect the genetic (DNA) code of HPV. If you are over the age of 30 (when cervical cancer is most likely to occur), it is recommended that you have the HPC test along with a Pap smear to increase out ability to protect you against cervical cancer. Early detection means early treatment. If you are under 30, we may order an HPV test if your Pap smear result is unclear or abnormal. Learn more about the HPV test by going to the website at www.thehpvtest.com.


Gardisil is the first FDA-approved vaccine that has been shown to protect against the most common types of HPV viruses. It is available for women up to 26 years of age. It is a series of three injections over a 6 month period. Learn more about the vaccine by visiting the web site at www.gardisil.com.

Menopause and Peri-menopause

Menopause is what happens to all women as their ovaries quit producing eggs. The ovaries decrease production of estrogen, progesterone, and other hormones. The loss of these hormones is accompanied by multiple clues from their body- they can be mild and transient to severe and interfere with your lives. It’s a time in a women’s life that is different. No more menses, no more ovulating, no more PMS, no more pregnancies. This can be a wonderful time in your lives; if you first understand what has happened and second, have control over how we want to manage it.

It might have been a rough ride for some women just getting to this point. The peri-menopause was what was happening for a few years leading up to menopause. At that time, there are unpredictable periods, breast tenderness, bloating and swelling, hot flashes then and maybe now. Sleep disturbance, vaginal dryness and painful intercourse may add to your discomfort. Concentration is often difficult and it brings on headaches which are common. Pregnancy is still possible during the peri-menopause years because you may still ovulate, it is infrequent and unpredictable. Contraception still must be used until menopause has been confirmed- usually until one year of no bleeding.

First thing you must do as a woman going through menopause, is to take care of yourself. Eat right, exercise, get an annual exam and mammogram, stop smoking and limit alcohol intake. Take a multiple vitamin and calcium supplements as directed. Calcium supplements are important because bone loss accelerates with the menopause, so prevention is important. Soy products help many women, as do some over the counter herbal products. Some women feel that these simple steps get them enough relief and the discomforts resolve. Other women seek help for the discomfort if it becomes too disruptive. Hormone replacement therapy has been available for many years. Recent research has bombarded the press and medical journals with conflicting and confusing information. Just remember, if you choose to take HRT (Hormone Replacement Therapy) these is a right way and a wrong way. You should discuss this with your health care provider. You also should discuss the risks as well as the benefits of HRT with your provider. Ask questions! There are many prescription brands of HRT available now and many are covered by most insurance plans.

Of note in the past several years is the availability of Bio-Identical Hormone Replacement therapy (BIHRT). Think of it as a customized formula made based on your symptoms. Please see the information at the top of this page. If you have any questions or would like to schedule an appointment, please contact us to make an appointment.

Frequently Asked Questions (FAQ’s)

1. I am considering getting pregnant within the next few months. Is there anything I should be doing now?

• If you have any medical problems now or in the past, you should be evaluated before conceiving. If you have diabetes, high blood pressure or any other medical conditions, your condition should be well controlled and stable before you conceive, in order to prevent birth defects and lower the risk of miscarriage. It is also important to have good nutrition and consume enough folic acid daily at a dose of 0.8-1.0mg. It is advisable to take prenatal vitamins daily prior to conception. There are many other things that should be addressed before conception. This is a good reason to schedule a preconception visit with Dr. Hage.

2. I am pregnant and need to take medication prescribed by another doctor. Is this safe during pregnancy?

• Some medications for ongoing medical problems need to be taken throughout pregnancy in order to keep those problems under control. No one can guarantee the safety of any medication during pregnancy, so we have to weigh the risk of taking the medication against the benefit. In general, during the first three months, only medications essential for your health should be taken because this is when the baby’s organ systems are forming and any birth defect potential would be maximal. After that there is less risk to the baby, except for a smaller group of drugs. This is a problem that should be discussed with Dr. Hage before conception. It is never a good idea to stop any prescribed medication without first discussing it with your doctor.

3. My first baby was born by Cesarean. Will I need to have another Cesarean?

• We do not offer vaginal birth after Cesarean (called VBAC), however, if you are interested in a VBAC, we will gladly arrange a referral for you to a facility that may be able to assist you. Most women may attempt a VBAC after one C-section, depending on the type of uterine incision made previously. However, there is a risk of the uterine scar separating and this occurs in up to 1 percent of labors after C-section. The decision to attempt VBAC should be a mutual decision made with your obstetrician.

4. I am 35 years old and hoping to become pregnant soon. What are my risks because of my age?

• Older women appear to have an increased risk of several things when they become pregnant. Medical problems such as high blood pressure and diabetes are more common. Miscarriage rates increase and fertility rates decrease. However, one of the biggest concerns is the greater risk of certain chromosomal abnormalities as the woman’s age increases. The most commonly known one is Down’s syndrome, however other syndromes are also increased. Women who are 35 at the expected date of delivery are offered genetic testing. The final decision about getting tested however, is that of the patient, not the doctor.

5. I am 40 years old and am having irregular periods and hot flashes. Is this menopause and how long will these symptoms last?

• The average age of menopause in the US is 52. The classic definition of menopause is one year without any periods, however, symptoms can occur much earlier. The classic symptom of menopause is the hot flush or flash. Problems that arise because of decreased estrogens at menopause are significant. The most worrisome is an increase in coronary heart disease and stroke, but there are other significant problems such as osteoporosis (thinning of the bones), urinary bladder and pelvic support problems, Alzheimer’s disease, etc. We know that hormone replacement therapy (HRT) will markedly reduce or eliminate many of these problems. HRT using Estrogens and Progestins has some health risks and there are many options for therapy. The patient must understand the risks of HRT compared to the benefits before initiating therapy. For more information on HRT, risks, benefits and alternatives, you may schedule a consultation with one of us.

6. I have been told that my uterus in enlarged and that I have fibroids. What does this mean?

• The uterus is mostly made of muscle. When tumors in this muscle develop we call them fibroids. Only rarely are they cancerous. These muscle tumors can distort to uterus and enlarge it sometimes leading to abnormal bleeding. They can also cause pressure symptoms and problems by pressing on adjacent structures in the pelvis. These can lead to bladder, kidney, bowel problems, pain, etc. The management of the fibroids depends upon their size and the symptoms they are causing. There are times when treatment is not necessary. Surgical treatment is also necessary in some cases. You may schedule a consultation with Dr. Hage to discuss your options for treatment.

7. My periods used to be every 28 days, but now they come every 2 to 6 weeks. What is wrong?

• There are several causes for abnormal uterine bleeding. Hormonal imbalance involving the thyroid gland, adrenal gland, pituitary gland, or ovaries may be the problem. The other common cause involves structural abnormalities of the uterus, cervix, or vagina. These include polyps, uterine fibroids, precancerous changes or even cancer. It is extremely important to be evaluated promptly when these problems occur. Many times these evaluations can be entirely performed in the office. Sometimes however, the evaluation requires surgery such as hysteroscopy, usually done as an outpatient.

8. I am 60 years old and haven’t had a period for 9 years. I have just started bleeding again. Is this a problem?

• Most bleeding after menopause is due to a benign condition, however cancer needs to be ruled out. All postmenopausal bleeding (defined as bleeding after a one year absence of periods) needs to be evaluated promptly.

9. We have been trying to get pregnant for over a year and have been unsuccessful. What can be done?

• Fertility problems occur in about 15% of the population. Approximately 35% of couples with difficulty conceiving have more than one problem. A full evaluation is important to find out the exact cause of the fertility problem. Areas targeted for evaluation include the sperm count, ovulation, an analysis of the Fallopian tubes, and various hormones. After evaluation a treatment plan can be instituted. Sometimes a referral to an infertility specialist may be necessary.

10. I have a lot of pain with my periods and have been told I have endometriosis. What does this mean?

• The lining of the uterine cavity is called the endometrium. If this tissue gets outside of the uterus it can implant and grow in various areas of the pelvis and abdomen. This is called endometriosis. It is a common cause of pelvic pain and can cause infertility. The location and extent of the endometriosis as well as the degree of symptoms would determine the treatment necessary. Treatments that Dr. Hage uses range from observation to medical therapy, to minor and major operative procedures. Treatment must be individualized.

11. I have an abnormal Pap smear. What should I do?

• A Pap smear is a screening test for cancer. However, the vast majority of abnormal Pap smears are not due to cancer. Some abnormalities are due to inflammation or inadequate numbers of cells, and may be managed simply by repeating the Pap smear after treatment of the cause of the inflammation. Pap smears showing atypical or precancerous cells are best evaluated by a procedure called colposcopy. During this procedure, Dr. Hage examines the cervix, vagina, and vulva using magnification. Areas of abnormality are sampled with a biopsy and a treatment plan is recommended. Many minor abnormalities are observed by means of frequent Pap smear combined with periodic colposcopy. Some abnormalities are treated using electrical excision, known as LEEP, an office procedure. If cancer cannot be ruled out by means of colposcopy, then a more extensive biopsy of the cervix called a conization needs to be performed. When you have a Pap smear done, be sure that you know the results and follow any instructions Dr. Hage gives you.

12. What is osteoporosis?

• Osteoporosis is a thinning of the bones and is most frequently seen in postmenopausal women. It is a silent process that makes the bones weak and brittle. When this happens, a minor fall can cause a fracture which sometimes requires major surgery (e.g. a broken hip). This disease is not related to arthritis. Treatment for osteoporosis includes hormone replacement therapy and other medications. Adequate calcium and vitamin D and weight bearing exercise maximize the effects of medication. It is also important for teenagers and young women to maximize their bone strength by consuming diets containing adequate calcium (1200 mg per day). Also, prevention of osteoporosis includes refraining from smoking and minimizing alcohol consumption.

13. I have a vaginal discharge and irritation that is not improving with the over-the-counter medication. What should I do?

• There are many causes for these symptoms such as infections with viruses, Trichomonas, bacteria, yeast, and so on. The only way to find out what is causing the problem is to have an examination with a microscopic evaluation of the discharge. Over-the-counter medication may be used for certain conditions, but if the problem does not respond, an exam will be necessary.

14. My physician has recommended an abdominal hysterectomy what are my options? What is a “DaVinci” hysterectomy?

• Please go to http://www.davincisurgery.com to find out more information.

Frequently asked questions about breastfeeding.

A. I want to breast-feed and I have small breasts. Will I be successful?

Breast size does not correlate with breast-feeding ability. Some women with very small breasts cannot breast-feed, but this is a rare condition.

B. Can I breast-feed if I have to return to work?

Yes. Many companies are making it easier for women to breast-feed and pump milk at work. If exclusive breast-feeding is impossible, partial breast-feeding in the morning and at night is an option.

C. If the baby is premature, can I breast-feed?

Yes. Breast milk is particularly good for premature babies even if it has to be administered through a tube.

D. I have had breast surgery. Can I breast-feed?

Some women who have had three to four incisions for fibrocystic breast disease may have some damage to collection ducts, but this rarely interferes with breast-feeding. Breast reduction surgery may be a problem, because the surgical techniques done in the past. destroyed some of the duct system. Most breast implants are placed under the breast tissue, where they should not interfere with breast-feeding.

E. Will I experience weight gain while I breast-feed?

Usually women will NOT gain weight, however there are many factors involved in weight gain.

F. Does breast-feeding prevent cancer?

Some studies have found an association between breast-feeding and a reduced risk of some cancers. Breast-feeding appears to have a protective effect against breast cancer. Data also suggest a 20% reduced risk of ovarian cancer.

G. What happens if I don’t have enough milk?

It is important to let the baby breast-feed longer, emptying each breast, and to use one breast predominantly for each feeding. Alternating breasts from one feeding to another will help.

H. What happens if I get mastitis or a breast infection?

If not treated early and properly, this can lead to an abscess. Mastitis can occur in the second or third week of nursing; the breast becomes red, hot, and tender, with one-sided swelling, a temperature as high as 101° F, and flu-like symptoms. Treatment should include nursing on the unaffected side first. Treatment with antibiotics, heat, fluids, and a pain reliever such as Tylenol or Advil is also helpful.

I. If I become pregnant, can I still breast-feed?


American College of Obstetricians and Gynecologists


This official web site of the American College of Obstetricians and Gynecologists provides health education information and much more.

ACOG Patient Education Pamphlets


American Cancer Society


American Medical Association


American Psychological Association


Baby Center


A comprehensive web site with information, instruction, and video- both animated and live action- of the growth of your baby and the birthing.

California Department of Health Care Services- Gynecologic Cancer Information Program



Mayo Clinic Health Oasis


This on-line information source has an extensive women’s health section.

National Alliance of Breast Cancer Organizations


National Library of Medicine


The National Library of Medicine web site provides diverse diverse health information.

National Osteoporosis Foundation


The National Osteoporosis Foundation is a leading resource for up-to-date, medically sound information on the causes, prevention, detection and treatment of osteoporosis.

National Ovarian Cancer Coalition


The National Ovarian Cancer Coalition seeks to raise awareness and promote education about ovarian cancer.

National Cervical Cancer Coalition


The Cancer Information Service


The North American Menopause Society


The North American Menopause Society (NAMS) is a nonprofit organization that provides a forum of a multitude of scientific disciplines with an interest in human female menopause.

Robotic Assisted Surgery




Cord Blood Registries and Banks




Miscellaneous Baby Sites



Parenting Websites



my Optum Health


Web MD


CNN Health News


Boston Scientific