NY Expert Gynecologist

Vulvar vestibulitis and pelvic floor spasm book Chapter by Dr. Levey

2012-01-13T07:27:00.000-08:00

I wrote the attached book chapter about 3 years ago with Dr. Allen Lebovitz who is a psychologist who now works on Long Island. He is an excellent pain psychologist. I recently re-read the chapter and realized it continues to have a high degree of relevance for the work I currently do.

Click here to read and enjoy the book chapter!

Managing Fibroids Surgically

2012-01-03T13:11:00.001-08:00

One of the greatest joys I get from doing my job is to be able to use cutting edge technology to care for very complicated patients. One a weekly basis I see women in the office who have been told they need a hysterectomy to manage their fibroids. The problem is that many of these women want to have children.

Using skills in advance laparoscopy and accessing the amazing technology afforded by the daVinci surgical assistant system I am able to care for women with large fibroids and generally difficult anatomy. Many of these women will go home the same day from surgery and most will be back to work in under 2 weeks.

My patient have chosen to come to have surgery with me because they know I care about preserving their uterus, their fertility, and their ability to make their own decision about their reproductive organs.

Please take a look at the video link to see how I do surgery using the daVinci system and what a nice outcome you can have. If you have any questions and would like a free consultation please email me with your contact information and images (MRI or ultrasound).

Thank you....

2011-11-26T06:51:00.001-08:00

Throughout the year I always let my family know how thankful I am for them however I rarely have an opportunity to tell everyone how thankful I am for my patients and my career. I am very fortunate to be able to wake up every morning and practice medicine, help women through some of their most difficult times and create success stories in the most difficult pain situations.

So, this Thanksgiving I am truly thankful for my patients and their continued faith in me to care for their problems with expertise, kindness, and meticulous attention to detail.

Happy Thanksgiving all.

The smoking gun....

2011-09-09T04:04:00.000-07:00

Are you still smoking cigarettes?

I apologize to the sensitive who may think my words to follow are too harsh but perhaps those are the exact people who need to read them.

I find it unbelievable that in spite of all the evidence people continue to do something so incredibly obviously self destructive. It is impossible not to feel bad for you. Versus people who do not smoke cigarettes you are far more likely to have a heart attack, stroke (have you ever seen how debilitating a stroke can be? How about spending the rest of your life without the use of the entire left side of your body?), and multiple forms of cancer.

This is all in the context of the fact that your personal odor due to smoking is likely to be incredibly foul and offensive to most people.

Not only are you being self destructive but you're just being plain stupid. It's been proven time and time again that nicotine addiction is just about the easiest addiction to break and does not have the same characteristics as other addictions when it comes to longevity. Further, most states (NY being one of them) provide free resources including medication, counseling services, and plans to quit.

I think sometime doctors don't go far enough in telling their patients to quit - so here it goes...

Stop being so incredibly foolish, put down your last cigarette now and quit. Get some help doing it for FREE!!!

Go to this website and get started....

http://www.nysmokefree.com/

Why Exercise is Important for Managing Chronic Pelvic Pain

2011-05-06T07:52:00.000-07:00

Chronic pelvic pain can make every day seem like an uphill battle; ordinary tasks that other people take for granted can become torture. If you have chronic pain, it may greatly decrease the quality of your life, leaving you depressed, irritable, fatigued, and unable to work or enjoy your favorite activities; even if you are taking medication for the pain, you may not experience much relief.

Although it may seem counterintuitive, physical activity is actually an important part of any program for managing chronic pain. While the thought of moving more while you are in so much discomfort might seem out of the question, evidence shows that regular exercise not only helps to reduce the pain that you feel, it can also improve your outlook and change the ways that you cope, mentally and emotionally, with your condition.

How can physical activity help to keep my pain under control?

There is a wide body of research which indicates that exercise has numerous benefits for individuals who suffer from chronic pain:

· Women who exercise regularly generally require less pain medication for the same amount of pelvic pain than women who do not participate in physical activity.

· Targeted exercises not only strengthen the muscles of the pelvic floor, but also increase blood flow to the area, which may help to reduce some types of pain.

· Regular exercise helps to decrease body weight, reducing the amount of stress on the body and improving your overall health.

· Exercise has been shown to help regulate brain chemistry and alleviate the symptoms of depression; this can have a pronounced effect on how women perceive the pain they are experiencing and how they are able to cope with it in their daily lives.

What kinds of exercises should I do?

Dr. Levey recommends a combination of cardiovascular (aerobic) exercise and strength training; how much of each of these you do depends on your personal circumstances – the cause of your pain, your overall physical health, and other factors that you and your doctor will need to take into account. In addition to these, your doctor may recommend certain exercises that focus on the muscles of the pelvic floor. Before you begin any exercise program, it is important that you talk to your doctor about the type of exercise that is most appropriate for you – he or she may refer you to a physical therapist that can help you design a personalized exercise program.

Should I still take my medication?

Under most circumstances, exercise will be part of any pain management program. If your doctor has prescribed medication for your condition, you should not stop taking it unless under the recommendation and supervision of your physician.

If you are experiencing chronic pelvic pain, don’t let it get in your way. Even if the pain is not related to any specific, curable condition, there are a variety of things you can do to manage the pain and feel better as you go about your daily activities. Talk to your doctor about your symptoms; he or she will be happy to work with you to figure out how to improve your quality of life.

Call us @ 646 290 9560 to make an appointment to discuss exercise and pelvic pain. Dr. Levey or Dr. Ostrov will be able to answer your questions.

Taking Medication for Pain - Food for Thought on Using Medication as Part of a Larger, Multimodal Pain Management Plan

2011-04-27T15:06:00.000-07:00

Chronic pain generally cannot be cured by pain medication alone; however, medicine can be used effectively to help control the pain as part of a broader treatment plan. If you have ongoing pain, the first step, of course, is to attempt to identify the underlying cause and eliminate it; however, if the pain is related to a chronic condition that cannot be cured outright, your doctor may recommend pain medication as part of a comprehensive plan for treating your condition.

What kinds of medications are indicated for chronic pain?

Depending on the cause of your pain, there are several different types of medications that a doctor who specializes in managing chronic pain may recommend. These include:

· Over-the-counter medication– analgesics such as acetaminophen, aspirin, and ibuprofen may offer partial relief for ongoing pain. Even if you are using non-prescription painkillers, keep in mind that they can have negative side effects, and they may interact with other forms of medication. Talk to your doctor before using any of these pain relievers and let him or her know about any prescription medications or herbal treatments you are using.

· Prescription pain relievers – If over-the-counter medications are not effective for keeping your pain to a minimum, your doctor may prescribe something stronger; however, painkillers alone may not be enough to completely eliminate your pain, and other forms of treatment may be integrated into your pain management plan.

· Corticosteroids – Anti-inflammatory drugs such as prednisone can be used to reduce inflammation and the associated pain. Sometime these medications are injected into painful areas along with medications such as lidocaine.

· Anticonvulsants – Certain medication originally designed for use in patients with seizures may be effective in managing pain. These may include gabapentin and pregabalin.

· Antidepressants and anti-anxiety medication– In some patients, certain antidepressants seem to work well for controlling chronic pain, even in individuals who do not have symptoms of depression. Similarly, some anti-anxiety medication may help improve the efficacy of the other medication you may be using at the time.

· Hormones – For women who have pelvic pain related hormonally responsive diseases certain regimens including combinations of hormones and anti-hormones may be used.

What are the other common modalities used for treating chronic pain?

Using pain medication for immediate relief is only a part of any effective pain management plan. Your doctor may recommend certain therapies or other procedures as part of your treatment regimen:

· Counseling – talk therapy (sometime called cognitive-behavioral therapy) can help you to work through issues such as depression, anxiety, emotional or sexual abuse, family problems, and other issues that may be contributing to your pain.

· Physical therapy – your physician may refer you to a physical therapist (for low back pain, hip and abdominal wall problems, and pelvic floor dysfunction) who can assist you with strength and stretching exercises, heat or cold therapy, massage, and coping mechanisms to help you deal with pain.

· Surgery – Sometimes it is best to remove or correct an underlying cause of pain in order to make pain medication more effective.

At NY Pelvic Pain and Minimally Invasive Gynecologic Surgery, PC we offer a wide range of options for managing your chronic pelvic pain. We take pride in spending time individualize treatment plans and manage each patient’s needs to suit their lifestyle and outcome desires.

Remember that while pain usually occurs to tell you that something is wrong when there is chronic pain it may not be due to any clearly identifiable factor. Even if you have chronic pain that is not severe, it is not a good idea to ignore it or wait for it to go away. By talking to your doctor about any ongoing pain you may be having, you can find out how to manage it and greatly improve your quality of life.

Please call our office at 646 290 9560 and make an appointment with either Dr. Levey or Dr. Ostrov for an evaluation of your chronic pelvic pain.

Do I Need A Pap Smear This Year? Back to Basics!

2011-04-20T20:55:00.000-07:00

Do I Need a Pap Smear This Year?

One of the questions women frequently ask when they visit their gynecologist is how often they should have a Pap smear. A Pap smear, or Pap test, is a procedure that doctors recommend for all women. This test is performed to detect signs of cervical cancer and other abnormalities in the vagina; it is typically done by your gynecologist during the course of a pelvic exam. Your doctor will insert an instrument called a speculum into the vagina in order to open it slightly so that he or she can see inside and collect a small sample of cells from the cervix.

What does the Pap smear test for?

The Pap test is designed to detect precancerous cells – cells that show abnormalities indicating that they may develop into cancer. Many women are also tested for HPV (Human Papilloma Virus) at the same time. HPV is a virus which can be transmitted through sexual intercourse; women who are positive for certain types of HPV may be more likely to develop cervical cancer.

Is the test painful?

You will feel some pressure when the speculum is inserted into the vagina, but in general, the test is not painful.

What should I do to prepare for my appointment?

You will need to schedule your exam for a time when you will not be menstruating, and you should not use douche or have intercourse for 24 hours before your appointment.

What do the results of the test mean?

If your test results are normal (or negative), this means that your cervical cells are healthy and there is no need for any follow-up. Most doctors will not call you if your Pap smear is negative. However, a positive test result can mean one of several things:

· There is inflammation present due to a yeast infection, HPV, bacteria, or other type of infection

· There are signs of cervical dysplasia – abnormal cells that may be precancerous;

· There are cancerous cells present.

If you have an abnormal Pap smear, your doctor will call you for a follow-up appointment, where he or she may perform a procedure known as a colposcopy to look more closely at the abnormal tissue. You may also undergo a biopsy, where a small sample of tissue is collected and sent to a laboratory for testing and diagnosis of your condition.

How often should I have a Pap smear?

There are several different medical organizations that offer recommendations for how often a Pap smear should be performed, including the American Cancer Society, the American Congress of Obstetricians and Gynecologists, and the U.S. Preventive Services Task Force. While the recommendations of these groups differ slightly due to the criteria by which they make their determinations, the general agreement is that all women should have their first Pap smear by the age of 21, or three years after they begin having sex, whichever comes first.

After your first test, you should continue to have a Pap smear every year until you have had at least three normal tests, at which time you and your doctor may decide that you only need to be tested every three years.

After you turn 30, your risk of developing cervical cancer is much lower; at this point, you may only need to be tested every three years. In some cases, women who have had consistently normal Pap smears may stop having them altogether after age 65. Women who have certain risk factors, such as a previous diagnosis of cervical cancer or a weakened immune system due to chemotherapy, organ transplant or HIV infection, may need to be screened more often.

Keep in mind that early detection is critical to the successful treatment of cancer of any kind. Make it a priority to see your OB/GYN for yearly pelvic exams, and talk to your doctor about how often you should have a Pap smear according to the recommended guidelines.

Please call 646 290 9560 or go online to www.pelvicpainnewyork.com to make an appointment.

Physical Therapy for Pelvic Pain

2010-04-21T09:30:00.000-07:00

It's not a new idea to me that patients sometimes balk as treatments they have never heard of or don't believe in.

I saw a patient just a few days ago with clear pelvic floor spasm. It is unusual for me to see someone with this as their only problem. But really, she had absolutely nothing else that was identifiable at the time of the visit.
So, I explained to her her the nature of the abnormality, the possibility of progression and of the difficulty of treating this problem. I had recommended physical therapy to her as the main modality of initial treatment. I took several attempts but I was finally able to explain to her that just like any other muscle in your body, the muscles of the pelvic floor can become spastic for a variety of reasons. She finally agreed to give it a try. I reassured her that all the physical therapists we use are experts in the pelvic floor and very experienced.

Most of the time when there is pelvic floor dysfunction it is secondary to another problem. That other problem may be a persistent problem such as endometriosis or an acute problem that has already been resolved such as a urinary tract infection. In either case, the pelvic floor muscles are acting to protect the underlying tissue from a perceived injury (as they would do with a broken bone for example). This spasm can long outlast the initial injury and become a chronic problem independent of the initial injury.

I have been recommending pelvic floor physical therapy to patients with many different types of underlying pelvic pain problems. This is often a critical adjunctive therapy (and sometimes the primary therapy) used to help patients improve their overall pain picture and improve their quality of life.

I hope this helps to better explain the need for physical therapy for certain pelvic pain conditions.

Please visit our website: www.pelvicpainnewyork.com for more details.
also, feel free to email me

drlevey@pelvicpainnewyork.com

Dr. Levey

New and Interesting Endometriosis Data

2009-08-23T06:38:00.000-07:00

More on Endometriosis
Periodically I share new and relevant information about common deseases, treatments, and cures with my patients. I normally share this information by sending out an email to our confidential email list. However, the 2 articles I will discuss today present information that is very new so I thought it was important to share with all.

The Clinically Important Article
In February of 2009, an Australian team reviewed 3700 live births and were able to determine that women with endometriosis, specifically with endometriosis in the ovary, had a 2-fold risk of preterm birth. I thought this was interesting when I saw it but believed that there was not a whole lot of additional data to support their findings. Recently, I read an article in a medical newspaper (Ob.Gyn News vol 44 N0. 10) discussing data that was presented at the European Society of Human Reproduction and Embryology. The researchers looked at a database of over 1.44 million births between 1992 and 2006. They determined that women who had been diagnosed with endometriosis has a 33% higher chance of delivering preterm. More interesting, and just as clinically relevant, they determined that there was a higher chance of other complications such a placental abnormalities, bleeding, and preeclampsia.

Based on this knowledge, I tend to agree with the authors' conclusions that women with preconceptionally diagnosed endometriosis should be seen and managed (at least in consultation) by a board certified perinatologist (maternal fetal medicine specialist).

The (Well Sort Of) Interesting Article

In this months journal Human Reproduction there was a very interesting article that evaluated a diagnostic test for endometriosis. They compared endometrial biopsy (the endometrium is the inner lining of the uterus that is shed every month during menses) samples for the amount of microscopic nerve fibers and compared that to specimens obtained from inside the abdomen.

Currently, obtaining samples from inside the abdomen is the gold standard for diagnosing endometriosis. This requires an experienced laparoscopic surgeon and endometriosis diagnostician to obtain the proper sample. However, obtaining a sample of the lining of the uterus is very simple and requires no surgical skill in laparoscopy. So, there is a clear advantage to using endometrial biopsy if it proves to be a useful diagnostic adjuvant.

The current study suggests that there is a high degree of correlation between nerve fiber density on the endometrial biopsy specimens and the finding of endometriosis inside the abdomen and pelvis. If we could use endometrial biopsies to better diagnose endometriosis it would save a lot of patients from having unnecessary surgery and it would help us better plan for surgery in patients who do need surgical intervention.

I am reluctant to start using and relying on this technique at this time as this study has several weaknesses. There were weakness in their samples such that the overall quality of their samples we low (only 25% were "satisfactory"). They said in their article that they did not have all of the possible biopsies from inside the abdomen. Thus, they made some correlations based on visual diagnosis only - this creates a significant problem because instead of comparing apples to pears they are now comparing apples to pears plus oranges - further confounding the data.

I look forward to further study of this very promising technique.

2009-04-16T10:31:00.000-07:00

Acupuncture and Nutrition: A way to improve symptoms associated with fibroids?

So, we work with a fantastic acupuncturist here is the office and I asked him what we could do to raise awareness of some of the ways in which acupuncture could possibly help women with various gynecologic conditions. The items below are for you information and were written by Robert Branch. He has over 20 years of experience in acupuncture and traditional Chinese medicine. I trust him to help you and welcome him into the fold of my network of specialists.

Fibroids or myomas are benign tumors found in approximately 20% of women over 35 years of age. Uterine myomas are the most common neoplasm of the female reproductive organs, and are associated with menstrual pain, heavy menstrual bleeding, and fertility problems (R.Lewis, P.hD., L.Ac.).One Chinese study used Traditional Chinese herbal medicine to treat 223 cases of uterine fibroids.

· Herbs were administered after menstruation. The authors reported a 72% reduction in the quantity of menstrual blood. Symptoms like abdominal pain, and backache were improved in 58.8%. The overall effectiveness rate was 92.4%. Myomas completely disappeared in 13% of the cases, were markedly diminished in 29%, slightly reduced in 19%, and unchanged in 28%.

Acupuncture is also recommended in the treatment of fibroids. Stimulation provided by acupuncture has been found to reduce proliferating fibroid cells.

Other natural treatments (potentially useful for symptoms associated with endometriosis), include:
· Rest and wear loose, comfortable clothing
· Perform deep breathing exercises and meditative practices
· Take warm baths (with aromatherapy if you wish.)
· Use essential oils like frankincense, myrrh, clary sage, peppermint, lavendar, rosemary,
juniper and thyme.
· Use a heating pad or hot water bottle on your abdomen
· Apply warm castor oil packs on your abdomen to invigorate the blood, assist the lymphatic
symptom and balance hormone levels. Apply warm castor oil to the lower abdomen and
cover with plastic wrap two to three times per day during the premenstrual and menstrual
period.
· Take herbal supplements that invigorate the blood (and those for resolving concomitant
patterns as applicable.)
· Avoid all foods which have been treated hormonally.
· Consume soy and soy products like tofu.
· Buy only organic fruits and vegetables.
· Avoid refined, rancid and hydrogenated oils.
· Use only unprocessed plant sources of essential fatty acids.
· Use oils rich in both linoleic and alpha-linolenic fatty acids such as flax-seed, pumpkin-seed
and chia-seed oils, but only if they are recently cold-pressed and refined.
· Include dietary spirulina, evening primrose oil, and oil from black currant and borage
seeds.
· Avoid sources of arachadonic acid, which comes from animal meats, dairy products, eggs,
peanuts and seaweed.
· Decrease the amount of dietary animal products, except fish.
· If you do consume meat, make sure it is at least organic, and not hormonally treated.
· Eat walnuts, dark greens, saffron and cold climate crops.
· Foods which are especially good for resolving blood stasis include: Kelp, lemons, limes,
onions, Irish moss, and bladderwrack.
· Antioxidants (vitamins C, E, beta-carotene, selenium, zinc)
· Super antioxidants (grape seed extract, pine bark extract, red wine extract, bilberry
extract)
· Omega 3 fatty acids (fish oil and linseed oil)

On contraception: Why make would anyone make an incision?

2008-08-03T12:54:00.000-07:00

In today's world of contraception women have more choices than they ever did. Those choices include oral contraceptives (birth control pills), patches, vaginal ring, IUD (the most commonly used form of contraception in the world), condoms, male sterilization, hormone implants, every 3-month injections, and female permanent contraception.

For women who choose female permanent sterilization they have already made a choice to never have another child. In support of that choice a woman's physician should encourage her to make the choice that comes with the fewest complications and equivalent efficacy to other methods of permanent sterilization. Problematically, though, many physicians are doing just the opposite.

When a woman chooses permanent sterilization (tubal ligation) as her means of contraception and she is not having the tubal ligation immediately after a Cesarean delivery, she has 2 major choices.

One choice is to go to the operating room in a hospital, have general anesthesia with a tube in her throat, and allow someone to breathe for her. Then a gynecologic surgeon will make 1-2 small incisions in the abdomen and place a camera to visualize the fallopian tubes while expanding the abdomen with gas (carbon dioxide). From this point several different methods may be used from burning the tubes to placing rings or clips on the tubes. She will then go to the recovery room for usually 1-2 hours to recover from the anesthesia and receive pain medication for the abdominal pain. She is likely to have some post-operative nausea and vomiting. She will then be discharged to home and may miss up to 2 weeks of work while she recovers*.

The second choice is to go to an office setting, take some Valium to relax, have an injection of pain medication in the arm and some in the cervix and stay awake for the procedure. The gynecologic surgeon will place a camera slightly smaller than a straw into the uterus and place implants in the fallopian tubes that will eventually serve to block the tubes. This procedure is called an Essure. The only pain associated with the procedure has been described in my office as moderate menstrual cramping that goes away in a short period of time (sometimes up to 4 hours). A woman who has had an Essure procedure in the office can go back to work the next day*. In 3-months time, an additional test is required to ensure the tubes are closed. This test is called a hystersalpingogram which is like an x-ray of the fallopian tubes.

I ask my patients who have chosen tubal ligation to think about what they would like. An incision, general anesthesia, and several weeks of discomfort and missed work? Or, a simple office procedure that takes a few minutes with minimal pain and a test 3-months later to guarantee there has been success.

You make the choice!

Visit us at www.pelvicpainnewyork.com to learn more.

*(No set of outcomes is ever guaranteed for any surgical procedure. Please discuss the risks, benefits, outcomes, and complications of all procedures with your physician)

Endometriosis: Missing the Pain Boat

2008-06-16T14:14:00.000-07:00

There are several surgeons in the NY area and many more around the country and world that understand the need for surgical resection of endometriosis when it is implicated in chronic abdominal / pelvic pain. I am included in this group. So, why is it so hard to manage endometriosis?

The simple answer is - it's not the endometriosis that's difficult to manage - it's the associated pain that is difficult to manage. It's critical that your surgeon (hopefully that person also offers you a comprehensive pain management plan for the long term) educates you to the fact your problem is not only endometriosis. It's critical for you to understand that you also have a pain problem.

A pain problem?!?

Yes - you likely have, in addition to the pain generators associated with endometriosis, a central pain syndrome that has developed over many years such that your brain and spinal cord have changed. So, if an expert in endometriosis removal does the best surgical procedure possible you may still have pain!

Ok, so what else? Well, when pain exists for a long time other - secondary - problems may exist such as interstitial cystitis / painful bladder syndrome (IC / PBS), irritable bowel syndrome (IBS), depression, pelvic floor muscle spasm and a host of less common problems. If your surgeon does a radical removal of endometriosis and your pain does not go away you likely have one of these problems (70% of patient with endometriosis also have IC / PBS). Yet, the surgeon may have no explanation for you.

If your surgeon does not understand these concepts then you may consider finding a new surgeon or consulting with an expert in the multidisciplinary evaluation and multimodal treatment of chronic pelvic pain.

Visit us at www.pelvicpainnewyork.com to learn more.

Defining Solutions

2008-05-19T14:12:00.000-07:00

A few days ago a patient asked me my opinion of the best solution to treat her fibroids. I gave her my opinion and she didn't seem happy with my answer. I had explained to her that the best options is the one that is going to give her the outcome she desires. If the desired outcome is only to decrease bleeding then I may have a bets solution for that. If the desired outcome is only to decrease pelvic pressure and associated pressure related symptomes such as urinary frequency then I may also have a solution for that. In then end, it seemed her fibroids weren't really bothering her. None of the above problems were issues for her.

She explained to me she was more surprised at, than she was displeased with my original recommendation - "do nothing". "Do nothing" is usually an appropriate option when there is no problem to fix. She left seemingly comfortable with the new plan of observation.

Please remember to ask your doctor why you require treatment for your fibroids if they are not bothering you.

Visit us at www.pelvicpainnewyork.com to learn more.