thank you good evening and welcome to doctors on call I'm Dr Mary Owen associate dean of Native American Health and director of the center for American Indian and minority Health at the University of Minnesota medical school I'm also a family physician for the Fond du Lac band of Lake Superior Chippewa and I'm your host on on tonight's program on women's health and female cancers the success of this program is very dependent on you the viewer so please call in your questions or email them to ask wdse.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Michael Cassian and OB GYN specialist with Essentia Health Dr Krishna colandival a hematologist oncologist with St Luke's Regional cancer center and Dr Addie Vittorio a family medicine physician with St Luke's Mount Royal Medical Clinic our medical students answering the phones tonight are Rebecca Jacobs of Asante Minnesota Emily Clark from Ivanhoe Minnesota and Andy Ledesma from Danube Minnesota and now on to tonight's program on women's health and female cancers thank you all for being here I told you we got one question early so I'm going to ask whoever wants to jump forward I think Dr Colin devil you answered it earlier if you have dense breast tissue should you opt for an annual ultrasound or MRI versus a 3D mammogram yeah so dense breast issue is something we see commonly uh usually the first line of screening is just 3D mammograms but one caveat is 3D mammograms are not good in dense breast tissue it can miss small cancers so sometimes we recommend an MRI but with MRI the problem is sometimes the insurance don't cover it so at that time we just stick with dense breast tissue but we are a bit more aware doing clinical blister exams same for all of you and I would say that I think both hospitals at least in this area have Specialists who are willing to have a consult and talk with patients about their mammograms and their dense breast tissue or their family history and give recommendations that may further support insurance coverage of those things okay so women aren't out of luck if they don't have that good insurance then talk to your primary doctor okay who usually can get it covered yeah if they have like a strong families tree or any inheritable like high-risk gene mutations like brca then they will be eligible for MRI it'll be much more easier to get down we talked we mentioned at the beginning of the show before we started here that post covid we are seeing higher rates of advanced cancer presentation or people coming in a little bit further ahead in the cancer than they had been before covid and that's something that you're all seeing go ahead I think the the biggest difference is that people have delayed screening and whether that's a mammogram or a colonoscopy a pap smear HPV testing you know people just haven't been to the doctor in several years and and that lack of screening is what I think has been the cause of it Dr Victoria any women's health condition yeah and I would add with Women's Health I mean a lot of the things I'm seeing and in my practice are that women have been over 50 have gone through menopause and then they have a bleed that they don't call their doctor about or tell anyone about and and any bleeding after menopause should be evaluated and so we're seeing people who maybe said well two years ago I had this but now it happened again that's kind of scary yeah yeah okay good so the answer is get in if you have questions especially if you've been waiting postcovid anything to add to that Dr colandival yeah no that's true actually last year when before vaccines were available and when everything started ramping up we saw a lot of advanced presentation of cancer but now I think everywhere with all the vaccines screening is back on track and so now it has calmed down better okay are you fearful with uh you know there's reports of us getting you know more strains of covid and causing a backlog again or causing people to be a free-for-all again or any recommendations to your patients sorry I uh I was here about 15 months ago and the recommendation was to get a vaccine and the recommendations still to get a vaccine so I think the landscape of covet has changed significantly um you know a virus just isn't going to kill everybody because then it dies too so as the virus mutates and changes you know we have to make sure that we are staying up on on vaccination and you know hopefully we will never need to go back into the universal masking and distancing and and that stuff because it has been a different disease for the last six months so hopefully people will know that they can come out and and get the health care that they need yeah and I would say that I mean just anticipate that you might wait you know a couple weeks longer for your mammogram you might wait still because of mainly staffing issues right now you know to get in with your doctor or with your specialist just because we are short on the workforce just like every other industry Dr colon devil in general though rates of cancer many many cancers are increasing that's true yes so thoughts on that or recommendations any what is that what are you talking with patients about that is all across the board and even now we are seeing cancers in more younger people recently I saw like the colon cancer is like more uh we're finding people more in like 30 to 50 age group and I think a lot of factors one is like an environmental more pollution uh pesticides and these kind of things are associated but it's never like a very clear-cut direct correlation then a diet people are in general the Obesity rates are high so that plays a very big role physical activity in general has decreased more stress so all these things are contributing and we it's definitely true that we do see a lot of cancers all right we have a whole a lot of questions now what are Dr Victoria what are some concerning signs and symptoms for endometriosis and how do I talk to my doctor about these concerns and feel free to jump in Mike when you me too but endometriosis I mean there is sometimes a family history of the disorder um and endometriosis is a proliferation of some of the menstrual tissue and it's there's a couple theories on it but um it's felt to be sort of outside the uterus where it's normally shed and so symptoms might be very painful very heavy menstrual cycle significant bowel or bladder complaints kind of associated with that I mean I've had people come in who say that when they get their period they faint on a regular basis because of pain or other issues and so that's usually a disease of men's training women because of how it occurs and you would check with your OB GYN or your primary doctor and they would give you kind of recommendations for going about testing sometimes there is not a lot of testing that is done in younger patients and sometimes there is testing that may involve a laparoscopy or visualizing sort of the other organs and the pelvic organs so they ask about how do you talk with your doctor about it and it's basically just tell your doctor your symptoms I'm having problems with my period here's what's going on and and you know we always have a series of questions we ask about how often what's it like what's your family history like and the main thing is just to talk to your doctor and they'll know the questions to ask absolutely I mean pain with intercourse difficulty any pregnancy or infertility um along with what Dr Victoria said is it's very common and endometriosis especially in the ogyn clinic is something that we deal with every day and every OB G1 has on the front of their mind and the younger patient so just come in and talk to your doctor and if it's treated early I mean you can prevent some of those things like the fertility related issues Dr cassine what signs and symptoms should I be concerned about for breast cancer so you know the the breast cancer diagnosis is it's usually always either from a screening mammogram or they find a lump and traditionally it was the patient found a lump in her own breast um depending on what recommendation you look at people aren't exactly recommending the clinical breast exam or a self-breast exam but certainly a lot of breast cancers have been found by patients in the shower if you have any changes in your breasts pain um you know changing in the skin redness anything like that be sure to come in so that's kind of the biggest change from Baseline is really what what people notice yeah so I think the boards found asymptomatically on Imaging yeah and the biggest thing is if you're under 40 know what your breasts are normally you know even if you're not necessarily doing a regular self-breast exam and if you're of the age you know 35 40 there's different organizations who give different recommendations start doing your monthly breast exam remind yourself to do that set your phone once a month and don't be embarrassed to talk to your doctor about any of this absolutely yeah Dr Vittorio again what age or when should I start in going in for gynecological exams that sort of varies depending on your situation so a gynecologic exam is is kind of a general term when we talk about doing um you know having someone look it may depend on whether you're sexually active so if you're sexually active and you're having issues pain discharge other things you would go in before sort of the recommended age of 21 for all women to have their first pap smear and a pap smear is different than just a gynecological exam a pap smear is where we take a speculum we put it inside the vagina we take a brush that kind of scrapes the skin cells off of the cervix which is little donut-shaped organ at the end of the vagina and we take those cells in for sampling with our pathologist or with a machine those cells at that area are particularly sensitive to disease and the disease that we're looking for is HPV and some of the things that can cause is dysplasia or abnormal cells or in more advanced cases cervical cancer so that should start at 21 in all women and HPV is human papilloma virus yes thank you very much that's great um Dr Colin dival what are the screening options for breasts we got a big one here breast ovary and uterine cancers so for breast cancer it's like 3D mammogram now that is the it's better than 2D mammogram on all institutions now offer it uh for ovary unfortunately we don't have any reliable screening tests and for uterine it's mainly symptoms because with uterine cancer the first symptom would be like bleeding uh like Dr Victoria told like postmenopausal bleeding is definitely a red flag so even though we don't have screening for uterine cancer we can pick those things early with if the postman or possible bleeding is checked I mean and and the one thing I would add about the ovarian cancers that traditionally it was thought to be quote unquote a silent killer and and really it's not a silent situation in general it's a non-specific so it might be that someone has acid reflux or they have bloating or they have pain and it doesn't go away if they take Tums or they take ibuprofen or you know if they avoid foods that they think are causing their symptoms and the patients when they ultimately I diagnose if you talk to them they'll say I've been having this for a year I've been having this for eight months and and so really I think as Dr Pretoria mentioned with the breast just knowing your body and knowing hey this is different something is different than you know I used to have acid reflux and take a medication that went away and now it's not knowing that something has changed is usually the first step excellent that's such a great Point anything to add Dr futorial yeah and I think if you're not getting kind of what you're looking for feel free to you know see someone's partner or check out another clinic because I mean there's no harm in looking if you really feel that you are there's something going on and women historically in medicine have not been well listened to regarding complaints for various reasons so it's important to sort of work with your physician and find someone who you feel listens thank you Dr Victoria back to you I'm under 18 or uh or over 18 but still on my parents Insurance can I get contraceptives without their permission or telling them you can go to see your doctor the discussion that you have with your physician in the state of Minnesota is considered confidential for purposes of Sexual Health mental health and drug and alcohol abuse that does not mean that your parents may not know that you went to the doctor they're obviously going to get a bill or a you know a notice from insurance that you were there but if they called up and said you know Dr Victoria what did you talk about with my daughter I would direct them towards you and having a discussion with you so the reason we do that is because we want people who are having intercourse to be able to come in and get birth control and not feel like all my parents are going to find out I'm just going to end up getting pregnant anyway because I can't go and get birth control or I've got an STD they can get treatment and you know we are not going to necessarily reveal things to their parents if there's a situation where you're in danger like you're being sexually assaulted and we do find out about that or something where it's important for other people to know for your own safety that is the one reason we'll break confidentiality thank you I I would also add we you know we have planned parenthood here in in Duluth and most of their services are free so if you are concerned because the bill will go to to your parents and and what the bill says is really not anything that we have any control over um so that is that is an option um and if you are pregnant you want a free ultrasound the Women's Care Center in downtown Duluth does a fantastic job with free ultrasounds okay great Dr colandival we'll start with you on this one I've been on hormonal birth control for a long time how does this impact my risk for breast cancer cervical cancer Etc yeah so a lot of Studies have been done on it but there is not a very significant risk increase in like breast cancer risk or like cervical cancer risk uh with hormonal contraceptives mainly it's more blood clots we see but with regards to breast cancer not necessarily so though and it actually decreases your risk of ovarian cancer so we know that there are risk factors for and against having ovarian cancer and being on the pill specifically for greater than 10 years decreases your risk of cancer of the ovary okay thanks yeah maybe I I want to add one more thing so hormonal contrast that is different than hormone replacement therapy so that can increase the risk for breast cancer hormonal contraception not necessarily so okay thanks Dr casting what age do you should you stop doing mammograms so that is a area of great controversy um the the most recent recent recommendation that I have read is either at age 74 or when the life expectancy is less than 10 years and I I you know what I counsel my patients on are this is what the recommendation is however you are your own individual and so if you are a very young 74 year old who has a very vibrant active life I tell people you know if you would treat a breast cancer at this point if you discovered it I would continue screening at least every other year it doesn't necessarily have to be every year if you're in an advanced stage yeah and if that's the key for for any malignancy is if you would treated then then you should be evaluated excellent Dr Vittorio I saw on Tick Tock that tampons can be toxic materials can have toxic materials what should I consider when shopping for hygiene products I think it it really depends you know we sort of look at sort of the exposure everything we use in the world is toxic everything is made of carbon so the sort of you know a judgment call these are products that do go in your body but they don't necessarily stay in your body for long periods of time they're in general made of cotton and sterilized because we've dealt with toxic shock syndrome before which is a staph infection caused by unsanitary feminine products so I think it just really depends on what you are looking for and what your values are you know just like you would buy organic food at the grocery store you would look at your tampons or your other products and say well what am I comfortable with what am I not comfortable with and that may involve looking at silicone cups as a way to control your menstrual flow tampons or using pads or other materials okay I'm really glad that that caller didn't just stick with Tick Tock and called in asked the doctor on that one um Dr Colin devil what genes are associated with breast cancer so the major ones get talked about is the brca1 and 2 and now we know more more genes check to palb2 these are the common ATM these are the common genes at least associated with higher risk and each gene can have different variants and sometimes there are some variants we don't know the significance here and usually when someone has a strong family history which means a mom or a sister has breast cancer or the age when they develop a breast cancer when they are less than 50 years old or an aggressive form of breast cancer then we do do these testing and they do a much little bit elaborate panel of all the inheritable high-risk gene mutations So based on that we can decide how this how the screening could be and this is one instance where sometimes we employ alternating mammogram and MRI every six months so this is where the family history comes in when you see your primary doctor whoever that might be they ask you all those kinds of questions to find out your risk and then decide whether or not gene therapy or whatever other screening is appropriate for you and most patients are referred to a genetic counselor either via phone consultation through their insurance or in person we do have genetic counselors in the area and that's really probably the best way to sort of get a good picture of the risk and get some of those testing that's needed covered so if there's any question then they're on to genetic counseling okay true and I would I would State because we were talking about covert earlier that genetic counseling is one of the advances in Telehealth has has really springboarded with with covet because we have several genetic counselors in the community and they were the first ones to jump on and say all right we can still do our job and the patient can be in their living room Dr Colin Neville you can say something yeah no yeah but generally counseling so once when the first line of different is always the primary care physician when they tell about the family history or anyone newly diagnosed with pancreatic cancer prostate cancer in the family then either they can refer to the oncologist or the genetic counselor so we also send in those tests and we also do some of the counseling part of it yeah okay and depending on the results it may affect your daughters it may affect people down the road and they may actually elect to have different procedures to either have a mastectomy or have I mean those are those are kind of rare events but it can affect others in your family and so it's important to look at great uh Dr Cassie what changes can I expect my body to go through during menopause there there are many that are reported so the the major four symptoms of of menopause so when the ovary stop producing estrogen our hot flashes night sweats sleep disturbances and vaginal dryness and almost every woman will report those four symptoms as far as cognitive changes weight gain fatigue it's incredibly variable but at some point almost everyone will have hot flashes and night sweats okay anything to add to that Dr Vittorio um yeah I mean I think mood changes are something reported or not necessarily sure if that's directly related to the hormone changes or if that's related to the lack of sleep and being irritable because you're uncomfortable all of the time but I mean even women in their late 40s 47 48 who still have regular periods can experience these things and I think the biggest thing is if your life is affected talk to your primary doctor because there are non-hormonal things we can do to help people be more comfortable while their body makes that transition and speaking of age again what is the cutoff for Pap smear testing at 80 years old do I still need one Dr Vittorio no no um so most of the time if you've had normal pap smears and you have had we're now doing dual testing so we're doing testing for the hemopapilloma virus along with our pap smears most of the time you can stop at age 65 if they have been normal and you have a normal risk profile and a normal risk profile would be most likely patients not on chemotherapy or immunosuppressive drugs things that make you more prone to get viral illness those patients who don't fit sort of the normal profile may be recommended by their doctor to continue those at a different interval but in general healthy disease-free people at 65 with normal history of pap smears can stop thank you we have a couple of cards on PCOS or questions on PCOS so what are the symptoms of PCOS and how do I get tested for it yeah so PCOS and endometriosis are probably the two most common things that we talk about in OB GYN you know other than pregnancy and in general women that have polycystic ovarian syndrome there's kind of two presentations one is both presentations are irregular Menses meaning that it doesn't fit a regular cycle of every 28 days or every 30 days um you may have acne abnormal hair growth on your face chin upper back um also finding the uh finding of multiple cysts on the ovary and ultrasound are the kind of the three diagnostic criterias the reason that it's important is that number one these patients oftentimes have difficulty getting pregnant and once we diagnose polycystic ovarian syndrome we can control that and bring about regular Menses and hopefully allow for pregnancy and then down the line these patients have a high risk of diabetes so being aware of that is certainly important anything to do to make sure it doesn't get work or what should they do to make sure it doesn't get worse you know a lot of is lifestyle changes and um the biggest things are weight loss um and if you do have diabetes or pre-diabetes controlling your blood glucose and then some of the stuff can be cosmetic as far as hair growth and acne and we can help with all of those okay great uh Dr Victoria again sorry Dr collodival are there any STIs that women who have sex with women should be concerned about is it different from the STIs sexually transmitted infections that can be transmitted from the penis and vaginal sex well I would tell you that women who are with women get STDs they may not get them at exactly the same rate that someone who has penetrative sex with ejaculation gets just because of the exchange of body fluids is a little bit different with regards to sort of the physics but women who have sex with women get gonorrhea they get chlamydia they get you know all of the STIs that we see and you know you can still get Hepatitis or HIV if you are a lesbian so it's important to be screened and tested the presentations can be different depending on the type of intercourse that occurs but there's really no reason why I would say I screen a lesbian woman different than I would you know a woman who has sex with men anything to add no I I just think the most important thing is a freeing conversation with your provider whoever that may be to discuss the symptoms and the history and you know that can lead to the evaluation okay I think we have time for one more we'll see how fast this one goes Dr uh Victoria what are the most effective contraceptions for preventing pregnancy well there's a lot of them I mean obviously the most effective contraception is about to have sex but people have sex and we know that and so your most effective contraceptions are actually going to be our Larks or our long ass our long-acting implantable contraceptives such as an IUD and so they have a you know kind of a one to two percent failure rate with perfect use um there are people who choose to use birth control pills the effectiveness is less lower in the 90s for that and that's with perfect use so that's you take your pill at the same time every single day and you never miss it which we know people have life and that goes along um kind of in between there is your you know other sort of methods for pregnancy contraception such as the ring we do have an explanation or an implant that produces progesterone which is fairly effective condoms are down there in the 80th you know one out of every four times you have sex with a condom you're at risk for pregnancy yes um and I think that being in women's health we always think about what what can the uh what can the women do but um the vasectomy is is the least invasive and so we certainly recommend that and I would say I get paid to sterilize women but the vasectomy is what we recommend and then taking out the Fallopian tubes is the standard of care now both for permanent sterilization and to prevent ovarian cancer in the future because it does increase uh decrease your risk of that all right excellent I want to thank our panelists Dr Michael cassing Dr Krishna colandival and Dr Addie Vittorio and our medical student volunteers Rebecca Jacobs Emily Clark and Addie Ledesma please join Dr Peter nalen next week for a program in infectious disease and immunizations when his panelists will be Dr Ken rip Dr Harmony Tyner and Dr Dylan Wyatt thank you for watching and good night thank you foreign