Welcome to our
practice. Please review these office policies.
Appointments:
The office is open Monday through Friday. We are closed Wednesday and Friday
afternoons.
Please give us 24 hours notice if you must cancel an appointment so that we
may offer that time to another patient. There is a $50 fee for cancellations
made less than 24 hours in advance.
Insurance:
If your insurance is GEHA, we will fill the claim for you as a courtesy.
Please provide us with any changes in addresses, phone numbers, or insurance
coverage.
Your insurance coverage is a contract between you and your insurance
company, and it is your responsibility to know your coverage.
Due to insurance reimbursement requirements a yearly well woman GYN visit
includes your exam and a Pap smear only. Additional consultation regarding
hormone replacement therapy, pregnancy planning, osteoporosis, or other health
issues must be done during another visit to be covered by
insurance.
Prescriptions:
Prescriptions for HRT and birth control are written with refills for one
year.
Take all prescriptions to your pharmacy within one month of receiving them.
The pharmacy can put a prescription "on hold" if you want to delay filling it.
Make sure your pharmacy gives you the appropriate number of refills.
There will be a $10.00 charge to replace a prescription whether due to loss
or expiration.
Prescription Refills:
Please anticipate your need for refills at least 2 weeks in advance.
A written prescription will be mailed to you for your refill within 5 days
of request.
Check with your pharmacy prior to calling our office for refills. There may
be refills remaining.
We do not phone in prescription refills.
We do not authorize refills on previous prescriptions once you have been
given a new written
If you run out of refills because you are overdue for your yearly exam, for
the first instance we will provide additional refills that will cover you to
your scheduled exam free of charge. For repeated instances, we will bill $10.00
to your account to be paid during your next visit.
Mail
Order Pharmacy:
Please allow sufficient mailing time, usually a minimum of 3 weeks.
Due to excessive time on hold, we are unable to phone in prescriptions to
mail-order.
We do not fax prescriptions to mail-order
pharmacies.
Orders for Mammograms, Bone Density Scans, and
Ultrasounds:
Orders expire 12 months from the date written. Please use your order within
that time.
There will be a $10.00 charge to replace an order whether due to loss,
expiration, or failure to take order to your
appointment.
Lab Results: The following are some of the
tests that may be ordered or performed by our office:
Pap Smears: You will receive your purple pap card in the mail,
usually within 3 weeks.
Bloodwork: You will be notified by mail, usually within 2 weeks or
with your pap results.
Cultures: You will be notified by mail, usually within 2 weeks or
with your pap results. If culture is abnormal, we will contact you usually
within 5-7 days.
Ultrasounds: You will schedule a follow-up appointment to discuss the
results or be notified by phone or mail within 1-2 weeks if the results are
normal.
Bone Density Scans: You will be notified by mail, usually in 1-2
weeks.
Mammograms: The mammogram facility will forward you the results. They
will contact you by phone only if a follow-up is needed. We will forward
additional request forms if needed.
Phone
Calls/Faxes:
We attempt to return phone calls within two business days.
So phone calls/messages can be accurately triaged, please leave a detailed
message with the front desk or on the voice mail. State clearly if you think a
problem may be urgent.
Questions/correspondence can be addressed to Dr. Thiel via fax. Please write
out a detailed message explaining your questions.
Nursing calls are returned throughout the day. Nursing calls received after
2 pm will be returned the next business day.
Calls for Dr. Thiel are usually returned within 1-2 business days.
Appointment calls are usually returned within 1 business day.
Billing calls are usually returned within 2-4 business
days.
Medical Receipts:
You will be given two copies of your receipt (superbill) when you leave the
office.
Please keep one copy of the receipt for tax purposes and your own records.
The additional copy can be submitted to your insurance company for
reimbursement.
If a replacement copy is needed there will be a $15.00 charge, and a copy of
the receipt will be mailed to you.
Medical Records:
Requests for photocopies of medical records require written authorization
from the patient and a payment of $27.50 before the records will be copied and
mailed.
A Records Request Form can be mailed or faxed to you on request. You can
also access the form online here.
All outstanding balances must be settled before we will fulfill records
requests.
Please allow 3 weeks for our copying service to complete and mail your
records.
By law, records are kept on file in our office for 7 years following your
last visit.
Health Screening Information
The following
includes our current recommendations for our patients' health and
wellness.
Pap
Smears - Pap smears screen for cervical cancer. Cells are gently
removed from the cervix using a brush and spatula or broom. Pap smears should be
done yearly. A liquid-based pap test is used in our office. This new Pap greatly
increases the number of cells collected and also improves the quality of the
sample to be reviewed by our cytology laboratory. Fewer abnormalities are missed
with this new method. A computer, a cytotechnician, and a pathologist review all
of our Paps.
Mammograms
- Mammograms are specialized x-rays that screen for breast cancer. One in ten
breast cancers are not detectable by mammography. These are often found by
breast exams. Early detection saves lives. Newer digital mammograms may improve
detection in women with dense breast tissue.
Recommended Age Ranges
for Mammograms:
35-40 = Baseline Mammogram
40-50 = Mammograms every one to two years
50 + = Yearly Mammogram
Self-Breast
Exam- A Self-Breast Exam should be done monthly about a week after
each menses. There is no magic formula for how breasts should feel. Women who
perform these exams regularly will know if there is a change in their
self-exam. We have shower reminders and breast models for
practice.
Hemocult Stool Screen - Samples of Stool are
tested for blood. This is for early detection of colon cancer and should be done
yearly after age 40. You can request sample kits if you are over 50. These can
be returned by mail. We will call only with abnormal
results.
Colonoscopy
- A Colonoscopy is also a screening for colon cancer. This test is usually done
by a gastroenterologist in a surgical suite and examines the entire large colon.
The procedure is performed with the patient under mild sedation.
Recommended Age Ranges for Exam:
50 >= Baseline Exam*
51 + = Every 3-10 years thereafter.
*Sooner if a
1st degree relative was diagnosed w/ colon cancer before the age
55
Bone Density
Scan (DEXA) - These scans screen for bone density/calcium content
and osteoporosis. A painless, quick scan of the hip and vertebrae is done with
the patient lying down. Bone "strength" and risk of fracture are calculated for
the at risk areas of the hip and spine and, if indicated, the forearm or wrist.
Recommended Age Ranges for exam:
50 = Baseline exam
If Normal - Repeat in 3-10 years If Abnormal - Repeat
every 2-3 years to monitor therapy
Scanning of the
wrist or heel is less accurate for determining fracture risk than scanning of
the hip and spine.
Diabetes Screen - The risk of
diabetes increases with age. Adult onset diabetes is more common in overweight,
inactive, or estrogen deficient patients and patients with a family history of
diabetes. If you are over age 45 and at risk, you should be screened with a
blood test.
HIV Screen - This is a blood test for
HIV/AIDS. If you have had a new sexual partner in the past 10 years or you are
unsure if your partner is monogamous, and have not already been screened, you
should check your HIV status. Early treatment can markedly reduce AIDS symptoms
and prolong life You must be rechecked 8 months after a previous possible
exposure to ensure that you are HIV negative.
Chlamydia - Chlamydia is a sexually transmitted
infection which may present with vaginal discharge and pain or be asymptomatic.
The infection can cause infertility. Cervical DNA testing is recommended yearly
if dating or within a few months of sex with a new partner. Condom use reduces
the risk of Chlamydia transmission, but does not always prevent it.
Immunizations - It is important to update
immunizations with your primary care physician.
HPV DNA
Vaccination (Gardisil) - available for women between ages 12 and 25. It
reduces the transmission of some of the high grade viruses that cause cervical
cancer. It's long-term efficacy is not yet known.
Hepatitis B
Vaccination - all children, teens, and sexually active adults, health care
workers, and overseas travelers should be vaccinated. Primary care providers or
your local health department can administer this 3 shot vaccination series.
Hepatitis A Vaccination - Overseas
travelers.
Diphtheria/Tetanus - Booster every 10
years.
Influenza - (flu vaccine) yearly for elderly and anyone who
wants to avoid this years flu strains.
Rubella - if childbearing
and not immune.
Tetanus - every 10 years
Vitamins
and Minerals-
Calcium - Women require 1000-1500 mg a day
of calcium from diet and supplements such as Caltrate Plus, Oscal, and
Osteoprime.
Magnesium - 500 mg, as well as other trace minerals
are required for strong bones. Magnesium supplementation can also decrease
migraine frequency.
*Vitamin D* - 1000-4000 IU for women over 50,
required to help build bones. Dairy supplements are the main source of vitamin
D. Sunlight is necessary to activate this vitamin.
Vitamin C -
500-1000 mg a day reduces infection, boosts the immune system and helps skin and
bones (collagen formation).
Folic Acid - 400 mg per day decreases
the risk of birth defects and heart disease.
Vitamin
B12 - Requirements increase with age. Sufficient amounts are in
most daily vitamin supplements. Some people may not absorb Vitamin B12
well.
Aspirin - Baby aspirin (81 mg) daily decreases the risk of
heart disease for women at high risk. Ask your primary care physician to
perform a risk assessment to determine if baby aspirin should be
taken.
Omega-3 & Omega-6 fatty acids - 1000-3000 mg per day of
these essential fatty acids reduces the risk of heart disease, reduces
inflammation, maintains joints, helps brain function, supports digestive
function, and much more. If you do not eat fish twice a week, you may want to
add fish oil or flaxseed oil capsules to your diet.
Perimenopause/Menopause/HRT
Many of our
patients are entering the perimenopause or are in menopause. The issues involved
at this time of life are often very complex. To thoroughly cover these issues we
need to schedule a series of appointments for you. There is too much information
to cover as part of a routine yearly gynecological exam. We will gladly set up
your appointments to discuss these issues in depth. Please let the receptionist
know that you need a HRT (hormone replacement therapy) consult
appointment.
Please visit the links on this page to get preliminary
information before your visit.
PATIENTS CURRENTLY ON HRT WHO NEED TO GET THEIR ESTROGEN LEVELS
CHECKED: Follow the instructions on the Instructions
for Estrogen (Estradiol) Level sheet when scheduling and preparing for your
blood draw appointment.
To learn more about the basics of menopause, view the pamphelt, The
Menopause Years, published by the American College of Obstetricians and
Gynecologists.
Various factors have an impact on your estrogen levels, including
medications, foods, etc. To see a complete list, view the Factors
Affecting Estrogen Levels handout.
Dr. Thiel may want you to fill out the Greene Climacteric Scale to
access your menopausal symptoms. You can fill out this survey prior to your by
clicking here.
We suggest that new patients coming in specific for HRT counseling bring this
survey completed to your first appointment.
Some women add testosterone to their hormone replacement regimens to improve
libido and sexual response. Read more by viewing our Testosterone
handout. To learn more about the female libido, please read The
Female Sexual Response.
Dr. Thiel has been following HRT research for many years. Throughout the
past several years, she has written updates and responses for her patients on
the current status of HRT news and research. You can view these by clicking on
the following:
Several responses have been published regarding the controversial Women's
Health Initiative HRT study. Three Dr. Thiel finds particularly relevent are
below:
In addition to
specializing in hormone replacement therapy, Dr. Thiel provides standard
gynecological services to her patients. To learn more about the gynecological
tests and procedure she performs, explore the links on this
page.
Pap Test
In addition to a pelvic exam, Dr. Thiel
performs a Pap test as part of each annual visit. She also performs follow-up
Pap tests when necessary. A pap test involves the sampling of endocervical cells
(cells from the outside and the canal of the cervix). A speculum is used to open
the vaginal walls. The procedure is quick (a couple minutes) and may cause some
pelvic discomfort.
Dr. Thiel always performs the liquid-based pap test,
SurePath, which involves the
preservation of the endocervical sample in a liquid vial.
To learn more
about the Pap test, view the American College of Obstetricians and Gynecologists
(ACOG) pamphlet, The
Pap Test. Information on abnormal pap test results can be found here.
This procedure involves
the use of a colposcope to examine and magnify the cervix. Colposcopy is often
used to as a follow-up to abnormal pap smears. ACOG has published a pamphlet on
this procedure, Colposcopy.
This procedure involves the
sampling of cells from the lining of the uterus, often performed to evaluate
abnormal bleeding. Dr. Thiel has compiled an information sheet which includes
preparation for the procedure, possible complications, post-procedure
instructions, and more information about the procedure itself. You can view this
at the Endometrial
Sampling page.
Dilation & Curettage
(D&C)
This is a diagnostic procedure which involves cervical
dilation in addition to uterine sampling. To read Dr. Thiel's information sheet
on this procedure, view Cervical
Dilation and Uterine Curettage. ACOG has a pamphlet as well, Dilation
and Curettage.
IUD Insertion
An IUD, or
intrauterine device, is a small apparatus that is inserted into the uterus as a
means of reversible contraception and/or to treat disorders such as abnormal
bleeding. Dr. Thiel uses hormonal IUDs from Mirena. For more information on
IUDs, check out the Intrauterine
Device pamphlet from ACGO.
Contraception
Dr. Thiel
provides her patients numerous birth control options. For a quick overview of
contraception methods availabe, view the article, Contraception,
from NIH. The doctor and the patient will work together to put together a birth
control regimen tailor to your needs. She will also provide birth control
non-contraceptive purposes, such as the treatment of abnormal bleeding.
Medem has assembled a very useful webpage, Contraceptive
Choices that is an excellent resource for contraceptive information,
featuring multiple ACOG articles.
If you are a current patient on birth
control pills look at the Birth
Control Instructions for information on various regimens.
Emergency
contraceptive pills are used up to 72 hours after unprotected sex to prevent
pregnancy. Now, Plan B is available in the US without a prescription for women
18 years and older. Dr. Thiel does prescribe Plan B for younger patients. For an
index of different emergency contraceptive and basic information, view Information
on Emergency Contraception Pills (ECPs)by ACOG and theEmergency
Contraception Patient Handout by OBG Management.
On this page you
will find information and articles regarding the following illnesses and
disorders encountered by our practice:
Vaginitis
Pelvic Pain
Dysmenorrhea
Endometriosis
Vulvar Vestibulitis
Abnormal Uterine Bleeding
Uterine Fibroids
Ovarian Cysts
Pelvic Support Problems
Uterine Prolapse
Urinary Tract Infections
Urinary Incontinence
Hemorrhoids
Menstrual Migraine
Premenstrual Dysphoric Disorder (PMDD)
Polycystic Ovary Syndrome (PCOS)
Hypothyroidism
Female Sexual Dysfunction/Hypoactive Sexual Desire
Disorder
Vaginitis - Vaginitis is the inflammation of the vagina, characterized
by increased/unusual discharge, burning, itching, and/or stinging.
Those patients who frequently have vaginitis can treat it with
over-the-counter medication when the symptoms are recognized. However, the
first time a patient exhibits any of these symptoms, she should visit the doctor
for an exam.
Pelvic Pain - There are many causes and qualities of pelvic pain. If
you are a patient experiencing pelvic pain, please contact our office
immediately.
Dysmenorrhea - Dysmenorrhea is the most common
cause of female pelvic pain. It often occurs during or before menstruation and
is so severe that it prevents sufferers from performing normal
activities.
Endometriosis - Endometriosis is a
disorder characterized by the growth of endometrial tissue (which normally lines
the uterus) in other places in the body, such as the ovaries or fallopian tubes.
It is a leading cause of pelvic pain.
Endometriosis
- Article by The National Institute of Health (NIH) (More
Extensive)
Vulvar Vestibulitis - This disorder is characterized by pain,
burning, stinging, and/or rawness near the vaginal opening. It often occurs
during intercourse or tampon use, and in severe cases, exercising, walking, or
sitting.
Abnormal Uterine Bleeding - Uterine bleeding is abnormal if the
menstrual period is not regular, the period is heavier or longer than normal, or
bleeding is menopausal/postmenopausal. If you are a patient with abnormal
bleeding, please contact our office immediately.
Ovarian Cysts - Ovarian cysts are small fluid-fill sacs that develop
on the ovaries. Normally, these cysts are harmless, but if they cause pain or
other symptoms they may require treatment.
Uterine Prolapse -
Uterine prolapse is a pelvic support problem specific to the uterus; the uterus
protrudes down into the vaginal area.
Uterine
Prolapse - Patient Article published by the Journal of the American
Medical Association (JAMA)
Urinary Tract Infection (UTI) - Urinary tract infections typically
exhibit urinary urgency, urinary frequency, and/or sharp pain or burning during
urination. UTIs need to be treated promptly to prevent further spread of the
infection throughout the whole urinary tract. If you are a patient with the
symptoms of a UTI, please contact our office as soon as possible.
Urinary Incontinence - Urinary incontinence is the inability to
control the leakage of urine from the bladder. There are many causes of urinary
incontinence, but nearly all cases can be improved with treatment.
Menstrual Migraine - Migraines are characterized by severe headache,
nausea, sensitivity to light/noise, dizziness, etc. Menstrual migraines occur
during or before the menstrual period, potentially due to a drop in estrogen.
Premenstrual Dysphoric Disorder (PMDD) - PMDD is a mood disorder in
which sufferers experience severe depression, anxiety, and/or irritability each
month before before menstruation starts.
Polycystic Ovary Syndrome (PCOS) - PCOS is a hormonal disorder
characterized by high levels of androgens. Symptoms include irregular or no
periods, small ovarian cysts, weight gain, especially around the waist, and
insulin resistance (among many others).
Polycystic
Ovary Syndrome (PCOS) - Article by the Office of Women's Health of the
US Dept of Health and Human Services (US Dept HHS)
Hypothyroidism - This disorder is the underproduction of thyroid
hormone. It occurs in roughly 5% of American women, causes symptoms of fatigue,
weight gain, depression, feeling cold, and constipation. If you would like to
discuss hypothyroidism with Dr. Thiel, it would be appreciated if you
printed off a Low
Thyroid Symptom Check Off List and bring it filled out to your
appointment.
Female Sexual Dysfunction/Hypoactive Sexual Desire Disorder - This is
the recurrent inability to attain (or maintain until the completion of
intercourse) the adequate physiological and/or psychological sexual responses.
If you would like to discuss FSD with Dr. Thiel, feel free to print off and
complete the following survey on sexual response: Female
Sexual Function Index. The survey also does a good job defining specific
sexual behaviors/terms.
The
Female Sexual Response is an article from the scientific journal, Sex
& Marital Therapy, which presents detailed explanations of the female
sexual response and hypoactive sexual desire disorder.
Osteoporosis
Osteoporosis is a
bone disease characterized by increased fracture risk and often reduced
bone mineral density.
Dr. Thiel provides her patients referrals for DEXA
scans (bone density scans) at their annual visits when advisable. She also
offers DEXA consultations to patients with osteoporosis and those with a high
risk of developing the disease, providing guidance in treatment and
prevention.
Risks Factors for Osteoporosis and
Osteoporosis Fractures
Advanced Age
Female Gender
Caucasian or Asian ethnicity
Family History of Fractures
Premature Gray Hair
Anticonvulsant Use
Corticosteroid Use
Heparin Use
Smoking
High Caffeine Intake
Excessive Alcohol Intake
Low Calcium or Vitamin D Intake
Sedentary Lifestyle
Thyroid Disorders
Infrequent or No Periods (Not due to continuous BC)
For thorough overview of the progress
made in osteoporosis treatment in the past decade, take a look at the NIH
article, Progress
in Osteoporosis.
HPV - The Human Papilloma Virus
Melissa J. Thiel,
M.D.,P.C.
Recent direct to consumer advertising by the makers of the
HPV DNA testing probe has created a new awareness and confusion about the HPV
virus.
What is HPV?
Human papilloma viruses are
a family of over a 100 viruses that can infect human cells. They are very common
and usually have been associated with warts. Some types of these viruses can
cause cervical cancer or precancerous changes on the cervix or vulva. Most of us
have hosted lots of these viruses during our lifetime. They come and they go and
our immune system usually keeps them in check. Men can carry HPV viruses and
transmit them to women, but penile and rectal cancers caused by these viruses
are less common.
WHO gets HPV?
HPV viruses are
acquired by contact. The HPV viruses associated with the female genital tract
are acquired by contact with another individual with an HPV virus. Contact can
be genital to genital or oral to genital contact. Condoms reduce but do not
prevent HPV transmission as they do not prevent all genital contact. Humans may
also carry these viruses in their mouths and certain HPV viruses are associated
with oral cancers particularly in tobacco users. In recent studies of college
women who are sexually active and checked for HPV every six months,
approximately 80% were positive for HPV. Most (over 90%) of these women had
normal pap smears and cleared the HPV virus on their own. Smokers are more
likely to have persistent HPV and develop cervical precancerous changes and
cervical cancer.
HOW IS HPV DETECTED?
HPV virus
is detected by DNA analysis of a cervical pap smear sample i.e. cells scraped
from the cervix, for the presence of HPV viruses. Whether the viruses identified
are either high grade or low grade is also determined.
WHEN
SHOULD HPV VIRAL TESTING BE DONE?
Currently the liquid based pap
smears are very accurate at detecting those women at risk for cervical cancer.
With the liquid based technology, women who have regular yearly pap smears and
these are negative are at extremely low risk for cervical cancer. Three negative
pap test lessens the probability of a cervical cancer to less than .0001 or 1 in
10,000. For women less than 30 years of age, the majority would intermittently
test positive for high grade HPV and over 95% would not ever develop cervical
cancer. For this group, HPV testing would create considerable and undue anxiety
since the presence of the virus is transient. The pap smear, at least in this
younger group, still is needed to identify those women with actual cervical
abnormalities produced by the HPV virus. If the pap smear shows only minor
changes such as ASCUS, or atypical cells of unknown significance, the pap is
often just repeated in 3-6 months, allowing the virus or inflammation or
irritation of the cervix to self correct. If repeat pap tests are atypical an
HPV test may be done to see if further evaluation is necessary. Those patients
with a negative pap will need to follow up with a pap within a year. Those with
an abnormal pap and the presence of high grade HPV virus will need further
follow up which includes a more detailed exam of the cervix or colposcopy. Women
with more severe abnormalities on their pap such as low grade (LGSIL) or high
grade (HGSIL) changes must also have their cervices evaluated with colposcopy
and an HPV test may be done.
For thirty years, we have known that
cervical cancer is sexually transmitted by a group of viruses. Pap tests,
especially the new liquid based types have virtually eliminated cervical cancer
from the regularly screened population. Unfortunately, most cervical cancer is
found in underserved women and women who do no have regular exams. This new and
expensive HPV test will help the triage of women already in the system, but an
effort to make available and encourage all women to have pelvic and cervical
exams on a regular basis will have a much bigger impact on women's gynecological
and general health. The yearly visit may be a woman's only health contact and
general screening for blood pressure, diabetes, heart disease, breast cancer and
other medical conditions. If you have a friend who does not have regular
screening, give her a gentle nudge, this is where the real gains in women's
health are made.
For HPV information from the American College of
Obstetricians and Gynecologists, view the ACOG
HPV Pamphlet.
WHAT ABOUT THE HPV
VACCINE?
Recently, a vaccine has been developed to provide
protection against diseases associated with infection from human papillomavirus
(HPV) types 6, 11, 16, and 18, to include genital warts, precancerous cervical,
vulvar and vaginal lesions and cervical cancer. This vaccine is approved for
females between the ages of 9 thru 26. Better immunity appears to be present if
the vaccine is used in the younger age range. It is not yet known how long the
vaccine will confer immunity as it is a recent development but the preliminary
data look very promising There are high grade viruses not treated by the vaccine
that may also cause cervical abnormalities and cancer, and these may because
more common with time; pap smears are still necessary.
When deciding if
the vaccine is right for you or your child, realize at this point HPV related
illnesses are still easily diagnosed and treatable. Long term safety and
efficacy data on this vaccine is not yet present. It is a decision that should
become easier with time. Currently the vaccine is not approved for women over
age 26, as it may not confer immunity.
Additional
Insight on the HPV Vaccine
By now you have been bombarded with
info on HPV and cervical cancer with all the ads by the manufacturers which
promote their tests and vaccines. There are some excellent web sites such as the
CDC (Center for Disease
Control) and the Immunization Action
Coalition.
Theses websites offer well-documented information, but I
also feel they do not give you all the perspective you need to make a decision
regarding the vaccine. So I will add some comments based on 25 years of
experience running some large clinics and private practice.
First, for at
least 30 years, we have known that cervical cancer is sexually transmitted by
the HPV virus and there are several types of this virus which can be a problem.
In studies of college women, approximately 80% of college women will have at
least one high grade or cancer causing virus. Unfortunately, what all these ads
do not tell you is approximately 95% of the time a women's immune system will
clear the virus on its own and the virus will not cause any permanent problems.
Furthermore, cervical cancer is incredibly rare in women who have regular pap
smears. In the last 25 years I have never seen a case of cervical cancer in a
women having regular pap smears by a gynecologist and read by a good lab. Most
of the cervical cancer seen in the United States is in women who rarely if ever
have exams. Money would often be better spent with better screening and less
over-diagnosis of HPV. The newer liquid based pap smears, if done correctly and
read by a good lab are very sensitive and accurate for diagnosing a problem
early and ensuring it self-corrects or needs to be further evaluated.
The American College of Obstetrics and Gynecology does not recommend
routine HPV testing under the age of 30, because of the high prevalence of the
HPV viruses. If a pap comes back with a significant abnormality, i.e. low or
high grade, a colposcopy can be performed to evaluate the cervix to look for
actual abnormalities and treat them. Unfortunately, I am seeing women who have
tested positive for high grade HPV on routine testing or after a pap smear with
just atypia on it and now are traumatized because they have a potentially cancer
causing virus. The amount of psychic energy, fear and worry that are wasted on
this common and almost always self-limited entity is astounding. There are
offices doing colposcopies on every positive high grade HPV or Atypical Pap.
This is nuts and further contributes to a women's fear. At times there are
clinical reasons for HPV testing, but too often it is overused and generates
fear.
The new quadravalent HPV vaccine, vaccinates against 4 types of
the approximately 100 types of HPV virus. It is recommended for girls ages 13
to26. This vaccine will prevent infection from the HP viruses that cause
approximately 90 percent of genital warts and 70 percent of cervical cancers.
This is a big step in the right direction but women still can get some of the
viruses that cause cervical cancer. Women still need pelvic exams and pap
smears.
Patients ask if they should get vaccinated against HPV. The
answer is complex and you need to read the above websites. First, the vaccine is
new and its long term efficacy and safety have not been fully established.
Unlike vaccinations for most communicable diseases, cervical cancer is
diagnosable and preventable. I disagree with making this vaccine mandatory for
young women as was done in Texas, because much can be done, if you choose, to
avoid cervical cancer. The vaccination may drastically reduce cervical cancer if
it is given to underserved populations of girls and women. If your daughters are
on the young end you could wait a year or two and re-evaluate the vaccine after
more safety data is in. If you are approaching age 24 to 26, you may want to get
the vaccine now.
Patient Surveys and Forms
Patient
Registration Form - Changes to your contact information? Fill this
out before you come to the office to save time.
Financial
Policy - Most up-to-date financial policy for our practice.
Records
Release Consent Form - Download and print this PDF file, then
forward it to our office for medical record copying.
The
Greene Climacteric Scale - Are you seeing Dr. Thiel for menopause
counseling? Print out this survey of menopausal symptoms and bring it to your
next appointment filled out.
Low
Thyroid Symptom Check Off List - If you are interested in discussing
thyroid issues with Dr. Thiel, print out this survey and bring it to your next
appointment filled out.
For information on the results of the Hepatitis B antibody blood test, see
the Hepatitis
B Antibody Results page.
Cultures The
results of cultures will be arrive by mail, usually within 2 weeks or with your
pap results. If culture is abnormal, we will contact you usually within 5-7
days.
Everyone loves
Dr. Melissa Thiel. I have referred many of my female patients to her and they
all praise Dr. Thiel after their visit with her. It is apparent that Dr. Thiel
is a very caring doctor who listens well and provides superior individualized
care. Dr. Thiel is truly a rarity in medicine today. She is willing to treat the
whole person and consider her entire well-being. She is truly a force in women's
health. I have sought her advice multiple times regarding female patients;
particularly when they have perplexing issues. Her feedback has always been
insightful and beneficial. To her further credit, Dr. Thiel is open-minded and
does not disqualify options that might be considered thinking "outside the box."
She recognizes that perscription medicines and surgical procedures are not
always the best or only course of action. Dr. Thiel always has her patinets'
best interes at heart and works to serve them; helping women to achieve optimal
health. If you are seeking a great women's health expert, I highly recommend Dr
Thiel. -Dr. Martin J. Skopp, DC, CCSP, ART www.skoppchiro.com
We at
Neurofeedback Consultants think that Dr. Thiel is the best overall physician in
the D.C. Metro area. She has been my personal gynecologist for many years and is
the gynecologist of four of my staff. We have referred many of our clients to
her over the years and all are as impressed as we are with her depth of
knowledge on a broad range of other health concerns in addition to women's
health. We specialize in brain health and the mind-body connection and we find
that Dr. Thiel understands this better than most physicians. She treats the
whole person and the causes of their symptoms rather than just their symptoms. I
would not hesitate to recommend Dr. Thiel to anyone who is interested in a
caring, thorough and knowledgeable physician who takes the time to learn how
best to help. -Deborah Stokes, PhD, Age 54. www.neuronew.com
During the 15 years
that I have been a patient of Dr. Thiel?s, I have experienced one serious
medical crisis, as well as a number of problems both acute and chronic. Whatever
the issue, Dr. Thiel and her staff have been unfailingly courteous,
compassionate, intelligent, and responsive. When the pathology of a nagging
condition revealed a rare disease, Dr. Thiel contacted me immediately, carefully
explained the situation, and arranged for an appointment with a gynecological
oncologist. In the weeks before the resulting surgery, she sought to allay my
anxiety, helped have my lab results reviewed, and supported my decision to seek
a second opinion. When I later returned from an overseas trip with alarmingly
similar symptoms, I was seen within 24 hours. In the years since that first
surgery, I have had a number of scares and one recurrence of the disease. Dr.
Thiel has always been there for me. There have also been the more mundane but
still annoying problems. But whether I have a question or need a referral, a
refill or an appointment, I know that someone will respond and help. I have
never been let down here, never left on my own. - Sonya Singer Livingston
Dr. Thiel is the consummate medical professional. She is laid back,
gentle, and a wealth of information. She always gives thorough explanations
about treatments and why they are necessary. Dr. Thiel is great about follow-up
calls as well. I will continue to see Dr. Thiel and her staff as well as refer
my patients and friends to her. -Dr. Kim Kitchen, D.D.S.
Bio-identical Hormones
4/10/09 -
Thoughts from Dr. Thiel
On this page: *Bio-identical Hormones:
An Explanation *Frequently Asked Questions *Progesterone: An
Explanation
BIO-IDENTICAL HORMONES: AN EXPLANATION
I
have prescribed bio-identical hormones for 15 years, and every few years there
is a new wave of hype, controversy, confusion, interest, and salesmanship
regarding their use. I will try to help decrease the confusion and explain the
terminology and the relevant facts.
What are
hormones? Hormones are natural chemicals secreted by glandular organs in
our body that perform important biological functions.
How do
pharmaceutical companies make hormones? Hormones are most easily produced
from various plant and animal sources (for example yams, or horse urine).
Scientists extract a hormone like cholesterol from its source, and chemically
alter it to create a compound that is similar to the estrogen your body makes.
Some of these newly synthesized hormones have the exact same molecular structure
as the estrogen found in the body, and some do not.
What does the
term "Bio-identical mean?" Bio-identical hormones are manufactured
hormones that are very similar to, or have the exact chemical structure of, the
estrogen your body produces.
Are Bio-identical Hormones derived
from plants? Pharmaceutical companies usually use plant sources to
manufacture hormones because they do much of the synthesizing work themselves,
and therefore make useful precursor molecules. These molecules are then modified
to makes a hormone. Pharmaceutical companies do not always use plants,
however.
In the case of "Premarin", pharmaceutical companies use pregnant
mare (female horse) urine to supply several types of estrogen, which are not all
bio-identical. The bio-identical estrogen, estradiol, is produced by these mares
and included in the finished product.
Are Bio-identical hormones
more natural? The word "bio-identical" does not mean more natural, safer,
plant derived, or more efficacious. ALL BIO-IDENTICAL HORMONES ARE CHEMICALLY
SYNTHESIZED BY PHARMACEUTICAL COMPANIES. You cannot extract estradiol from
ovaries (the only truly natural source) to give to women. Hormones for
therapeutic use must be chemically produced.
So how do I know
which hormone is the most natural and safest for my body? The line
between natural, safer, and synthetic does not really exist. These terms are
overused and manipulated by many special interest groups (compounding
pharmacies, pharmaceutical companies, natural hormone clinics) to self promote
and in many ways confuse and scare women. Every woman is different. Different
types of hormones (bioidentical or not) are appropriate for different people
based on their personal history, and how their body responds to them. Hormones
that are not bio-identical are not less safe to use. Do you care about what
the chemical structure of your blood pressure medication is? Like men on Viagra,
you just want it to be safe and work!
Bio-identical hormones, like
any medication, can cause harm if not carefully monitored, if not prescribed in
the correct dosage, and if the appropriate delivery system (oral or transdermal)
is not used.
What you need to know about hormone
therapy:
1. You want a hormone preparation with a long track record
of efficacy and safety.
2. You want a product that can be tailored to
your specific symptoms and physiologic requirements.
3. You want a
product that has been tested and delivers consistent dosing from prescription to
prescription.
4. You want careful monitoring of your symptoms and
optimization of the dose to achieve both short term symptom relief (i.e.
decrease in hot flashes) and long term benefits (i.e. protection of
bones).
To achieve these results, physician experience and detailed
knowledge of the various therapies is paramount.
FREQUENTLY ASKED
QUESTIONS
1. What are compounding pharmacies and are their
products safer?
Compounding pharmacies are independent pharmacies
that are licensed to combine FDA approved medications or nutritional products
into a delivery system (cream, lotion, tablet, lozenges, suppository) for
distribution to patients. Many products can be customized for dose and delivery
(orally or transdermally). Generally, this is a wonderful option for patients
with special needs.
There are some concerns voiced by the North American
Menopause Society (NAMS) regarding patient safety in regards to compounding.
Fifteen years ago, there were limited choices of hormone therapy in the United
States. We basically had Premarin, an estrogen, and Provera, a progesterone. If
a patient did not do well on this combination, we had little other choice. At
that time I would use a compounding pharmacy to make what my patients needed.
The compounding pharmacies purchase the hormones they use (usually
bio-identical) from large pharmaceutical companies, often European, and mix them
(compound them) to the doctor's specifications. The pharmaceutical companies did
not directly market these bio-identical hormones because bio-identical products
cannot be patented and must be sold generically. This would limit profits. I
would carefully monitor my patients' progress and blood levels using a reference
lab (i.e. Mayo) to ensure that each batch was the same (or each batch had
the same bio-availabilty). Unfortunately, there were many times when a
patient's hot flashes would return or they would begin to bleed. Their blood
levels would show a very different level than the past batch. A different tech
may have made them, measured incorrectly, used a different gelatin capsule, or
gotten the hormones from a different supplier. Any and all of these changes will
alter what the patient receives.
The batch to batch potency and
consistency of compounded medications is not tested or regulated by the FDA.
This can be dangerous for a patient if they are not carefully followed by a
doctor with experience in recognizing and managing these medications.
The pharmaceutical companies then began designing new ways to patent
bio-identical hormones by creating new delivery methods. They now market many
bio-identical hormones as long-acting formulations, vaginal rings, patches,
mists, and gel pumps. These preparations are FDA regulated to be the same from
batch to batch and reflect the dose on the label. There are unlimited amounts of
dosing options and combinations of FDA regulated bio-identical hormones.
Unfortunately, many physicians are not familiar with the many choices that are
available. For many it is a nuisance to try to match all the different hormones
therapies to individual patient needs and desires.
PROGESTERONE:
AN EXPLANATION
What is Progesterone, and why do I need to take
it?
Many patients are confused by what progesterone is and how it is
used in menopause.Progesterone is the hormone the ovaries make after
ovulation and during pregnancy. After the ovarian follicle releases an egg
(ovulation), the follicle changes into a corpus leuteum (a hormone producing
sack). The corpus leuteum produces progesterone. This hormone has many purposes,
including preparing the lining of the uterus (the endometrium) to receive a
fertilized egg, and helping the uterus shed the lining if implantation does not
occur. Progesterone also helps support an early pregnancy until the placenta is
developed enough to take over.
In menopause, if a woman has not had a
hysterectomy, and she desires hormone replacement supplementation, a progestin
(progesterone-like compound, MUST accompany estrogen therapy to
decrease the likelihood of developing endometrial cancer. The balance
between the two hormones must be correct to afford adequate protection. When the
balance is correct, the actual risk of developing uterine (endometrial) cancer
is lower than women not taking any hormones at all.
There are
several progestins (progesterone like compounds) available to patients. All are
chemically synthesized. Provera, medroxy-progesterone acetate, is the most
common progestin used in the U.S., and was used in the Women's Health Initiative
(WHI) study. It may be associated with a very small increased risk of breast
cancer. There are other forms of progesterone. These include micronized
progesterone which is a bio-identical form (brand name: Prometrium), and
norethindrone acetate, a non-bio-identical progesterone. Norethindrone acetate
has been in birth control pills for over 60 years and consumed by millions of
women a year. It is not associated with an increased risk of breast
cancer and has a proven and safe track record. There is no data to say that
bio-identical progestins are safer or better than some of the non-bio-identical
progestins. The nuances and risk benefit ratio for each of these formulations
must be tailored to the individual patient.
When HRT (hormone replacement
therapy) is prescribed, the balance between estrogen and progesterone must be
closely regulated to decrease the growth of the uterine lining and reduce the
risk of uterine cancer. This means you should not take estrogen without
progesterone, unless you have had a hysterectomy. With compounded
bio-identical hormones the absorption of the different hormones may vary and may
not provide adequate protection from uterine cancer. Progesterone is poorly
absorbed through the skin. In cream formulations it is inadequate to protect the
uterine lining from cancer. Unfortunately, the promoters of these products do
not inform women of this safety issue.
Once again, women are the victims
of marketing based on fear. Instead of responding to the hype, we need to
intelligently discuss the short term and long term effects of hormone therapy
based on 60 years of scientific data with thousands of participants. Hormone
therapy has demonstrated over and over to help protects women's hearts, bones,
joints, brains, and colons. Hormone therapy reduces ones risk of diabetes if
used at the appropriate time and in the appropriate combinations and dosages.
The prescribers of hormone therapy should have experience, training, and
knowledge in women's mid-life health, pharmacology, and gynecology.
Unfortunately, celebrities, pharmacies, and non-specialists all have something
to say or sell. Few are dedicated to the long term health and well-being of
women.
