Amanda Wilde (Host): Welcome to Health Dose, your go-to source for quick and reliable health and wellness news. In this episode, uncomfortable OBGYN questions answered with Dr. Kevin Sorah, Obstetrician Gynecologist at MyMichigan Health. I'm Amanda Wilde, your host. Dr. Sorah, welcome to the podcast.

Kevin Sorah, DO: Thank you so much for having me. Excited to be here.

Host: Well, thank you for being here. The questions here may be a bit uncomfortable, although you are used to them and they're also important. So that's why we're here and I'm going to just delve right in. What are the most common reasons for pain during intercourse, and how can those be addressed?

Kevin Sorah, DO: So there's many possible causes. And it's important to initially get a good history and ask lots of questions to try to get to the bottom of what could be causing pain with intercourse. So some of those questions may be, how long has this been going on for? Is this a brand new problem? Is there any abnormal discharge? Is there bleeding? Is there other symptoms that are maybe not related directly to intercourse, like chronic pelvic pain, bowel issues, bladder issues. That helps us start to kind of figure out what's going on.

So, if this is a newer problem, I'm more concerned about potentially an infection going on. So an exam would be important to potentially get cultures or do specific kind of testing to rule out sexually transmitted infections or yeast infection. Somebody has chronic pelvic pain, we may get an ultrasound in addition to an exam in order to look for ovarian cysts or adnexal masses, fibroids, possible adenomyosis. If somebody has periods that are painful, then we're more concerned about something like endometriosis, which can potentially be treated with medications, but may also need surgical evaluation as well. And then if somebody's postmenopausal or nearing menopause that decreased estrogen that they experience might cause vaginal tissue to be thinner and more or less flexible and more prone to tearing. And those patients can have pain with intercourse, but also experience bleeding. Patients that have always had this issue, we may be more concerned that there's something with the pelvic floor that's, there's dysfunction.

So maybe there's hypertonicity so that they can't relax and that causes pain during intercourse. So those patients may benefit from pelvic floor physical therapy or vaginal dilating therapy. But again, we have to ask a lot of uncomfortable questions potentially to really start down the pathway of getting help.

Host: On the pelvic issue that, and a lot of people do have pelvic floor issues and other kinds of not normal things happening in that area. Can you explain what exactly happens during a pelvic exam and is it important to get those regularly, whether or not you have symptoms?

Kevin Sorah, DO: Sure. I would say it absolutely is important. I always say at least yearly, you should have a pelvic exam, even if you're not due for a PAP smear. And that's something I always like to distinguish whether or not somebody had a PAP smear during a pelvic exam. Because I think it's a common misconception.

Somebody had a pelvic exam, they may think that they also had a PAP smear and that's not the case. The main components of a pelvic exam would be first doing a visual inspection. Looking at the vulva and the labia and the surrounding skin and groin area to make sure there's no lesions that are present.

Make sure there's no skin abnormalities. Also look for signs of pelvic organ prolapse. The next step would be to do the speculum exam, which is, a source of apprehension for a lot of patients. So this is where we use a speculum to look inside at the cervix, looking at the vaginal walls to make sure, again, there's no visible abnormalities, but also reevaluating for some of that hypertonicity I was talking about, but also things like pelvic organ prolapse, with the speculum exam. So I always say it's important for patients to like communicate, especially during the exam, if they're feeling uncomfortable, and, I'll tell them I'll stop at any time if they are too uncomfortable.

It's also important for them if they've had a bad experience or negative experience in the past, that they should let us know ahead of time so that we can address it appropriately, because it may be just that they need a smaller speculum, or it could be a sign of something going on that hasn't been addressed yet.

Host: Yeah, often it's the anticipation of what a speculum might mean or what a pelvic exam might mean that is more anxiety producing than the actual exam. But how do you work to make patients comfortable, both with the kind of questions I'm asking here and during exams?

Kevin Sorah, DO: Like I said, just keep an open line of communication. I don't know if somebody's uncomfortable unless, I'm seeing the expressions on their face that they're uncomfortable or, if they're not communicating it out loud, I don't necessarily know that they're feeling uncomfortable.

The last part of that pelvic exam would be that bimanual exam where we're feeling for any kind of abnormalities, feeling for fibroids on the uterus, feeling for bogginess, feeling for adnexal masses, and really assessing the patients tenderness as well.

Host: So there are three parts of the pelvic exam. There's the visual exam, the speculum, and then the manual exam. And speaking of screenings, how often should we be getting screened for cervical cancer and what can we expect during that screening process?

Kevin Sorah, DO: So cervical cancer screening is done with the PAP smears, which I mentioned earlier. That involves using a brush and a spatula to collect cells from the cervix during a speculum exam, and those cells will get put into a specimen container and sent to the pathologist and they'll look at it under a microscope, for abnormalities essentially.

So screening starts at age 21. And then if everything's normal, screening occurs every three years. Later on, sometimes at age 25, I generally do at age 30 start doing HPV co testing, which is done with the same swab. And then we can potentially space those screenings out every five years.

And this is strictly in women who have had no abnormal PAP smears. If there's an abnormal PAP smear, then we need to look into that further. Generally, the first step's going to be a coloscopy and then potentially taking biopsies. And if there's certain abnormalities there, then we may need to do an excisional procedure to remove those abnormal cells so that they don't have a chance to become cervical cancer.

And then those women, even if things are normal on the colposcopy, we're still doing closer surveillance. So we're not going three years in between. We're going to do the next PAP smear much sooner.

Host: So we've been talking about annual exams and screenings that help us keep us safe. I'm going to ask you about a couple just common problems women often have and how you treat those. One is irregular periods. I'm sure there are many causes, but I'd like to hear what you tend to see and what are the treatment options.

Kevin Sorah, DO: Right. So irregular periods are often due to ovulatory dysfunction. So we see it commonly in women who are approaching menopause as well as patients who are just now starting to have periods. They may have irregular periods for a while until things become more regulated. Oftentimes, one of the more common things that we see is PCOS or polycystic ovarian syndrome.

It's a common cause of anovulation and infertility. One of the most common causes. Also there could be thyroid dysfunction, prolactin levels can be elevated and those can cause ovulatory dysfunction too. So that's where that history comes in to really get to the bottom of why someone may be having it.

And then we can move on to potential treatment options, which could include birth control, cyclic progestin therapy, lifestyle modification, weight loss, or other medications depending on the cause.

Host: Do you find pretty good success?

Kevin Sorah, DO: Yeah, when you figure out what's going on, and you treat it appropriately, it all depends too, not just on what the cause is, but ultimately what the patient's goals are. If the goals are just to have regular periods, birth control can help with that. If somebody's trying to get pregnant, that, we go down a different pathway and we may need to use medications to help induce ovulation.

But yeah, once we figure out the cause, there's definitely hope for relief.

Host: Well, let's apply that to this next question because this is somewhat common too. Ways to address vulvar itching, or discomfort. What are some effective ways to look at that or deal with that?

Kevin Sorah, DO: Sure. So when somebody experiences those symptoms, usually one of the first things that they think of is that you probably have a yeast infection. So a lot of times they'll go and try over-the-counter remedies and it may or may not help. And if it doesn't help, they may go to an urgent care and then different treatment like with an antifungal. It's very important if symptoms don't get better in those situations to actually come in and get evaluated and certainly have a pelvic exam to rule out other potential causes of vulvar itching. So not the only possible cause. There can be inflammatory skin conditions like lichen sclerosis. Those are treated with topical steroids. And there's the postmenopausal aspect I mentioned earlier when there's decreased estrogen, that tissues changing and potentially can cause similar symptoms like itching and discomfort.

But there's also skin abnormalities of the vulva and vagina, like dysplasia and even cancer that can maybe present that way. And it's difficult to see down there all the time, exactly what's going on. So certainly important to get an exam if you know, something isn't right or doesn't feel right, because there are options for relief.

Host: That does seem to me to be one of the takeaways of what we're talking about is that it's important to seek some help when you know something's not right, and once we can pinpoint it, it's probably very treatable.

Kevin Sorah, DO: Exactly.

Host: Well, my last question, my first question was about intercourse. So this last question sort of brings us back.

Oh, I wanted to ask about contraception, because there have been great changes in contraception over the last several decades, and I'm curious, what are the latest advancements in contraception and how do they compare in terms of efficacy and side effects in comparing to each other?

Kevin Sorah, DO: Sure. As you said over the last few decades, there's been many, many options of birth control that are available. There's birth control pills. There's patch, the vaginal ring, there's injectable contraceptives, there's hormonal and non-hormonal IUDs. There's the arm implant, the subdermal arm implant.

All of these are effective at birth control and preventing pregnancy, but can also be used for other things like regulating periods, decreasing bleeding with periods, decreasing pain, treating acne. It all depends on what the patient's goals are. It may not just be contraception.

So the first thing is to really discuss those with your provider so we choose what's right for you, through shared decision-making. And each different type has its own risks and benefits and contraindications. So it's important to really, be open about your history and really get to the bottom of what would be the best option for you.

Some of the more recent developments, the Nexplanon or the subdermal arm implant, that was just FDA approved very recently for up to five years now as opposed to three years. So that's exciting. There's been over the last few years there's new progestin only pills that have higher dose progestins, so they're, more likely to prevent ovulation compared to the traditional progestin only pill, the mini pill.

And potentially, like I said, prevent ovulation, but also, maybe be a little bit more forgiving if you don't take the pill exactly at the same time every day. And then there's also a new copper IUD that was just FDA approved, that hopefully will be available sometime this year. I don't think that it's quite available yet, but that has a lower dose of copper, than the Paraguard, which is the current copper IUD that's available, the only copper IUD that's available.

And so it's lower dose of copper, potentially better side effect profile as far as bleeding. But it's only approved for three years as opposed to the Paraguard, which is 10 years. So lots of good options. It's just you gotta figure out what's best for you.

Host: I was just going to say, what fits one woman might not fit another, but something else works better. And working with a gynecologist such as yourself will help us figure that out.

Kevin Sorah, DO: Yep, absolutely.

Host: Thank you so much for this straightforward conversation about gynecological health issues Dr. Sorah. I really appreciate you being here.

Kevin Sorah, DO: You're welcome. Thank you so much for having me.

Host: Dr. Kevin Sorah is welcoming new patients at MyMichigan Obstetrics and Gynecology in Sioux Ste. Marie, Michigan. To learn more, visit mymichigan.org. Thanks for listening, and if you enjoyed this podcast, check out the entire podcast library for topics of interest to you. This is Health Dose from MyMichigan Health.