Bleeding After Menopause; Nipple Confusion?; PSA vs. BPH; Coumadin & Vitamin K; Iron for Anemia.

I recently attended the 25th Reunion of my medical school class.  If you are quick with math, you know now that I graduated from medical school in 1987!  The reunion of the LSUMC Class of 1987 was in New Orleans, & I guess we have gotten old enough that we "earned" the opportunity to celebrate at Arnaud's Restaurant.  This grande restaurant served great food, & provided a balcony over-looking Bourbon Street... so we really felt the New Orleans experience!  The highlight of the night was a tour of the restaurant, where we learned that it occupies the entire city block & is a conglomeration of 14 houses which were individually purchased & joined together over many years.  I guess that explains the variable decor & the steps up & down from one room to another!  And of course, the true highlight of the entire weekend was the opportunity to spend quality time with many friends, most of whom we see all too seldom!  I have found that the bond we established during our 4 years of medical school seems to be an ever-lasting one, & I am already looking forward to our 30th reunion.  Even better than that is the fact that due to social media, we will likely be better at keeping up with one another from here forward!

Despite my "play time," I did broadcast "Let's Talk Medical with Doctor Gigi" from my parents' home in Port Allen, LA.  Following are the highlights of that June 8, 2012 episode.

Bleeding After Menopause:

We have discussed that menopause is the absence of ovarian function, either due to the "death" of the ovaries or due to their surgical removal.  With the lack of ovarian function there is also a lack of a menstrual cycle as it is the ovaries which normally produce the hormones which cause this cyclic bleeding monthly.  Once you lose ovarian function, you stop having periods, & though the bleeding usually does not just stop, the cycles usually get further & further apart.  Once there is no period for one year, you are fully menopausal... also known as "post-menopausal."

It is very important to know that once you have stopped having periods for 1 year, you should never have a period or vaginal bleeding again... & this includes "spotting!"  In fact, doctors call any of these "post-menopausal bleeding," & we generally assume that this is endometrial cancer (= cancer of the uterine lining) until proven otherwise.  Of course, if you have had a hysterectomy then you have had your uterus removed, so you no longer have an endometrium (as this is the inner lining of the uterus).  Thus a person with post-menopausal bleeding would not need to be as  concerned if she does not have a uterus.  But if she has a uterus, she MUST see her GYN or Primary Care physician for a physical exam, probably a pelvic ultrasound, & likely a biopsy of her endometrium... & she should NOT wait!

Fortunately most post-menopausal bleeding is found to be due to benign causes, but the work-up for cancer must prove this as it cannot be assumed!  Often times the cause is infection, but I believe the most common etiology is vaginal dryness (= atrophic vaginitis) which is common is women who have lost their estrogen hormone.  Fortunately a small amount of estrogen cream applied to the vagina & external tissues can make these dry tissues healthy again, resulting in resolution of the abnormal bleeding, as well as a return to more supple, pliable, moist genital tissues which makes sex more fun!

Also, note that if you take hormone replacement for menopause, you might have bleeding depending upon how you take those hormones, & how long you have been on them.  If you take them in a cyclic fashion... 25 days of progesterone, with the last 10 days combined with estrogen, followed by 5-6 days of no hormones... you should bleed monthly (during the 5-6 days of no hormones).  If you take both the estrogen & progesterone every day, you might bleed irregularly for the first 6 months, but after that, you should not bleed... so call your doctor if you do!

As a last note, a Pap smear only tests for cervical cancer.  That means that it looks for cancer on the bottom of the uterus.  It does not tell you anything about endometrial cancer, so even if your Pap was recently normal, you must call your doctor if you develop unexpected post-menopausal bleeding!

Nipple Confusion?:

Don't get me wrong, I strongly believe in breast feeding!  It provides the most natural source of nutrition to our babies, & the first 3 days of breast feeding is particularly important as the breast milk is very special at that time.  It is called "colostrum," & it is loaded with antibodies (from the mother) which provide the baby with a great immune system until he can produce his own!

But will it confuse the baby if you inter-mix the breast feeding with a bottle?  People have proposed that if you feed the baby a bottle, he will get "nipple confusion" & not feed properly.  I really don't subscribe to this idea, as I know that babies are born with what doctors call "primitivereflexes, which are hard-wired from birth to help the baby survive.  This includes a "rooting" reflex which causes the baby to turn his head toward anything that tickles or presses against his cheek, & a "suck" reflex which causes him to suck anything put in his mouth.  So a baby really doesn't care about nipples or bottles, he just has reflexes which drive him to find nutrition!  So I believe that most babies can be fed both & not get confused.  Of course, over time they might develop a preference for one or the other, but you can deal with that when or if it happens.  If he happens to prefer the breast, great!  If he prefers the bottle, you can always pump your breasts & place that breast milk in the bottle he likes.

I propose that having a baby who will take both the breast & the bottle is beneficial.  If somehow your breast milk does not come in properly, you could be starving &/or dehydrating your baby if you do not offer him a supplement!  Also, what will you do if you get ill & have to take medication which is not safe for your baby (Mom's body will share many medications with her baby by secreting them into the breast milk as it is produced)?  What will you do if you want to go out & have an adult beverage?  And don't forget, breast feeding is a fabulous bonding opportunity for Mom & baby, but what about dear old Dad?  Allowing him to feed the baby (with a bottle of breast milk OR formula) will help insure that he & the baby bond as well!

PSA versus BPH:

Does a normal PSA mean that the prostate is fine?  No, it means that the "prostatic specific antibody" is normal, thus indicating that it is unlikely that you have prostate cancer or prostate infection/inflamation

What about symptoms like:  urinary frequency (= the need to urinate often), urinary hesitancy (= a delay in starting urination when you try), nocturia (= having to get up at night to urinate), or poor urinary stream (= a weak stream, so basically you don't make bubbles in the toilet, & perhaps you don't make noise)?  These are symptoms of an enlarged prostate... what we call "Benign Prostatic Hypertrophy" or BPH.  If you have these symptoms you should discuss them with your doctor, who will likely do a digital rectal exam (= DRE) to check the size of the prostate, & also to feel for masses which could be cancerous.  If there are no masses & the PSA is normal, it is not likely that you have prostate cancer, so treatment for the enlarged prostate can begin.   Certain blood pressure medications can shrink the prostate, so often Hytrin (= Terazosin) or Cardura (=Doxazosin) are used if the man has high blood pressure AND BPH.  If he does not have high blood pressure, often Flomax (= Tamsulosin) is used.  If these medications do not help, surgery is generally indicated.  The old surgery is the Transurethral Resection of the Prostate (= TURP) which is more bloody & requires a longer time in the hospital with a foley catheter in the bladder.  The newer pocedure is the GreenLight Laser treatment, which uses a laser to remove the excess prostate tissue.  Due to the laser cauterizing the tissue, there is almost no bleeding & faster healing, so it is usually done as an out-patient procedure... though you usually go home with a catheter which is removed in the Urologist's office the next day.

Coumadin & Vitamin K:

Coumadin is a blood thinner used to decrease  the risk of blood clots (and thus strokes) in people who have an irregular heart beat, such as atrial fibrillation.  It is also used when a person has a deep vein thrombosis (= DVT) or even a pulmonary embolism (= PE), as these blood clots must be thinned, dissolved, & then prevented.  Coumadin interacts with many foods & medicines, thus it will vary in effectiveness depending on what you eat & the meds you take.  In particular, Vitamin K reverses the effect of Coumadin.  For this reason, doctors recommend that anyone who takes Coumadin should also follow a low Vitamin K diet.  This is difficult for many people as Vitamin K is found in large amounts in leafy green vegetables.  So, must a person who takes Coumadin change his diet radically & avoid leafy greens?  Well, it is best to simply avoid Vitamin K food products, but this is impractical for some people.  I recommend therefore that if you really enjoy leafy greens or other high Vitamin K foods, eat them... but do so consistently.  Find the amount of Vitamin K contained in these foods & try to eat the same amount of Vitamin K every day.  In doing so, your Vitamin K level will be stable so the doctor will be able to find the dose of Coumadin that will work with that dose of Vitamin K.  So if you ever end up on Coumadin, but love spinach, don't worry.  You can eat it, but you will have to eat it daily or find something with a similar amount of Vitamin K to eat daily.

Many of you may know that there is a new blood thinner on the market.  It is called Pradaxa, & it is very special in that it is not affected by food & meds.  In fact, doctors need not monitor labs to insure proper effectiveness.  Unfortunately it is new so we are still getting familiar with it, & of course it is expensive.  Perhaps it's biggest downfall however is that it's effect is not reversible, so if you are injured & bleeding, the doctor cannot give you medicine to reverse it's blood thinning effect, meaning that you will bleed freely until it's effect wears off.  Conversely, Coumadin can easily be reversed by giving the patient a large dose of Vitamin K... so perhaps in the long run, it is the safer blood thinner.

By the way, Coumadin is the name-brand version of Warfarin.  You have likely used Warfarin around your house or camp, as it is commonly known as rat poison!

Iron for Anemia:

Anyone who has ever taken an iron supplement knows that iron often causes constipation & stomach upset.  I learned many years ago about a supplement which is great for treating anemia, and which does not tend to cause stoamch upset.  It is called "hematinic" which I tend to think translates to "blood tonic."  Since learning of its existence I have not written a prescription for iron, as my patients have responded very well to the hematinic & have essentially no side-effects.  You should be able to find a hematinic in a good health food store.  Like any other medication, you need to follow your body's response to the supplement, so be sure to get lab work after 1-2 months to be sure your blood counts are improving.

Keep in mind that I am happy to answer your medical questions.  Just call during the live show or e-mail me any time.  "Let's Talk Medical with Doctor Gigi" airs live during "The Skip Show" on Fridays at 1:00 PM Eastern time.  We're on WTAN 1340-AM in the St. Pete/Clearwater area, or you can catch us live via where you will also have access to our recorded podcasts.  Our contact info is as follows:  (727)-441-3000 or toll-free (866)-TAN-1340 or

Hope to hear from you soon, & until then, here's to our health!

Doctor Gigi