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August 16, 2016

An Interview With Michael Litrel, MD, FACOG, FPMRS – Part 2 of a 3 Part Series

Of all the specialties you could have chosen, why did you choose obstetrics and gynecology?
I was quite surprised myself that I chose OB/GYN. I really hadn’t thought of it as a specialty before I attended medical school because I was more inclined towards surgery. However, when I delivered my first baby, it was such a miraculous moment in my life. It was 3:00 in the morning, and I remember it distinctly. I was in awe that this child actually came from a woman’s body. Ten seconds later, as I was placing that baby into that little infant warmer, I realized that I wanted to participate in this miracle; that I was going to be an obstetrician. It was a profound moment for me, and I can’t begin to express how much great personal satisfaction and enjoyment I’ve received over the years by taking care of women and women’s issues.

Your wife Ann also works at Cherokee Women’s. Do you find it difficult to separate work-related issues from home life, or do you find it can strengthen a relationship?
Ann works on public relations for the clinic and I have my medical practice so yes, we work under the same roof and our paths do cross but we each tend to our own professions. I’m a doctor, something I’ve wanted to be since the age of seven and Ann is, first and foremost, an artist.Dr. Litrel and Ann photo

In answer to the second part of your question regarding separating work-related issues from home life, I think it’s very important to be married to your best friend and someone you trust implicitly. Ann is both of those to me.

We have a strong, healthy relationship and have been married for 28 years. Like any normal couple, we have our ups and downs, but we know how to apologize and go on from there. We’ve grown together and share similar interests. We agree on many things, including our relationship with God, and about becoming better people. As we advance through life, we continue to support, encourage and help each other. We’ve known each other half our lives so I wouldn’t say being a doctor and discussing work-related issues makes either my job or my marriage harder, any more than Ann being an artist and sharing her passion for it impacts either of those things.

You have an identical twin brother named Chris. When growing up, did you find that you and he shared that proverbial ‘brain’.
As identical twins, he and I understood each other so well that we didn’t learn to speak early or verbalize our thoughts to other people.

Dr. Litrel, Chris and Mary photoHowever, we’re very different. My brother is a lawyer by trade, and a lawyer’s thought process is entirely different from a doctor’s. Physicians focus more on immediate problems, whereas attorneys think three years ahead of time. Still, we’re very close and I rely on his counsel a great deal.

If you decided to retire tomorrow, what would you do?
Do you mean if I stopped practicing medicine? Well, I love what I do so as long as I’m healthy enough to keep doing it, I don’t really want to retire unless I absolutely have to. If anything, as I get older, I’ve become a better surgeon so I’d like to continue for as long as possible.

My other passion would be writing and speaking about the relationship between health and spirituality, something that’s very important to me. That’s one of the reasons I was drawn to the care of women and their health—because what life event could possibly be more spiritual and meaningful than the birth of a child?

I chose to specialize in surgical gynecology because human beings grow inside of a woman’s body, and sometimes you need a surgeon that can bring them safely into the world. I enjoy it, not only for the concrete aspects of surgery, but also for the deep spiritual meaning of this process known as the creation of a life.

We can clinically describe how a single cell turns into a newborn baby over 280 days, but the process itself is miraculous. It’s a testimony to the fact that our lives have deep purpose and deep meaning, and that God grants us life.

If you were to write another book, what topic would you choose?
As it happens, I’m currently working on a book on pelvic reconstructive surgery, but I’m also tying it in with the correlation between health and spirituality. Women not only endure suffering and damage to their bodies, but also to their souls. We all do. So the book I’m writing expands on that subject.

Women have unique human problems because of the nature of creating new life inside their bodies, and there’s suffering that comes from that process. So from that perspective, I’m writing about the nature of surgery in terms of when to have it and when not to have it. I’m also writing about the nature of health since health is not only about the physical but about the sexual and spiritual aspects as well.

I’d like to educate patients on the fact that we’re not human beings having spiritual problems, but that we’re spiritual beings having human problems. These human problems we all sometimes have call for the attention of a surgeon.

Do you like to travel? If so, where was your favorite place?
One of the things I like about practicing medicine is that I don’t have to travel anywhere. People from all over the world come to see me. I guess I’m more of a homebody than I am a traveler. I like keeping my life pretty simple. I have traveled and visited many different countries, but it’s not my favorite thing to do. I’ll go, but I prefer to stay home.

As a busy OB/GYN surgeon, I’m sure the demands can be overwhelming. How do you deal with those demands – both at work and at home?
I try to manage my schedule in such a way that I can always be in top form whenever I have patient duties. When I see my patients, I remain completely focused and concentrate on them. I also make sure I leave openings in my schedule to allow for free personal time. That way, I know that I can continue to do what I do indefinitely to prevent burn out.

Instead of allowing myself to get overwhelmed, I try to set up my calendar in a manner that guarantees I can be in peak mental condition all the time, thus insuring that I give the best care I possibly can. I’m 50 years old so I know myself well enough to know what works for me.

To unwind after work hour, Ann and I will often go for a walk around the neighborhood for about 40 minutes. We may go to the gym for some exercise, or out to have something to eat. Our favorite date is going out for a glass of wine, an appetizer, some dessert, and maybe catch a movie. That’s probably been our favorite type of date for the last thirty years.Dr. Litrel and Ann photo

I think we all need to give ourselves personal time to build up a relaxed, spiritual reservoir so that we can make good choices. To me, good choices are eating right, exercising, taking my wife out, having friends over, laughing and enjoying life—that’s MY relaxation.

Coming from an Asian-Italian background, how did you combine the two worlds when it came to traditional customs, beliefs and holidays?
Since I have a mixed ethnicity, I always had a few problems in the sense of fitting in. I was born in 1965 and there weren’t that many Chinese-Italian people out there back then. Although we’ve come a long way as a society in the sense that people are much more tolerant of interracial marriages today than they used to be, it was a bit difficult for me at times when I was growing up.

I probably chose my profession, because as a kid, I didn’t fit in too well with the world around me. I think that’s one of the reasons I was so drawn to medicine. In medicine, it’s not about skin color, ethnicity, wealth, or socioeconomics. It’s about helping and healing people.

As for holidays and customs, my mom’s father and stepmother lived in New York City. They were vegetarian Buddhists. For Chinese New Year, my step-grandmother would make a traditional Chinese meal, after which we would go into the city and celebrate. When fireworks were still legal, we would light them and throw them at the dragon. I remember how much fun that was.

As for the other side of my family, my dad had a lot of Italian friends—in fact his business was Italian food manufacturing. He worked with a lot of Italians, so we spent most of our time in their environment. New York is very rich in Italian flavor and community, so we got a lot that particular ethnic exposure too.

I still have Italian friends in New York. My grandparents have since passed away, so I’m not as in touch with my Chinese roots these days as I am with my Italian ones.

What is your very first childhood memory?
I remember when I was 3 years old we were moving to the house that would become my childhood home. I remember driving down that block and coming to the house that I would grow up in.

Ok, I just have to ask: When you watch medical movies or TV shows, do you find yourself mentally correcting the inconsistencies?
When I was younger, I used to think about all the things they were doing wrong. Now I simply sit back and enjoy what I see on the screen. I’ve come to understand that they’re just trying to create drama, and I recognize that movies and TV are all about the story.

When I was training to be a resident I used to watch ER—and that was actually a very good show. Michael Crichton was asked to be a consultant on that show because he was a Harvard trained doctor. It was a good series but sometimes it was just too much. To draw viewers, they would try to condense all these improbable situations into a one-hour episode of heightened drama and sensationalism. A lot of it was very real but it was just too intense. I DID enjoy it though. I also used to like M*A*S*H*. I still watch medical shows today because it made people aware of what it’s like to be a doctor, or a doctor in training.

What inspires you to continuously educate yourself and want to learn more? Did you have a mentor?
I think I became a doctor because I wanted to matter to other people. I also think that perhaps childhood pain is the root of my deep desire for my life and my actions to matter.

For me, life is about evolving, learning and constantly getting better and better. I don’t think my motivation to learn can be attributed to any one person. I’ve had excellent teachers and mentors throughout my life, and I feel blessed to have had them, but I don’t think that I can ascribe sole mentorship to any one person.

I think the best way to live is to always improve one’s self. I’m hoping my children have learned that from Ann and me. I pray they will always strive for self-improvement in their lives. I think that the people who don’t try, who don’t aspire to progress, who choose to remain stagnant in their viewpoints—these people become trapped in the belief that they are always right, when in fact, they can be tragically wrong.

Symptoms to bring to your doctor photoOftentimes women accept minor gynecological or urinary symptoms as a normal part of being a woman. The truth is those minor symptoms may be indicative of a more serious condition.

It is important to take charge of one’s health, stay up to date on annual visits, and make sure to speak with a doctor about any concerns, no matter how minor they may be. By recognizing and disclosing these symptoms early, doctors may be able to diagnose and treat underlying pelvic or urinary conditions.

If a woman is unsure whether to call her doctor, here are some symptoms that may go unnoticed but can be cause for concern:

  • Urinary Incontinence – Leaking urine is commonly seen in women who have had multiple pregnancies, or who are advancing in the aging process. However, urinary incontinence is not something a woman should take lightly. Leaking any amount of urine while laughing, sneezing, coughing, or exercising can be a sign of several urinary conditions, including bladder prolapse. Don’t wait until an annual exam to bring this to a doctor’s attention. There are treatments and lifestyle changes one can make to minimize the symptoms of incontinence.
  • Unexplained Bleeding Bleeding that is not associated with a monthly cycle should be brought to a doctor’s attention immediately. While one shouldn’t stress about the worst case scenario, possible conditions that could cause the bleeding range from fibroids and cysts, to ectopic pregnancies, anemia, or even cancer.
  • Pelvic Pain – Any pelvic pain whether it is during sex, or any other time should be mentioned to a doctor. There could be underlying causes that may need to be examined further and/or treated such as a sexually transmitted disease, endometriosis, or uterine fibroids.
  • Changes Anything seem out of the range of normal, lately? A change in discharge, itching, visible bumps or bulges, or burning while peeing are definite reasons to call your gynecologist immediately. These unpleasant symptoms may be signs of vaginal infections, sexually transmitted diseases, urinary tract infections, or other vaginal conditions that require a doctor’s diagnosis and treatment.

At Cherokee Women’s Health, we are here for any concerns you may have about your gynecological health. Make an appointment at one of our two locations where our highly specialized doctors can diagnose and treat any worrisome symptoms.

Pelvic Organ Prolapse (POP) refers to the sagging or drooping of any pelvic organs due to damage, trauma, childbirth or injury.

The pelvic floor consists of a group of cradle-shaped muscles that hold pelvic organs in place. The pelvic organs include the uterus, bladder, cervix, vagina, rectum and intestines. Like any other part of the body, these muscles, with their surrounding tissues (fascia), can develop problems.

If you fill a small plastic bag with grocery items, say for instance, a box of cereal, a few cans of vegetables, some jars and a package of rice —the bag should hold the items with no problem. But if you hang that full bag on a wall hook and leave it suspended, you’ll start to notice the items in it begin to bulge against the membrane of the bag as it takes on the shape of its contents.

After a while, depending on how heavy the items are, the corner of the cereal box or rim of a can may start to bulge and even poke through as the bag stretches, weakens and eventually tears from the weight of the items in it. The groceries may even begin to protrude and dangle outside of the bag as the tears get larger.

Pelvic pain photoPelvic prolapse happens much the same way. As the muscles and tissues holding the pelvic organs weaken, degrade or tear, the pelvic organs slip or drop through, sometimes forming a small hanging internal bulge. At other times, depending on the damage, they may actually dangle externally from the vagina or anus, causing problems and inhibiting their function. This is called prolapse.

Who is at Risk for Pelvic Organ Prolapse?

One in three women suffer from POP. Any activity that puts undue pressure on the abdomen can cause pelvic floor disorders. Typically, labor and childbirth are the leading causes of prolapse, especially when a woman has had several children, a long, difficult labor, or has given birth to a larger child.
Pelvic organ prolapse becomes more common with age, usually around menopause when tissues damaged during a woman’s childbearing years begin to lose strength. Other causes are:

  • Obesity: Excess weight places increased pressure on the abdomen.
  • Pelvic organ cancers: Tumors can also put additional pressure on the abdomen.
  • Constipation: The bowel puts increased pressure on the vaginal wall when constipation is a chronic problem.
  • Uterus removal (hysterectomy): During surgery, there is always a possibility of inflicting damage on pelvic organ support, resulting in dislocation of any organ within the pelvis.
  • Smoking and respiratory problems: Excessive coughing, especially if chronic, can put extra strain on the abdomen.
  • Genetics: Pelvic connective tissue weakness may be hereditary. Often, if immediate female family members have suffered from prolapse, there is a greater possibility that you will too.
  • Heavy lifting: Excess abdominal pressure from heavy lifting may cause POP.
  • Diseases of the nervous system: There is a greater risk of developing pelvic organ prolapse for women who suffer from multiple sclerosis, spinal cord injury or muscular dystrophy.

What are the Symptoms of Pelvic Organ Prolapse?

It is entirely possible not to have any symptoms at all. Sometimes pelvic organ prolapse is only discovered during a routine gynecological examination. Minor symptoms are a feeling of annoying pressure of the uterus or other pelvic organs against the vaginal wall, minimal malfunction of those organs, and mild discomfort. Other symptoms are:

    • Painful intercourse
    • Vaginal bleeding or spotting
    • A sensation of pelvic pressure
    • Feeling as if something is falling out of the vaginal opening.
    • Bowel movement problems such as constipation.
    • Urinary problems such as needing to void frequently, especially if this interrupts sleep (overactive bladder) or involuntary urine release (incontinence).
    • Stretching or pulling sensations in the groin or pain in the lower back.

Symptoms may be aggravated by jumping, lifting or standing. Relief is usually found after lying down for a while.

When Should You See Your Doctor?

If you have increased sensations of pelvic pressure or pulling which is exacerbated by lifting or straining, but relieved when you lie down.

  • If sexual intercourse has become painful or difficult.
  • If lower back pain or pelvic pain interferes with daily living.
  • If you can feel a bulge inside your vagina or see one protruding.
  • If you have irregular spotting or bleeding.
  • If urinary problems have developed, such as leakage, an urgent need to void, or more frequent urination, including two or more times a night.
  • If you suddenly develop bowel movement problems.

Diagnosis

At times, pelvic organ prolapse may be hard to diagnose, especially if a patient does not complain of any symptoms. Patients might be aware there’s a problem but cannot actually pinpoint its location.After asking questions regarding symptoms, medical history, past pregnancies, and other health problems, your doctor will perform a physical examination. Then, if organ prolapse is suspected or discovered, the following additional tests may be ordered:

    • Urodynamics test: Results will indicate how your body stores and releases urine.
    • Intravenous Pyelogram (IPV): An x-ray that reveals position, size and shape of the bladder, kidneys, ureters and urethra.
    • Cystoscopy: This lets your doctor see the interior lining of your bladder and urethra.
    • Computed Tomography Scan (CT scan): X-rays showing details of interior pelvic area structures.

The doctor will then use a classification system to decide the organ prolapse level so he can best decide treatment options. Often, only simple non-invasive treatments and lifestyle changes are recommended for minor prolapse. If surgery is warranted, the following may be suggested:

  • Cystocele repair: Repair of the bladder
  • Urethrocele repair: Repair of the urethra
  • Hysterectomy: Removal of the uterus
  • Rectocele repair: Repair of the rectum
  • Enterocele repair: Repair of the small bowel
  • Vaginal vault suspension: Repair of the vaginal wall
  • Vaginal obliteration: Closure of the vagina.

What Can You Do?

  • Eat fiber: Try to get at least 20mg daily to prevent constipation. Regular elimination is essential to good pelvic health.
  • Kegel exercises: These strengthen and tighten pelvic floor muscles and can be done anywhere, any time—on the sly.
  • Maintain a healthy weight: Your abdominal muscles will thank you.
  • Avoid heavy lifting: If you have to grunt to lift, it’s too heavy.
  • Gentle exercise: Walking is great. Put on those sneakers and try to gradually work up to 20 minutes a day.
  • Drink plenty of water: Not gallons, but about 8 cups a day. This also helps with constipation.
  • Bowel training: Try to schedule bowel movements at the same time every day. It may take time, but eventually your body will cooperate.
  • Don’t smoke.

Pelvic prolapse often sounds worse than it is. For many women, there are hardly any symptoms. For those who DO suffer, there is help available, whether it is a simple lifestyle change, surgical repair, cosmetic enhancement or reconstruction.

If you have questions about your gynecological health or would like to consult with one of our pelvic reconstructive surgeons, please call 770.720.7733 or contact us here.

August 10, 2016

First Gynecology Appointment PhotoFirst Gynecology Appointment
At Cherokee Women’s Health, we understand the nerves a woman may experience when making a gynecology appointment, even for a routine annual examination. Our goal is to make patients feel as comfortable and assured as we can, beginning with their first appointment. To help prepare for an appointment, here are some expectations and answers to commonly asked questions about our practice and a routine gynecology examination.

Health History
Honesty is important when disclosing one’s health history. Doctors need to be aware of the past, so they can accurately care for a patient. Usual topics covered in a health history will include any medications currently being taken; sexual history; past pregnancies, surgeries, or treatments; and a familial history of cancer and other diseases.

Come with Questions
Don’t hesitate to bring up any concerns, no matter how trivial they may seem. It is best to be straightforward about symptoms, in the event that additional procedures need to be scheduled. Don’t leave our office with any questions unanswered! There is no need to be self-conscious about asking questions or discussing symptoms because our doctors have years of experience in their field. They discuss these topics daily with their patients.

What to Expect

  • A routine appointment lasts about an hour. Several exams take place during the appointment including a pelvic exam and a breast exam. Patients should also be prepared to provide a urine sample to test for pregnancy, and to catch any abnormalities in the sample that may indicate disorders or infections.
  • A pelvic examination is performed to ensure that both external and internal areas of the vagina are normal, including a pap smear which is used to test for cervical cancer. At a patient’s request, a culture can be ordered to screen for any sexually transmitted diseases. The pelvic exam can make patients uncomfortable, but it is important to relax during the process. Reproductive health is important!
  • A breast exam is completed to check for any lumps or irregularities in breast tissue. Based on family history of breast cancer, and your age, you may be referred for a mammogram which will screen for breast cancer.
  • An opportunity to ask questions is part of the appointment. Be proactive and mention anything that is concerning. Honesty is essential to providing the best personalized care to our patients.

What is Hymenoplasty?
Simply explained, hymenoplasty, also known as hymenorrhaphy, is the cosmetic repair, restoration, or construction of a woman’s hymen. Restoration of the hymen is also referred to as revirginization.

What is a Hymen?
In order to explain hymenoplasty surgery, a description, along with some information about the hymen might be beneficial.

The hymen consists of human tissue which resembles an oval rubber washer that partially or completely covers the vaginal opening. This ring-shaped membrane can be thin and flexible or thick and rigid. It begins to form while the female is still in the womb, usually beginning in about the fourth month of pregnancy.

Contrary to what many believe, except in rare cases, the hymen is NOT an impenetrable seal. If this were the case, there would be no portal for menstrual flow or healthy, normal vaginal discharge to leave the body.

Historical romance writers often describe the heroine in their bodice ripper books as having a Teflon hymen that causes her to wince or cry out painfully while in the throes of that first sexual encounter. Her lost virginity is also typically evidenced by vivid, crime scene-like blood splatter on pristine white sheets. However, in reality, that first rupture, regardless of the method, doesn’t always draw blood, and is not always painful.

Hymenoplasty photoLike the appendix, a hymen serves no real purpose. Yet, throughout history, this nondescript sheath of skin traditionally and very mistakenly has served as undeniable, positive proof of a woman’s purity and innocence. Even to this day, in many cultures, an intact hymen still indicates virginity, especially if there is the presence of blood upon first penile penetration.

Clinically speaking, however, a torn or damaged hymen is not irrefutable confirmation of virginity loss by sexual hanky panky. Depending on its rigidity, perforation of the hymen can be caused by normal everyday activities such as strenuous athletics, horseback or bicycle riding, a simple gynecological examination with speculum or gloved finger insertion or masturbation. Even placing a tampon into the vagina may rupture it.

In some cases, a hymen may not be present at all, as approximately 1 in 1,000 women are born without one.

What Are Some of the Reasons for Hymenoplasty?
Hymenoplasty is a cosmetic fix for women who may wish to repair or reconstruct their hymen. Their reasons for seeking this procedure are varied, and may be physical or psychological.

  • Reclaiming control: In the case of sexual assault, a woman is understandably left with traumatic psychological issues. She may feel that she was robbed of not only her innocence, but the opportunity to present the virginal gift of an intact hymen to the person of her choice. Hymenoplasty may not only offer the physical restoration she seeks, but may also supply some psychological comfort and healing as well.
  • Burying the past: Sexual curiosity and experimentation are a natural part of the growing process, especially during adolescence when hormonal changes and surges occur. Peer pressure may often compel a young girl to succumb to sexual activity before she’s mentally prepared for the emotional impact associated with such physical intimacy. As she matures, she may feel regretful that she indulged in that curiosity too early or too often, and may seek to bury evidence of what she might, in retrospect, view as promiscuity or bad judgment. Revirginization may psychologically allow her to turn back the clock and start over.
  • Cultural beliefs: Because the presence of an intact hymen is still important in many cultures, a woman may want to provide this indication of purity to her spouse for their upcoming nuptials.
  • A gift: Many women who have already been sexually active may wish to give their partner a virginal experience, whether it be as a surprise, for a special occasion, or on their wedding night.
  • Accidental rupture or tearing: For some women, penetration of the hymen via bicycle or horseback rides, slipping on ice, or tampon insertion is simply not acceptable and they opt for hymenoplasty to restore what was damaged unintentionally.
  • Enhancement of sexual pleasure: After childbirth, the vaginal muscles may weaken. Flaccidity also occurs over time with age. Hymenoplasty also tightens these muscles, giving the added benefit of a more sensually stimulating sexual experience.
  • Imperforate hymen: This is a condition where the entire vaginal opening is covered by the hymen. It is not usually discovered until a young girl enters into puberty and her menstrual flow is blocked. The hymenoplastic procedure to correct this is called hymenotomy, and a small hole is made in the membrane to allow blood flow.
  • Septate hymen: The hymenal tissue is split into what looks like rope-like bands. They resemble tonsils that are connected at both ends, and may impede tampon use or penile penetration. This is also corrected by hymenotomy. A septate hymen can also refer to a very thick or rigid hymen, like the almost bulletproof one of romantic lore mentioned earlier, and may require surgical penetration.
  • Microperforate hymen: This is similar to an imperforate hymen and is corrected in the same manner. A microperforate hymen has a small opening only adequate enough to permit menstrual flow. It does not usually present a problem or require enlargement unless a female wishes to use tampons.

What Happens During Hymenoplasty?
Hymenoplasty is usually a simple out-patient procedure that can be done in our clinic under local anesthesia. Any torn skin around the edges of the hymen is gently and neatly cut away, after which the remaining tissue is stitched together, leaving a small opening. This restores the hymenal ring to a normal size and shape.

If there is not enough skin to restore the hymen, or if a hymen is nonexistent, the surgeon may create one, using either some of the body’s own thin vaginal skin (vaginal mucosa) or a synthetic tissue. A small blood supply may be added, either artificial or the patient’s own taken from a piece of vaginal flap, thus simulating the traditional bleeding upon subsequent penetration.

What is the Recovery Time?
The surgery can be expected to take anywhere from one to two hours depending on the amount of repair needed. Though this is a clinical procedure with no hospital stay necessary, and women may return to work the next day, strenuous activity and heavy lifting should be avoided. During the first 48 to 72 hours, there may be some slight bleeding, but this is perfectly normal.

Full healing takes approximately six weeks. There will be no visible signs of surgery and it will be impossible to tell the difference between a natural hymen and a reconstructed one. At this time, the reconstruction process will be complete and all the sensations associated with virginal, first time sex may be experienced.

Complications
There are rarely complications. However, the doctor should be contacted if the patient experiences any of the following symptoms:

  • Dizziness
  • Pain beyond moderate discomfort after three days
  • Unusual or foul smelling discharge
  • Intense itching
  • Abnormal bleeding
  • Inflammation.

Depending on why you might request hymenoplasty, this may be a delicate subject to discuss. Rest assured that our doctors are familiar with the many reasons patients ask for this procedure, and fully understand your discomfort and shyness in regard to this subject. It’s your body. We want to help make you as comfortable and confident with it as possible.

To learn more about hymenoplasty or to schedule an an appointment with one of our doctors, please call 770.720.7733.

What is Clitoral Hood Reduction?
Clitoral hood reduction, also known as clitoral unhooding, clitoral hoodectomy, or clitoridotomy is a cosmetic surgical procedure which reduces the excess skin (prepuce) that covers the clitoris. The technique not only
enhances the visual appearance of a woman’s pubic area, but it also serves to improve sexual pleasure by making the clitoris more accessible. As the name implies, the clitoral hood conceals the clitoris nestled inside, similar to an uncircumcised penis where the foreskin sheathes the head in its non-erect state.

What is a Clitoris?
Before launching into a description of the surgery itself, it may be of interest to understand the function, location, and description of the female clitoris.

The clitoris is a woman’s primary and most complex erogenous zone. The head (glans) of this tiny body part is estimated to have more than eight thousand sensory nerve endings twice as many as the glans of a penis. Though its sensitivity and size can differ from female to female, it normally resembles a pea or small pearl. When aroused by oral or manual stimulation, the clitoris becomes engorged much the same way the male penis does, thus enabling a woman to achieve orgasm.

In order to more easily picture the location of the clitoris, simply imagine the nude frontal view of your pubic area. What you are looking at in your lower region is called the vulva. The cushioned ridge you feel beginning halfway down from your navel is the mons veneris. As you continue to move downwards, it separates into two cheek-like mounds that are separated by a vertical opening with lip-like tissue. Those lips are called the labia majora.

By gently pulling apart the labia majora, you will expose two more inner lip-like flaps of tissue on the left and right. These are labia minora. At the base of the labia minora, leading up to the anal opening, there is a small bony ridge called a perineum. At the upper tip of the labia minora, that small tube-like protrusion is the clitoral hood. Peeking out through, or hiding inside the opening of that hood is the tip of the clitoris.

The entire clitoris itself is about 4 inches long, but, as explained earlier, the head or glans, is small, roughly the size of an eraser on the end of a pencil, and it is extremely sensitive to touch.

Clitoral Hood Reduction photoWhy Would a Woman Need a Clitoral Hood Reduction?
Because the size, shape and thickness of the clitoral hood differs from woman to woman, this procedure is not always done for medical reasons alone. It can also be done for aesthetic purposes to give the vulva a neater, trimmer look.

In some cases, the clitoral hood may be extremely large, inhibiting access to the clitoris, thereby preventing the achievement of sexual gratification. A thick or large hood may also cause friction against clothing which can lead to soreness, redness or inflammation.

Often, a woman with an enlarged hood may also have large labial lips that protrude in a manner she may find unsightly. Both the clitoral hood and the labia, if quite prominent, can sometimes create obvious bulges that can be seen outlined against close-fitting outerwear. Women may opt to cosmetically correct prominent labia through a procedure called labiaplasty at the same time as they undergo a clitoral hood reduction.

What Can be Expected During and After the Procedure?
Clitoral hood reduction surgery is normally done as an outpatient procedure under local or general anesthesia. A specialized laser and surgical instruments remove a predetermined amount of superfluous hood tissue, insuring that accessibility and stimulation to the clitoris is no longer restricted. The clitoral head is not modified in any way. Only the hood is altered. At this time, if the patient so chooses, the surgeon may perform additional procedures to the genitalia, such as vaginal tightening, hymenoplasty or vaginoplasty.

Clitoral hood reduction is microsurgery. The procedure, after complete healing, will leave no scars. Tiny, barely visible incisions will be concealed in the folds of tissue around the surgical area.

There will be some numbness experienced after surgery, but this will subside. The numbness is in no way indicative of nerve or any other damage. In fact, after the effect wears off, sensitivity to the clitoris will be heightened due to easier access to it.

The entire procedure will take approximately an hour depending on what needs to be done.

Aftercare and Recovery
The area will be tender and inflamed, but rest and application of ice will help, along with over-the-counter pain relievers. After about two or three days, the patient will be able to return to work. Complete recovery will take approximately six weeks, and the patient will be cautioned not to engage in sexual intercourse during that time in order to avoid complications. Strenuous activities such as horseback or bicycle riding, running, and heavy lifting should also be avoided during this time. Special care to keep the area clean is important in order to avoid any possibility of infection.

What Are the Complications?
Complications are rare. However, your doctor should be contacted if there are any of the following problems:

  • Intense pain or discomfort
  • Inflammation or numbness after several days
  • Any foul odor or unusual discharge
  • Excessive bleeding.

Interesting Facts Regarding the Clitoris
The size and shape of the full clitoris was not revealed until 1998. Until that time, even though physicians knew of its existence, it was either eliminated from anatomy publications that previously mentioned it briefly, or it was ignored altogether. A 3D sonography image was not available until 2009. Throughout history, the importance of the clitoris to a woman’s sexual pleasure has either been disputed or dismissed altogether. In fact, in the 1500’s, the presence of the clitoris in women was used as irrefutable proof of witchcraft, and was referred to as the ‘devil’s teat’. Perhaps the clitoris snuggled deep within the camouflage of a thick clitoral hood back then saved many a woman from imminent death.

We’re Here to Help
Our highly qualified doctors are here to frankly and openly discuss whether this procedure is right for you. Genital surgery, whether for physical, aesthetic or psychological reasons, is an intimate and important decision. We are here to guide and advise you without judgement, bias or preconception. The more confident and comfortable a woman is with her body, the more pleasurable and satisfying her intimate life will be. We are here to provide the help and advice to make that happen.

To make an appointment with one of our doctors, call 770.720.7733.

August 5, 2016

Nutrition is an important part of pregnancy. It gives moms the opportunity to increase their intake of vitamins, minerals, and essential nutrients. This boosts their energy, helps their babies’ development, and can even improve some of the symptoms of pregnancy. But as important as what to eat when pregnant is a topic that’s decidedly less fun: what not to eat during pregnancy.

Foods to Avoid During Pregnancy

  • Raw meats. Raw or undercooked meat can carry all kinds of bacteria. Stay away from rare beef and poultry, sushi, uncooked hot dogs, and items that contain raw eggs, which may include salad dressings and sauces (be careful about Caesar salad dressing and aioli!), raw cookie dough, and desserts like tiramisu.
  • Other meats. Just because it’s cooked doesn’t mean that it’s safe. Expectant mothers should avoid eating deli meat, smoked seafood, fish containing mercury, refrigerated pate or meat spreads, and fresh meat that may have been exposed to pollutants.
  • Soft cheese. Some imported soft cheeses–including brie, feta, Camembert, and many Mexican quesos–are not made with pasteurized milk, which increases the risk of listeria. Love soft cheese? Read the label! If it was made with pasteurized milk, you’re free to satisfy your cravings.
  • Unpasteurized anything. Milk is the biggie, but moms-to-be should also avoid unpasteurized juices, especially ones bought from local farms.
  • Unwashed veggies. Vegetables provide essential nutrients for pregnant women and the babies they carry. Just make sure to wash them before digging in.
  • pregnant woman eating yogurtCaffeine. New studies show that small amounts of caffeine are okay later in pregnancy, but expectant mothers should keep a close eye on their caffeine intake. Try to avoid caffeine entirely during the first trimester. Consume no more than 200 mg per day later in your pregnancy, or you may increase your risk of miscarriage, premature birth, or low birth weight. (*Tips for pregnant women who consume caffeine: drink plenty of water, remember that decaf coffee contains caffeine, and look for hidden caffeine in protein bars, yogurt, and candy).
  • Alcohol. Most moms know not to drink alcohol during pregnancy, because it can lead to Fetal Alcohol Syndrome. But in today’s climate of “sure, that’s fine!” advice, it bears repeating: no matter what you see in the news, alcohol is a big no-no for moms-to-be.

Cherokee Women’s Health helps expectant mothers in Canton through the unique experience of pregnancy. For a personalized diet plan, advice on healthy eating and fitness during pregnancy, and other prenatal care, schedule an appointment with one of our certified physicians or midwives.

regnant Woman Eating Yogurt

August 4, 2016

ThermiSmooth

Achieve Smoother, Firmer Skin with ThermiSmooth

ThermiSmooth is a simple office procedure for smoothing fine lines, wrinkles and sagging skin in all areas of the face:

  • Forehead
  • Eyes
  • Cheeks
  • Mouth
  • Neck

Patients have remarked this 30-minute procedure feels like a “warm massage” while a hand-held device delivers radiofrequency energy to the surface of the skin, heating the cells and stimulating the body’s own collagen production.

ThermiSmooth requires no anesthesia, takes little time and works beautifully. A series of 3-6 treatments is recommended for optimum results.

  • Gentle therapy
  • Non-invasive procedure
  • No downtime
  • Series of 3-6 treatments

One patient, who just started her series of ThermiSmooth treatments, says, “I’m turning 50 this year and was on the verge of scheduling a consultation with a plastic surgeon to address my wrinkles and sagging skin, but I was hesitant to go under the knife. That’s when I heard of ThermiSmooth. I did some research on RealSelf.com and was blown away by the before and after photos so I immediately scheduled an appointment. I’m so glad I did. I’ve received two treatments so far and already my skin feels better, looks younger and my makeup goes on smoother. And it really does feel like a warm massage! I can’t wait to see the results after my final treatment.”

To schedule your ThermiSmooth appointment, call 770.720.7733 or contact us here.

August 2, 2016

Dr. Crigler photo
As an OB-GYN who’s a vegan, husband and father, Dr. Crigler shares his views on diet, exercise, and bringing patients a great health experience. Working in the field of women’s health – as does his wife Lauren – he talks about how they’ve shaped each other’s practices, and how he turns off his “clinical side” at home.

12 Symptoms, One Fix: How Can Patients Experience Better Health?

Q: From your recent blogs, it’s evident that you and your family maintain a proper diet as the foundation for your health. Does going vegan have any advantages for female reproductive health, and if so, what are they?
Dr. Crigler: A plant based diet has multiple benefits for women’s health, including decreased risk of breast, ovarian and colon cancer. Meat and dairy have both been associated with increased risks of each of these cancers. Even for our pregnant patients, a vegan or plant based diet free of dairy and meat can be very healthy for both baby and mother. As we recommend taking prenatal vitamins for all women, supplementing vitamin D and B12 is more important with a vegan diet. This diet has also been associated with a decreased risk of preeclampsia. It also results in a purer breast milk with no added hormones and less risk of food allergies for the infant.

In addition to female health improvements decreasing the cancers I spoke about, I want to mention lupus, acne, high cholesterol, irritable bowel syndrome and heart disease as conditions that are likely improved with plant based diet changes.

Dr Crigler doing situps with patient photo

Dr. Crigler doing situps with his patient and baby!

Q: What percentage of the health problems you deal with regularly would you guesstimate might easily be solved through nutritional changes and exercise? Can you give some examples?
Dr. Crigler: 100%. Plant based diets will assist in losing weight, decreased systemic inflammation of the body, decrease incidence of type 2 noninsulin dependent diabetes, decrease constipation and risk of hemorrhoids (for our pregnant patients) and help decrease exposure to exogenous hormones often found in meat and dairy products. Exercise helps maintain ideal body weight, increase insulin sensitivity (reducing gestational diabetes) and also helps keep mom in shape for the laboring process. After all, they don’t call it labor for nothing! Northside Hospital Cherokee has a good online maternity resource- that’s one place to start.

Q: Now that you’ve been in private practice for several years, are there additional areas of knowledge in women’s health care you would like to explore to better help your patients?
Dr. Crigler: Many of my patients ask me about sexual health including pain with intercourse, decreased sexual desire, inability to climax and vaginal dryness. While a very sensitive topic, this is very important for the health of a relationship and the mental and physical health of the patient.
I plan to explore dietary, natural, non-invasive medical devices, pharmaceutical, and surgical ways to help patients address these important concerns.

Q: Every doctor has his or her own approach to making a patient feel comfortable. How do you personally try to put your patients at ease to encourage open, honest dialogue?
Dr. Crigler: I try to imagine how I would want my two sisters, mother or wife to be treated during a gynecologic visit. I sit down and I listen. I realize these conversations are quite personal and that I may be the only person in the position to address these issues. I attempt to destigmatize these topics; such as painful intercourse, fecal or urinary incontinence or inability to orgasm.

Q: After each patient appointment, what do you want the patient to have or to have experienced when they leave?
Dr. Crigler: I want them to feel they were given the opportunity to express their concerns, they were listened to and that I truly care about helping them. I want them to come out with a better understanding of their health condition or problem and be confident in the treatment plan that we make together.

Q: Can you share an example of a patient where one appointment made a difference in their health decisions or treatment?
Dr. Crigler: I saw an 80 year old diabetic, arthritic patient with complete pelvic prolapse who still lived on her own, cooked for herself, and really valued her independence. Two doctors at other clinics recommended different surgeries that would likely take weeks to months to recover from and put her at risk of infection. I saw her as a 3rd opinion and offered her a pessary to hold everything in place. We happened to have the exact size she needed in stock and she left that day with a cure to her prolapse, no recovery time and I am sure made it home in time to cook her own dinner.

Husband and Father:
A Wide Perspective on Women’s Health

Q: There are many similarities between your profession and your wife’s, in that you both deal with the health and maintenance of the human body by reducing pain and restoring function—you, medically and she, therapeutically. Is that a coincidence, or did one of you inspire the other to select your specialty?
Dr. Crigler: We met in our anatomy class in medical school, so we were already on a path to helping people in the medical field. Our emphasis on the role that diet and exercise play in health, pain, function and disease prevention was mutually inspired with the help of several documentaries and books for inspiration.

Q: How much impact and input do you have on each other’s professions? For example, does your medical knowledge help your wife Lauren understand her patients better—and does Lauren’s input of what her patients go through during therapy (ie; pain, struggle, mental issues, etc.) help you approach your own patients with more enlightenment?
Dr. Crigler: Our professions impact each other’s quite a bit. We talk about the impact of medication, food and therapeutic exercise in all kinds of conditions. Medical doctors tend to emphasize freedom from symptoms while physical therapists emphasize increased function. We both have several techniques that help meet both of those goals for a more holistic treatment plan. We enjoy learning from one another and most definitely provide better care for our patients due to all of these free consults.

Q: Other than the usual ‘how was your day?’, do you normally leave shop talk at work, or do you find it makes for interesting conversation at home?
Dr. Crigler: I might discuss interesting or challenging cases with Lauren, especially if I am looking for a different perspective or physical therapy ideas. When I am on call, I usually just report any number of babies I delivered that night. She gets excited about every one as she reminisces about her deliveries. It makes not having me home worth it when she knows that another woman was having a life changing experience.

Q: After dealing with patient health issues all day, do either of you find it difficult to turn off your clinical sides?
Dr. Crigler: That’s funny. The very first thing I hear when I get home is “daddy, daddy, daddy, huggy, huggy”. After the hugs and kisses, I get to hear about their superheros and construction sites for about 30 minutes until we wind down for bath and our bedtime routine. Having my sons so excited to see me makes it pretty easy to put on my daddy hat and leave work behind…until they go to sleep that is.

Q: You mentioned that you had the privilege of not just seeing your sons being born, but also delivering them yourself. Do you remember your first thoughts as they both came into the world, or did you remain in ‘doctor mode’ until the whole process was over?
Dr. Crigler: I was in residency while both my sons were born so while I had delivered a couple of hundred babies already, I was still nervous. I did my best to play both the supportive husband and skilled obstetrician role at the same time during the labor. As they were crowning, I did tear up in amazement that we had made this miracle, and then simultaneously, as trained, remembered “protect the perineum”, in hopes to limit any vaginal tears. After delivery, I placed them both on my wife’s chest, cut the cords, and then went into complete husband-daddy role. 

Snapshot: Medical Rescue

Q: Almost every medical TV show and movie shows the star physician out somewhere on his day off enjoying a dinner or other relaxing activity. He’s minding his own business, when suddenly some drama occurs that requires the help of a doctor. Has this ever happened to you?
Dr. Crigler: Just last weekend my family and I went up to Cave Spring, GA to take the kids to the springs and cave. On our way back, it was raining and we rode by a serious collision on the opposite side of the road that appeared to have just happened. I immediately pulled into the closest gas station and left the kids and Lauren in the car to run across the median to help out. Fortunately, only one person was injured and she was talking. She did have a large laceration on her head, complained of neck pain, was very anxious and had evidence of a concussion. With the help of a couple of other Good Samaritans, we comforted her, stabilized her neck, and controlled the bleeding until EMS arrived. I then ran back, soaked, to my family as we rode carefully home, thankful everyone was safe and healthy.

July 14, 2016

Prolapsed bladder, also known as Fallen Bladder or Cystocele, is a condition where the bladder drops down from lack of support. A concave shaped group of pelvic floor muscles and tissues hold the bladder and other organs in place. Due to a variety of reasons, these muscles and tissues can weaken over time. This causes the bladder to descend from its fixed position and slip downwards into the vagina, much like a big toe begins to rub, then protrude through an old, worn sock. In more severe cases, the bladder may dangle completely outside of the vagina.

What Causes Prolapsed Bladder?prolapsed bladder photo

  • Childbirth: A difficult delivery, long labor, a large baby or multiple births are the most common causes. A baby’s eagerness or shyness to enter the world can be difficult on a woman’s vaginal tissues and muscles.
  • Strain: Heavy lifting, straining during bowel movements, excessive or chronic coughing can weaken the pelvic floor muscles.
  • Menopause: Once Mother Nature decides we’re done with babies and periods, the body no longer produces estrogen, which is vital in maintaining the health of vaginal tissue.
  • Obesity: Excess weight also puts undue strain on pelvic muscles and tissues the same way carrying a sack of potatoes can strain the arms and back.

What are the symptoms?

  • A sensation of pressure in the bladder or vagina
  • Leakage of urine when coughing, exerting oneself, sneezing, laughing, etc.
  • Protrusion of tissue from the vagina that may bleed or be sore
  • Frequent bladder ifections
  • A sensation that thne bladder is not completely empty right after urinating
  • Difficulty urinating
  • Pelvic pain or discomfort
  • Lower back pain
  • Painful intercourse
  • Incontinence during intercourse.

In cases where the bladder prolapse is mild, women may not experience any symptoms at all, and the condition may only be discovered during a routine examination.

When Should You See Your Doctor?

If you notice that you may have any of these symptoms and suspect a prolapsed bladder, you should see your doctor immediately. This condition often means that other pelvic organs may also be prolapsed, as the same muscles and tissues hold the uterus, cervix, vagina, rectum, and intestines in place as well. This is not a condition that repairs itself. It usually worsens over time, but it can be fixed thanks to many modern methods available today.

Diagnosis and Tests

In obvious cases, an examination of the pelvis and genitalia can visually confirm prolapsed bladder. If less evident, the doctor may use something called a Voiding Cystourethrogram to confirm diagnosis. This is a sequence of x-rays taken while the patient is urinating so that the physician can see the bladder shape and what may be causing flow problems. He may also request additional x-rays of different abdominal sections to eliminate other theories, after which he may test muscles, nerves and the force of the urine stream to conclude his diagnosis and recommend treatment. Additional tests, if necessary are:

  • Cystoscopy: examines the bladder using a scope
  • Urodynamics or Video Urodynamics: measures bladder pressure and volume
  • Ultrasound: Uses sound waves that form an image
    Magnetic Resonance Imaging (MRI): Magnets and radio waves that produce images of soft internal tissues and organs.

Treatment

If tests confirm prolapsed bladder, your doctor will categorize its degree as mild, moderate, severe or complete. If it is mild, it usually requires no immediate treatment other than to refrain from heavy lifting or exertion.
For more serious cases, depending on health, age and other factors, some non-surgical treatments include:

  • Pessary: A device placed into the vagina to hold the bladder in the correct position. He may also prescribe an estrogen cream to prevent vaginal wall degradation and infection. Just like dentures, pessaries need regular, thorough cleaning.
  • Estrogen replacement therapy: Estrogen strengthens, maintains and preserves vaginal muscles.
  • Electrical stimulation: Probes send small electrical currents to contract the muscles and strengthen them. Electrical stimulation can also be magnetically delivered from outside the body targeting the pudendal nerve to help with incontinence.
  • Biofeedback: A sensor is used to check muscular contractions during exercise to make sure they are being done correctly and are being beneficial.

Surgery

Should you need surgery, one of the following may be recommended:

  • Tension Free Vaginal Tape Surgery (TVT): A mesh tape placed under the urethra like a sling to keep it stable and in place.
  • Retropubic Suspension Surgery: Abdominal surgery to lift sagging urethra and bladder neck.
  • Electrical Stimulation: A series of sessions using a vaginal or anal electrode to aid stress and urge incontinence.
  • Urethral Bulking: Injection of bulking agents (collagen, autologous substances) around the urethra to treat incontinence.
  • Burch Colposuspension: Attachment of the vaginal wall to a ligament near the pubic bone.
  • Urethral sling surgery: A sling that lifts the urethra to its correct position and to aid urine retention.
  • Posterior Tibial Nerve Stimulation (PTNS): A small electrode introduced into the lower leg. The procedure decreases the need for frequent urination and requires several sessions.
  • Sacral Nerve Stimulation (SNS): An electrical stimulator placed under the skin of the buttocks that sends pulses to the lower back nerve (sacrum) to aid with bladder control.
  • Transobturator Tape Surgery (TOT): Similar to TVT with some small variations.

Types of Reconstructive Surgery

  • Anterior and Posterior Colporrhaphy: Resuspension of rectum and bladder.
  • Sacrohysteropexy: Repairs uterine prolapse by attaching the cervix to the sacrum with mesh.
  • Sacrocolpopexy: Repairs vaginal vault prolapse by attaching the vaginal vault to the sacrum with mesh.

What Can You Do?

  • Maintain a healthy weight.
  • Eat fiber to prevent constipation.
  • Don’t smoke. Chronic coughing contributes to bladder prolapse.
  • Train your bladder by trying to maintain a regular schedule of set times for urination.
  • Wear clothing you can remove easily if you suffer from frequent urination or overactive bladder.
  • Do Kegels and strengthen your pelvic floor muscles.
  • Cut back on tea, coffee and sodas that contain caffeine. Caffeine can have a diuretic effect.

Prolapsed bladder and its effects can be uncomfortable, restrictive and inhibit a normal lifestyle. Our highly trained GYN specialists can address these issues so you can get back to living the life you deserve.

Call and make an appointment today at 770.720.7733.

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“Dr. Litrel was a fantastic doctor. I had my first exam with him, although at first I was skeptical about a male doctor for my GYN. But after I met him I’m glad I kept an open mind, and I couldn’t have dreamed up a better doctor. He cares about you as a person and not just a patient. The front desk ladies and nurses were very friendly and it’s a great office, very clean and not intimidating. I highly recommend Cherokee Women’s Health.”
– Vicki