Publications

Summer 2003

• A Message From..
• Saint Barnabas Emphasizes on Women's Health Care
• Department of OB/GYN Launches Innovative Parent care E-mail Service
• The Center For Menopause and Reproductive Endocrine Consultative Services
• Understanding the Female Migraine
• Promoting Cardiac Health in Women
• Reduce Your Pre-Surgery Jitters
• A Clinical Research Study For Osteoporosis Prevention
• Breast Cancer Survivor Places In Fitness Competition

A Message From..

A MESSAGE FROM... VERONICA RAVNIKAR, M.D. CHAIR, DEPARTMENT OF OB/GYN
SAINT BARNABAS MEDICAL CENTER

Dear Readers:

The Department of Obstetrics and Gynecology at Saint Barnabas is pleased to present you with the newest issue of Women & Healthcare. We hope the topics covered in this publication are of interest to you. Our Department is dedicated to improving and promoting the health care of women in New Jersey and nationwide.

For questions and comments about any services at Saint Barnabas, or for a physician referral, please call 1-888-SBMC-DOC. For information about Childbirth and Parent Education courses, please call the Women’s Health Department at (973) 322-5360.

I wish good health to you and your family, and a safe and relaxing summer.

Sincerely,

Veronica Ravnikar, M.D.

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Saint Barnabas Emphasizes on Women's Health Care

Saint Barnabas Medical Center has made a commitment to women’s health care that resonates throughout every department, every program and service. From birth to the later decades of life, the Medical Center cares for mothers, daughters, granddaughter, aunts and sisters. More than 100,000 women are treated at Saint Barnabas each year. John F. Bonamo, M.D., MHCM Executive Director of the Medical Center, discusses this dedication to the health of women, and his own special bond to the female community as a former Obstetrician/Gynecologist.

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Department of OB/GYN Launches Innovative Parent care E-mail Service

Expectant parents are faced with a bewildering range of pregnancy and parenting information – books, magazines, television, and the well-meaning advice of friends and family. It is difficult to know how to sort it all out. Now, obstetrical patients at Saint Barnabas Medical Center have a resource to guide them through their pregnancy and the first year of their baby’s life: the Saint Barnabas weekly ParentCare e-mail. This free weekly service offers expectant and new parents customized information, news, and resources from the parent education staff, and allows the hospital team to develop a richer, more supportive relationship with their patients.

News You Can Use

Patients can start receiving weekly ParentCare e-mail messages at 20-weeks gestation. Messages are personalized to the patient’s due date and continue for the first year of their baby’s life. During pregnancy, the Medical Center’s messages include week-by-week information on fetal development, wellness tips, and valuable resources.

After the baby is born, messages offer child development information, practical tips on baby care, health and safety, and other topics of special interest to new parents. Saint Barnabas ParentCare e-mail also provides brief reviews of the latest research on pregnancy and newborn issues in an easy-to-understand format.

How It Works?

You can sign-up by going online at https://www.theparentreview.com/saintbarnabas and giving your name, due date and e-mail address. Your privacy is carefully protected. Messages are tailored to your week of pregnancy or age of child. For example, at 23 weeks the e-mail your receive has a brief message pertaining to issues of interest for that week. Unlike any other weekly e-mail, this message is based on the newest evidence-based practices and our years of experience supporting families through pregnancy.

For further questions, please call the Women’s Health Department at (973) 322-5360. 

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The Center For Menopause and Reproductive Endocrine Consultative Services

Now women have yet another specialized service offered at Saint Barnabas, and this care is provided by none other than the Chair of the Department of Obstetrics and Gynecology, Veronica Ravnikar, M.D. The Center for Menopause and Reproductive Endocrine Consultative Services offers a complete referral evaluation and full spectrum treatment for women with conditions that affect the menstrual cycle, fertility and hormonal issues. "My practice is designed for the patient with more complex and difficult health concerns who needs a consultation," says Dr. Ravnikar. "I am a consultative coordinator of care of the patient along with the referring physician. We bring an entire team together to sort out the patient’s needs." Young women experiencing problematic menstruation or the lack of a period, and complex cases of women in post menstrual transition are the primary group seen by Dr. Ravnikar in her office at the Medical Center’s East Wing. In addition to difficult menopausal and post-menopausal conditions, she also treats disorders including endometriosis (medical and/or surgical management), pelvic pain (medical and/or surgical management), polycystic ovaries & insulin resistance syndrome, infertility, amenorrhea (lack of menstrual periods before menopause due to medical conditions including pituitary dysfunction), irregular vaginal bleeding (medical and/or surgical management), uterine fibroids (conservative and surgical treatment) and hirsutism. Dr. Ravnikar reviews the patient’s entire record and gives a very detailed analysis of the situation, along with a recommended treatment plan that may include other specialists. She speaks with all physicians involved to "co-manage the care of the patient." In addition to a full medical history and physical, the patient may also be referred for tests to complete the medical picture. Dr. Ravnikar, is an esteemed gynecologist who is board-certified in both OB/GYN and Reproductive Endocrinology Infertility. She joined Saint Barnabas as Chair last April and continues to be a widely published expert in her field. She holds numerous positions in professional societies and health-related organizations. In addition, Dr. Ravnikar held a co-principle position in the Women’s Health Initiative. "By knowing the most current studies I am able to interpret the data on as individual a basis as possible," relates Dr. Ravnkiar. Her original research covers such topics as menopause and sleep, bone density loss in amennorrheic women, menopause and smoking, menopause osteoporosis and various aspects of hormone replacement therapy. For further information or to make an appointment, please call (973) 322-9982.

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Understanding the Female Migraine

ERIN ELMORE, M.D.
Attending Neurologist, The Institute for Neurology and Neurosurgery Saint Barnabas Medical Center

Migraine headache is a commonly encountered neurological disorder that affects people of all ages and occurs in equal frequency in both sexes before puberty. However, following puberty, it becomes three times more common in woman than men. Several studies have revealed a prevalence of migraine in women, close to 20 percent, whereas in men the prevalence is around 6 percent. As a female physician and migraine sufferer, I have had a particular interest both professionally and personally in migraines headaches.

What are the symptoms?

The pain associated with a migraine headache is typically described as unilateral, throbbing and aggravated with physical exertion or certain head movements. However, the pain may also begin as bilateral or become generalized if initially unilateral. The headache can occur at any time, although frequently it occurs during the morning hours or upon awakening. Migraines can typically last from several hours to all day, although if left untreated they can last up to 72 hours. Nausea and/or vomiting, light and sound sensitivity may accompany the headache. An aura may precede the headache that can involve visual, motor, sensory or language disturbances. Alterations in mood, irritability, fatigue, vertigo or lightheadedness may also occur.

What are the triggers?

Migraine headaches are often referred to as vascular headaches but ongoing research suggests that other mechanisms may be at play. What is clear is that a number of factors, both internal and environmental, can influence the timing, severity and frequency of a migraine. Stress, certain foods, alcohol, nicotine, caffeine, sleep disturbances and barometric changes are just a few of the triggers of migraine attacks. In particular, hormonal changes during a woman’s life including menarche, menses, pregnancy, oral contraceptive use, menopause and hormone replacement therapy can have a profound effect on the course, severity and frequency of migraine headache attacks. Left untreated, these headaches can have a profound and debilitating effect on the course of a woman’s life including days lost at work, school, social engagements and family obligations.

The menstrual migraine is a well-recognized phenomenon. Headaches can occur any time during a woman’s cycle. Often, women will recognize a pattern to their headache as occurring before, during or after menstruation or near ovulation. It is thought that when estrogen levels drop, so do serotonin levels, thus triggering a headache. Prostaglandin production may also fluctuate, thus contributing to the occurrence of a headache. Migraine can be associated with oral contraceptive use and, in fact, headaches are one of the most common adverse affects reported by oral contraceptive users.

During pregnancy, migraine headaches can actually improve in up to 70 percent of sufferers as estrogen levels tend to stabilized during the second and third trimesters. However, migraine may worsen during the first trimester when hormonal fluctuations can be severe. The postpartum period can be heralded by a return of headaches as estrogen levels fall. Moreover, breastfeeding has not been found to protect against the recurrence of migraine. Peri-menopause and menopause are periods during a woman’s life when there can be dramatic shifts in hormonal levels. Exacerbations or improvements in headaches can occur during this time. Moreover, estrogen replacement therapy can further aggravate migraines until the correct dose and route of administration is found. As hormonal fluctuations stabilize, however, headaches may improve.

How is it treated?

To effectively treat a migraine, an understanding of what triggers the headache is essential. Once this is understood, there are effective medications that can provide relief from the acute headache and others that can help prevent the headache from recurring. Correct dosage and the timing of when the medication is administered are important points to keep in mind to effectively treat a headache. Recent studies have indicated that taking a migraine medication early in the course of a migraine can substantially reduce the severity and duration of the episode. Additionally, lifestyle and behavior changes must also be incorporated into the headache treatment plan.

What medications are effective?

Serotonin receptor agonists (triptans) include sumatriptan, naratriptan, rizatriptan, zolmitriptan and other newer preparations. These medications can offer substantial relief from the acute migraine attack. Ergot medications such as dihydroergotamine mesylate and ergotamine tartrate can also relieve the acute pain of migraine. However, all medications can have potential side effects and overuse of any pain medication can result in a worsening of headache symptoms. Nonsteroidal anti-inflammatory medications (NSAIDS) can be quite effective in the treatment and prevention of menstrual migraine if dosed correctly. Headache treatment during pregnancy can be especially challenging as many of the migraine treatments are contraindicated due to their vasoconstrictive actions and potential harmful effects on the developing fetus. Caffeine, NSAIDS and acetaminophen, however can be used relatively safely under the guidance of your obstetrician.

Standard prophylactic medications include many of the anti-convulsant medications such as divalproex sodium, carbamazepine and topiramate. Tricyclic antidepressants such as amitriptyline, selective serotonin receptor inhibitors (SSRIs) such as fluoxetine and sertraline or beta blockers such as nadolol or propranolol can be very effective in preventing headache recurrence. However, if a woman is not using birth control or is trying to become pregnant, these medications should be avoided due to the potential deleterious effects on fetal development.

As mentioned before, oral contraceptive use and hormone replacement therapy can have a profound effect on migraine headaches. Reducing the estrogen dose and type, and changing the frequency of dosing and route of administration can help to reduce migraine headaches attacks.

Finally, it is important to understand how you can gain control over your migraines by understanding the triggers unique to your headache syndrome. Avoiding certain foods such as aged cheeses, chocolate, packaged meats or monosodium glutamate (MSG), alcohol such as red wine, skipped meals, smoking, lack of sleep or oversleeping, and bright light can minimize your risk of developing a migraine. Taking a short break during a stressful day and incorporating exercise, yoga, meditation or soothing music can be useful strategies to incorporate into you headache prevention plan. Most importantly, discuss your symptoms with your physician or headache specialist for appropriate diagnosis and treatment of your headaches.

For an appointment at The Institute for Neurology and Neurosurgery, please call (973) 322-6600.

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JACQUELINE SCHWANWEDE, M.D.

Attending Cardiologist at
Saint Barnabas Medical Center

Cardiovascular disease is the leading cause of death and disability for women in the U.S. In 1997, a total of 466,101 deaths in this country alone were attributed to cardiovascular disease. Approximately one half of these were women. The common misconception is that coronary heart disease is a "man’s disease." A survey by the American Heart Association reported that only 8 percent of women questioned recognized that heart disease and stroke are the leading cause of death and disability among women. Cardiovascular diseases kill more women each year than the next sixteen causes combined. One in two women dies of heart disease and stroke, while only one in twenty five dies of breast cancer.

Women and Heart Disease

A source of confusion is that women usually present with coronary artery disease at an older age than men. Presumably, this is because of the presence of endogenous estrogen in premenopausal women which is protective. This assumption is somewhat supported by observation data that women who have had premature menopause seem to have a higher risk of coronary disease than premenopausal women of the same age. The mechanism is complex and is partially due to the protective effect of estrogen on lowering total cholesterol and LDL (bad cholesterol).

Women also present with "atypical" anginal symptoms, that is, those that are non-exertional and may also have various components to their history. This may include shortness of breath, dizziness, fainting, weakness and arm and shoulder pain. These atypical symptoms may cause a delay in diagnosis. This leads also to the concern that women may be evaluated less intensively and perhaps not treated as aggressively as they should be. Based on data published for the National Registry of Myocardial Infarction I on 350,000 patients hospitalized for MI, women were less likely to receive thrombolytic therapy, aspirin, heparin or beta-blockers. In addition, they underwent cardiac catheterization, interventional therapy such as PTCA or bypass surgery less frequently. As a result there were higher mortality rates among women who present with heart disease. This may also be attributed to the fact that women present with heart disease at least ten years older than their male cohort and have many more associated medical problems contributing to their poor outcomes.

It makes sense then, to emphasize primary and secondary prevention and the recognition and treatment of modifiable risk factors for cardiac disease.

Addressing Risk Factors

Nonmodifiable risk factors such as age and family history can be addressed with a recommendation for a heart healthy lifestyle including exercise and healthy diet.

Tobacco use and exposure remains a major area of concern. In a prospective study of 121,000 nurses, the risk of CHD was six times greater among smokers than non-smokers. Also, the risk of sudden death was increased 2 to 4 fold. It is alarming to note that more than two million women age 18 or older continue to smoke. The risk is even more striking in women with hypertension, diabetes and high cholesterol and/or who use oral contraceptives. Obviously the recommendation is to quit smoking and/or not to start.

Hypertension is more common in American women than American men. Recommendations are to promote factors which lower blood pressure, including weight management, decrease sodium intake, decrease alcohol intake and increase physical activity. The goal is to keep blood pressure lower than 140/90 and optimally around 120/80.

Diabetes Mellitus needs to be aggressively treated with glucose management, careful diet, exercise and careful follow-up with the patient’s physicians for strict glucose control.

Some gender differences exist when predicting coronary artery disease based on lipid profiles. Low HDL (good cholesterol) levels predict increased incidents of coronary artery disease in both men and women. Low HDL is affected by such factors as heredity, smoking, obesity, and lack of exercise. Estrogen may elevate HDL.

A number of epidemiologic studies have confirmed the relationship between high cholesterol and cardiovascular disease in both men and women. LDL reduction for patients with coronary disease should be less than 100. In patients without coronary disease the LDL ideally should be less than 130. Recommendations to achieve this are with diet, weight management, smoking cessation and lipid lowering drugs.

Other issues include battling obesity and achieving and maintaining an ideal body weight. In order to achieve this a healthy diet as well as a physically active lifestyle is necessary. Studies have shown that walking greater than three hours per week can be associated with reducing the risk of coronary artery disease.

The Role of Hormone Replacement Therapy

Hormone replacement therapy in perimenopausal women is a topic of great interest. It is not known if estrogen replacement therapy as primary prevention can reduce coronary disease. We await the results of a study called The Women’s Health Initiative slated to be completed in 2006 to give us data on whether giving HRT to perimenopausal women will be beneficial as a primary preventative measure.

Estrogen use in the contest of secondary prevention has also been controversial. The HERS study, published in 1998 did not support the use of HRT in postmenopausal women with established CAD. It is not recommended at this time to give estrogen to post menopausal women for cardiovascular benefit.

On the horizon, a new class of drugs called selective estrogen receptor modulators is promising. Women may benefit from some of the protective effects traditionally associated with estrogen such as lowering total cholesterol and LDL cholesterol and preventing osteoporosis. Raloxifene is the only selective estrogen receptor modulator clinically available. A study called RUTH (Raloxifene Use for The Heart) is a clinical trial evaluating the use of the drug in 10,000 postmenopausal women with documented coronary disease or who are at high risk for the disease.

Many of the risk factor modification recommendations apply to all women as both primary and secondary prevention. Our best chance of surviving heart disease is to prevent heart disease.

For a referral to a Saint Barnabas Medical Center cardiologist, please call 1-888-SBMC-DOC.

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Reduce Your Pre-Surgery Jitters

Susan Weinstein, R.N., B.S., H.N.C.
Director, Women’s Health Education
Saint Barnabas Medical Center

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A Clinical Research Study For Osteoporosis Prevention

An estimated eight million American women have osteoporosis and an estimated 34 million more have low bone density, leaving them at greater risk for bone fractures.

A clinical research study of an investigational medication that may prevent osteoporosis is now underway.

To qualify, you must be:

• A female age 45 or older
• In good general health and have not been diagnosed with osteoporosis
• More than six months, but no more than 60 months postmenopausal

Women who qualify will receive study-related medical care at no cost for one year.

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Breast Cancer Survivor Places In Fitness Competition

For 32-year-old Ann Nappi of Watchung, winning third place in a National Physique Committee-sponsored fitness competition in Northern New Jersey was as rewarding as a Bronze Olympic medal – not only because of the months of hard training and strict nutrition she devoted to this goal, but also because four years ago she had undergone a double mastectomy and intensive chemotherapy for breast cancer.

In January 1999, then age 28, Mrs. Nappi discovered a lump in her breast while nursing her then 8-month-old son, Frankie. The discovery was particularly poignant since Mrs. Nappi had lost her mother to breast cancer when her mother was just 30, and both grandmothers to the same illness in their early 40’s. Mrs. Nappi’s worst fears were confirmed when her own lump was found to be malignant. With an infant at home as well as a31/2-year-old daughter, Alexandra, to care for, she underwent a bilateral (double) mastectomy with Sarah Schaefer, M.D., a breast surgeon affiliated with The Breast Center of the Saint Barnabas Ambulatory Care Center, followed by reconstructive surgery.

Coming Back From Cancer

Though a personal trainer prior to surgery, Mrs. Nappi found the months following surgery difficult. Between recuperating from surgery, chemotherapy treatment, and reconstructive surgery, she engaged in small amounts of exercise aside from caring for her children. Gradually, she built up her fitness regimen, however, and resumed her career. Today, Mrs. Nappi has never felt better.

The Women’s Extravaganza, held in Hackensack last Fall, has three divisions: Body Building, Fitness (that includes a gymnastics component), and Figure that focuses on a strong, lean physique. For the 5’2" mother of two, Figure was the perfect competition category.

"I am a personal trainer for other breast cancer survivors," says Mrs. Nappi, "And I empathize with them. When you’re in the midst of it, you don’t feel like you are ever going to feel healthy again. I am also sensitive about women’s feelings about their femininity. This disease can impact women on several levels, and one of them can be their self-image. Today’s technology and surgical capabilities are so amazing however, that I like to assure women that they can look and feel terrific."

"At first, many of my clients look at me as if to say, ‘What can this kid know about cancer?’ When I tell them my story, their mouths drop open. I like them to know that there isn’t just life after cancer, there’s the opportunity for tremendous success." Thanks to her own hard work, commitment, and discipline, Mrs. Nappi won third place despite being one of the older contestants.

"It’s always gratifying to see individuals who are diagnosed with cancer recover from their disease," says Richard Michaelson, M.D., Chief of Medical Oncology at Saint Barnabas, and Mrs. Nappi’s oncologist. "And it’s wonderful to see people thrive and overcome their challenges in such a powerful way. To see Ann overcome the physical effects of chemotherapy, the emotional effects of a breast cancer diagnosis, especially at such a young age and with knowledge of her family history, and then to place in a national physique competition after bilateral mastectomy and breast reconstruction is, as Ann would say, ‘Just awesome.’"

To reach The Cancer Center at Saint Barnabas,
please call (973) 322-5200.

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