Q: Both my mother and maternal grandmother died from ovarian cancer. I also have one aunt with breast cancer. I am concerned about my risk of developing this disease and I have been in a screening program, including pelvic examinations, Ca-125 blood tests, and pelvic sonograms. I have recently heard that there is another blood test, the BRCA-1 and BRCA-2 blood test. Should I have this test?

About 10% of all ovarian cancers develop secondary to inherited genetic abnormalities (mutations). The mutations most commonly associated with either ovarian or breast cancer are the BRCA-1 or BRCA-2 mutations. The presence of these mutations can be detected by a test conducted on a blood specimen.

Ideally, testing for these mutations should be done in the context of counseling by a genetic counselor. A genetic counselor will confirm your family history and evaluate other risk factors. They will review the potential advantages and limitations of this testing.

Patients who may benefit the most from BRCA-1 or BRCA-2 testing are patients with multiple family members with cancers of either the ovaries or breast. Male breast cancer in the family is suggestive of the presence of a BRCA-2 mutation. Given the family history of one primary relative (mother), one secondary relative (grandmother) with ovarian cancer and one secondary relative (aunt) with breast cancer, it would be appropriate to undergo genetic counseling and following that make a decision regarding proceeding with obtaining a BRCA blood test.

Q: How does one develop "ovarian cancer" after their ovaries have been removed?

If the ovaries are surgically completely removed, a patient cannot develop ovarian cancer. Unfortunately, the patient can develop a cancer that is clinically similar to ovarian cancer. These ovarian-like cancers arise from the peritoneum (the lining of the pelvis and abdomen) or the fallopian tubes (if not removed at the time of the removal of the ovaries). Patients with these tumors present with clinical signs and symptoms similar to the presentation of patients with ovarian cancer (such as abdominal bloating, early satiety, diarrhea, constipation, pain, and weight changes). Similar to most ovarian cancers, these tumors tend to have an advanced disease stage at diagnosis, with tumor nodules often found throughout the pelvis and abdomen. The appearance of these tumors under the microscopic is also similar to the most common ovarian cancer, serous carcinoma. The surgical and medical treatments are identical to that for ovarian cancer. Unfortunately, patients with these tumors tend to experience a similar prognosis.

It is important to appreciate that a cancer syndrome identical to that of ovarian cancer can develop after removal of the ovaries. The patients at highest risk for these rare tumors are patients with BRCA genetic mutations.

Q: What can a woman do to enhance her sexual pleasure as she ages?

Sexual response, as defined by Masters and Johnson, involves excitement/arousal, plateau, orgasm and resolution. These phases are similar for both men and women. A third element, desire, or motivation, which precedes arousal, is also important, particularly for women. Women may experience change in any of these aspects of sexual response as they age. Orgasm becomes less intense, for example. Such changes may be compensated for within a relationship.

For women in a satisfactory sexual relationship, certain changes with aging are to be expected. Decreased vaginal lubrication, particularly with menopause, along with increased vaginal dilation over time is matched by less penile engorgement and can lead to less satisfaction with ––intercourse. More manual stimulation of the penis may be needed, and committed couples may need to adjust their sexual repertoire to accommodate to these age related changes. When mutually acceptable solutions cannot be found, sex therapy can be helpful.

Many worldwide surveys indicate that women are a relatively dissatisfied lot, sexually speaking, with 13-49% reporting some form of sexual dysfunction. Low sexual desire was associated with surgical menopause and aging in one study.

Age-related loss of sexual desire has been an intense focus of media interest. The possible reasons for this loss of desire are complex. Emotional intimacy and relationship satisfaction influence the earliest stages of the female sexual response, desire. Women in less-than-satisfactory relationships may find, with aging, that their progressive decrease in relationship satisfaction leads to a further lack of sexual interest. Sexual dysfunction on the part of the male partner may also go unrecognized or unacknowledged in a relationship. Erectile dysfunction can be due to medications, illnesses or psychological factors. With aging and the onset of menopause, hormonal factors may contribute to sexual distress. Hormone withdrawal can lead to vaginal dryness and painful intercourse. Women who wish to maintain optimal sexual function should assess all aspects of their sexual life. In addition to taking stock, a self-assessment such as the one indicated below might indicate specific areas of sexuality that require attention or treatment.

Questions that might indicate that sexual desire is an issue: Is the relationship rewarding? Does the woman feel attractive to her partner? Has her partner maintained sexual interest over time? Are spontaneous sexual thoughts and feelings uncommon (less than once a week)?

Questions that might indicate issues with arousal: Does genital sensation seem diminished or inadequate? Is there a lack of vaginal lubrication or engorgement? Is there a perception that genital sensation is 'not the same as it was'? Is there any vaginal or pelvic pain associated with sex?

Questions that might indicate issues with orgasm: Has orgasm become noticeably less frequent, less intense or less reliable in concert with sexual activity? Can orgasm be achieved with self-stimulation but not intercourse or other sexual activity with a partner?

Knowledge of which domain of sexuality is affected is beneficial prior to seeking consultation. A medication history is also especially important, since several commonly used antidepressant medications can cause a loss of desire, arousal, and/or orgasm. In these cases, erectile dysfunction medication may be effective, however, in general these medications do not improve female sexual function.

Women with vaginal pain or poor lubrication who are menopausal may benefit greatly from hormone therapy. Women with low desire have been treated with testosterone with some evidence of improvement. However, this treatment has not received FDA approval at this time and its long-term safety is not well characterized. A careful assessment of the benefits versus the known and unknown risks of this form of therapy is important before its consideration.

Q: What does it mean to have a "Board certified" Ob/Gyn?

Beginning in 2008, the American Board of Obstetrics & Gynecology (ABOG) will transition from a program of cyclic recertification to one of lifelong maintaining certification (also known as MOC). What this means is that OB/GYN physicians will maintain their certification on an on-going basis. There are four components of MOC which are 1) Professionalism, 2) Life long learning, 3) Cognitive knowledge, and 4) Practice review. To meet the requirements for "Professionalism," a physician must be in good standing with their state board and hospital and hold an unrestricted license to practice medicine. Moreover, the physician must follow the ethical and professional principles established by the American College of Obstetricians and Gynecologists and endorsed by ABOG. To meet the requirements for "Life long learning," the physician must read a series of articles on important information in their field and answer questions regarding this information. To meet the requirement of "Cognitive knowledge," the physician must periodically pass a secure written examination. To meet the requirements for "Practice review," the physician must complete a series of modules on what is considered to be current "best practices," and to review a sample of charts from their practice to ascertain if they are practicing according to the guidelines in these modules. Importantly this is a continuous, on-going process for the life of the physician in clinical practice. ABOG and its Diplomates are committed to "traveling the road to maintaining excellence."

Q: How can I find out if my Ob/Gyn is Board certified?

"Is Your Doctor Certified?" is a free service to the public provided by the American Board of Medical Specialists (ABMS). For information visit their site at www.abms.org.

Q: What are some of the signs of ovarian cancer?

Ovarian cancer symptoms are persistent and a change from normal. Key factors in early detection are the frequency and number of symptoms. Some, but not all, of the symptoms that are more likely to occur in women with ovarian cancer than women in the general population are:

• Bloating
• Pelvic or abdominal pain
• Difficulty eating or feeling full quickly
• Urinary symptoms (urgency or frequency)

For more information visit the Gynecologic Cancer Foundation at www.thegcf.org.

Q: What are my chances of having heart disease?

One out of every three women will develop heart disease in their lifetime. Rather than extreme chest pain, women are more likely to experience less dramatic symptoms such as nausea, shortness of breath and dizziness, to name a few. To learn more about the risk factors for a heart attack, go to www.nhlbi.nih.gov/health and look at "10-Year Heart Attack Risk Calculator".

Q: What is genital herpes?

Genital herpes is a sexually transmitted disease which is more common in women than in men. Once contracted, the herpes virus stays in the body and although treatable, there is no cure.

Some of the symptoms of genital herpes are:

• Itching or burning in the genitals or anal area
• Flu-like symptoms, including fever
• Swollen glands
• Pain in the legs, buttocks, or genitals
• Vaginal discharge
• Feeling pressure in the area below the stomach

A person can pass along the infection even when they experience no symptoms, including infecting a newborn. Women who suspect they may be infected should talk frankly with their Board certified Ob/Gyn. For more information go to www.cdc.gov.

Q: What is Osteoporosis?

Osteoporosis (porous bone), is a disease affecting women two times as often as men. It is characterized by low bone mass and structural deterioration of bone tissue often leading to fractures of the hip, spine and wrist. Some of the risk factors are:

• Gender – women get it more often than men
• Age – the older you are the greater the risk, but it can strike at any age
• Body size – small, thin women are at greater risk
• Ethnicity – White and Asian women are at higher risk than Black and Hispanic women
• Family history – osteoporosis tends to run in families

Over 44 million Americans have osteoporosis, but it can be prevented and treated. To reach optimal bone mass and continue building new bone tissue you should:

• Take the age appropriate level of calcium
• Take Vitamin D to ensure maximum calcium absorption and bone health
• Exercise daily (particularly weight bearing exercises)
• Don't Smoke
• Avoid alcohol

For more information go to www.niams.nih.gov.

Q: What is menopause?

Menopause, often called "the change of life", usually occurs between 45 and 55 years of age, and is the time in a woman's life when her period stops. Leading up to menopause, a woman's body slowly makes less and less of the hormones estrogen and progesterone.

Although the symptoms of menopause vary, other than the cessation of menses, some of them are:

• Hot flashes and night sweats
• Trouble sleeping through the night
• Vaginal dryness
• Mood swings and crying spells
• Trouble focusing
• Feelings of confusion
• Hair loss or thinning on head
• Hair growth on face

There are many ways to manage the menopause. For more information go to IMS – International Menopause Society www.imsociety.org and NAMS – North American Menopause Society www.menopause.org.

Q: What is HPV?

The genital HPV infection is a sexually transmitted disease that is caused by human papillomavirus. Approximately 20 million people are infected and by age 50, at least 80 percent of women will have acquired HPV.

Most people who have a genital HPV infection do not know they are infected, yet they can transfer the virus to a sex partner. Most women are diagnosed with HPV on the basis of an abnormal Pap test.

In June 2006, the Advisory Committee on Immunization Practices voted to recommend the first vaccine developed to prevent cervical cancer and other diseases caused by HPV. The vaccine is most effective and recommended for women ages 9 to 25, and prior to initiation of sexual activity. For more information go to The Centers for Disease Control and Prevention www.cdc.gov.

What is the newest information on Hormone Replacement Therapy (HRT)?

Hormone therapy may be safer in younger women than you thought? A recent secondary analysis of the data from the Women's Health Initiative (WHI) published in the Journal of the American Medical Association (JAMA.2007:297) revealed that there was no increased risk in coronary heart disease in women on hormone therapy in the age group between 50 and 59 years of age. Although the risk of stroke remained increased, the overall mortality was not statistically increased. The hazard ratio for breast cancer in women on combined estrogen and progesterone hormonal therapy in the 50 – 59 year group was increased similar to women at older ages, but also was not statistically significant. The risk of the diagnosis of breast cancer was increased after five years for the entire study population of women receiving combined estrogen plus progesterone (conjugated equine estrogens plus medroxyprogesterone). The breast cancer risk is partly counterbalanced by a reduction in the risk of the diagnosis of colon cancer. The WHI study also reflected a safer side effect profile for women on estrogen alone, in contrast to women on both an estrogen and progesterone.

What does this new finding mean for women? Basically, it supports the use of hormonal therapy for women with menopausal symptoms who do not have adverse risk factors for sake of breast cancer. As with all medications, the lowest possible effective dose should be utilized over the shortest possible duration. And most importantly, women should be provided with the last information regarding risks and benefits of hormonal therapy to allow them to make an "informed choice".