Dr. Ben-Yehuda’s Medical Newsletter  Volume 3:Vaginal Infections: Investigate before you Medicate

    Disclaimer: This newsletter is devoted to Dr. Ben-Yehuda’s areas of interest that coincide with topics recently raised by patients. This general information should not replace a personalized consultation with your physician.

    Multiple studies have shown that more than 60% of women who treat themselves for “yeast infections” with over-the-counter medications DO NOT have a yeast infection. This is important because wrong treatments delay cure.

    Some basic facts about infections:
    • Vaginal infections are the most common causes for visits to a gynecologist.
    • The vagina in women of childbearing age has a “normal” discharge (clear or milky and non-foul smelling).
    • An abnormal discharge (increased amount, different color, smell, and irritation) MAY be an infection, but may be allergic, hormonal, or a sign of other more serious problems.
    • If it IS an infection, there are three common culprits (yeast not being the most common). They are bacterial overgrowth, (bacterial vaginosis), vaginal candidiasis (yeast), and trichomoniasis (a sexually transmitted infection).

    Here are some basic facts about the vaginal environment.
    • It is not sterile. The vagina is dominated by lactobacilli (about 70% of the bacteria in the vagina), but also contains small amounts of other micro-organisms (including yeast at about 5%).
    • It is normally an acidic environment. Normal vaginal pH is about 4. Pathogenic bacterial growth is inhibited at this pH.

    When either pH or the normal bacterial balance is upset, an infection is possible. Things that can influence this balance include: age, sexual activity, hormonal status, hygiene, immune status, antibiotics, feminine hygiene products (such as douches and lubricants), vaginal medications, or sexually transmitted infections.

    What are the common symptoms and causes of these infections? Half of vaginal infections are actually Bacterial Vaginosis, and the most common symptom is described as a “fishy” odor. The next most likely infection is a yeast infection, which is characterized by symptoms of itching and a “cottage cheese” type of discharge. Finally, there’s Trichomoniasis, which is a sexually transmitted infection. The symptom for this infection is a heavy frothy discharge.

    The treatment of each infection is different because the cause of the infection is different. Please see a gynecologist before treating yourself. As mentioned earlier, it is easy to be wrong. Wrong treatments can delay cure. For women who are interested in prevention of frequent infections, increasing vaginal lactobacilli (acidophilus) as a probiotic (especially with vaginal use) may help balance and maintain a normal vaginal environment.

    As previously stated, it’s important that women know the basic signs of various infections and don’t self-medicate every instance like a yeast infection. When in doubt, see your physician for confirmation and correct course of treatment.

    Dr. Ben-Yehuda’s Medical Newsletter  Volume 2:Bladder Infections – Learn Before It Burns

    Disclaimer: This newsletter is devoted to Dr. Ben-Yehuda’s areas of interest that coincide with topics recently raised by patients. This general information should not replace a personalized consultation with your physician.

    Bladder infections are among the most common infections in women. Often people refer to a bladder infection as a “UTI” (urinary tract infection) however, they are not synonymous. While most UTI’s are actually bladder infections (95%), a UTI can mean an infection anywhere in the urinary tract including the urethra, bladder, ureters, or kidneys. About 12% of women experience a bladder infection at least once a year and about half of all women will experience bladder infections at some point in their lives. And not surprisingly, 15% of all prescriptions written for women are for bladder infections.

    Symptoms usually involve a change in urinary habits: burning with urination, a feeling of incomplete emptying immediately after urinating, and needing to urinate frequently. Women are at a greater risk for bladder infections due to the short distance between the anus and the urethra, as well as the short urethral distance to the bladder.

    A normal vaginal environment (normal vaginal bacteria and a normal pH) decreases the chances of invasion by the kind of bacteria that normally cause bladder infections. What can change that environment? Decreasing estrogen levels (as in menopause) are associated with decreases in normal bacteria and increases in pH, thus increasing the risk for infection. Sexual intercourse also increases susceptibility to infection by direct seeding of external bacteria into the vagina and lower urethra. Other disturbances to normal vaginal bacteria (certain antibiotics and spermicides) can also increase infection risks.

    Bladder infections are treated with antibiotics that specifically target the offending bacteria. The goals of treatment are to relieve symptoms and decrease the chances of the most dangerous consequences of bladder infections: kidney infection and sepsis (invasion of bacteria into the blood stream).

    Recurrent infections (more than 3 per year) may warrant a urologic evaluation or prophylaxis (taking daily low-dose antibiotics or taking antibiotics after each episode of intercourse).

    There are also several preventative steps that can decrease your risk of getting a bladder infection. Many people have heard of drinking cranberry juice to reduce bladder infections. Well, it’s true. Cranberry juice contains tannin (A-type Proanthocyanidin), which is a chemical known to decrease a bacteria’s ability to stick to the bladder wall. It also acidifies the urine which makes the environment more hostile for bacteria. Drinking actual cranberry juice seems to work better than taking various forms of cranberry pills. One needs to drink about 16 oz. of cranberry juice a day to achieve this preventative effect. Urinating immediately after intercourse may also help. This physically “flushes” recently seeded bacteria from the urethra and lower bladder. Finally, topical estrogen for menopausal women may be helpful as it helps increase normal vaginal bacteria and decrease vaginal pH.

    In conclusion, bladder infections are common in women. There are things women can do to reduce the chance of getting them, if not prevent them altogether. I hope this bit of knowledge keeps you all more comfortable.

    Dr. Ben-Yehuda’s Medical Newsletter  Volume 1:VBAC (Vaginal Birth After Cesarean Section)

    Disclaimer: This newsletter is devoted to Dr. Ben-Yehuda’s areas of interest that coincide with topics recently raised by patients. This general information should not replace a personalized consultation with your physician.

    In March 2010 the National Institutes of Health (NIH) published a report titled “Vaginal Birth After Cesarean: New Insights.” I will summarize some of their findings below. First, some general

    In 1996, the total C/Section rate in this country was 21%. In 2007, it was 32% (the highest ever recorded). In 1996 the VBAC rate was 28% (about 1 in 4 women who had a C/Section and attempting another delivery, were trying to deliver vaginally). By 2007, the VBAC rate was about 10%. Given these significant trends, the NIH wanted to find out why things changed so rapidly in 10 years. The following questions and answers mirror the discussions I have with my patients who are considering a VBAC.

    Q: In women who attempt VBAC, what is the rate of vaginal delivery? What factors influence that rate?
    A: 74% of women who try VBAC succeed. Factors that INCREASE the likelihood of success include: Being “thinner” (BMI <30Kg/m2), having had a previous vaginal delivery, and if the prior C/Section was due to malpresentation (breech - a baby born buttocks first). Factors associated with a DECREASED chance of delivering vaginally include: Presence of maternal disease (hypertension, diabetes, heart disease, etc.), if the prior C/Section was done for failure of progression of labor (baby too big to fit), being currently past the due date, and being induced with the current pregnancy. There are some statistics that will be presented below. Please keep in mind that statistics can be interpreted in two different ways: relative risk, and absolute risk. I will highlight the difference while using the NIH’s own numbers and try to make sense of it all in the end. Q: What are the benefits/risks to MOTHERS in VBAC attempts? A: Benefits include: 1. Decrease in maternal mortality (4/100,000 die in VBAC attempts, 13/100,000 die in elective C/Sections). INTERPRETATION: While the relative risk of dying after a C/Section may seem significant (3 times as many women die after an elective C/Section than a VBAC attempt), the overall risk of dying from an elective C/Section is just 0.013%. 2. Shorter time in the hospital. 3. Decreased risk of blood clots (40/100,000 VBAC vs. 100/100,000 in elective C/Sections). INTERPRETATION: More than twice as many women who have elective C/Sections get blood clots, but the chance they will get a blood clot is only one per 1000. 4. Decreased risk of placenta covering the cervix and placenta invading the uterine muscle in subsequent pregnancies. Risks include: Uterine rupture (a separation of the uterine muscle, creating a hole in the uterus). This is the most-discussed risk of VBAC. It occurs in 778/100,000 women attempting VBAC vs. only 22/100,000 women having an elective repeat C/Section.In other words, the overall risk of uterine rupture in women attempting VBAC is less than 1%. If the uterus ruptures, 14-33% of women will need a hysterectomy to stop the bleeding. We can’t tell who will have a uterine rupture. If this happens, the chances that a baby dies are about 6% (see the next section on fetal risks/benefits). That’s 6% of the 778/100,000 that had a rupture, or 0.047% chance of a baby dying of this when a mom tries VBAC. Q: What are the benefits/risks to a BABY with VBAC? A: Benefits include: 1. Less risk of rapid breathing due to incomplete squeezing of baby’s lungs that occurs in a C/Section 2. Better breast feeding success, and less interference with mother-infant bonding. Risks include: 1. An increase in neonatal (1st 28 days of life) mortality rate. Mortality rate for infants of mothers who attempt VBAC is 110/100,000 compared to 50/100,000 in elective C/Section patients. INTERPRETATION: Twice as many babies die with VBAC attempts, but the overall chance of a baby dying within the first 28 days of life after VBAC trial is 0.11%. 2. Increased risk of cerebral palsy risks or strokes. Risk of cerebral palsy or stroke with VBAC (based on one large study of 33,000 patients) is 46/100,000 vs. zero/100,000 in the C/Section group. INTERPRETATION: The largest study examined by the NIH shows that in babies of moms attempting VBAC, 0.046% will have cerebral palsy or stroke. Q: If the overall risks of VBAC are small, why are they not offered more? A: Professional liability concerns are important in limiting the option/discussion on VBAC. About 1/3 of obstetricians do not even offer VBACs due to this. When doctors are concerned about this issue, it may also influence HOW the risks of VBACs are presented to a patient. For example, a physician who prefers not to do VBAC may emphasize the relative risk and say “you know, you are twice as likely to end up with a dead baby if you try VBAC vs. an elective repeat C/Section.” As you can imagine, this can greatly impact a woman’s decision. In summary, VBAC discussions require a thoughtful and meaningful investigation into BOTH risks AND benefits. They involve explanation of ACTUAL vs. RELATIVE risks, and require personalized risk assessment. All this requires time, something that many obstetricians have less and less of. I will close with the following quote from the National Institutes of Health report: “When trial of labor and elective repeat cesarean delivery are medically equivalent options, a shared decision making process should be adopted and, whenever possible, the woman’s preference should be honored.” VBACs are a regular part of my practice. My patients are afforded the time and environment to discuss this option before making an important decision about their delivery. For more: The full study referred to above can be found at