Stop the Mood Swings, Insomnia, and Hot Flashes Today

Karen Knapp MD HCA Virginia Commonwealth Ob/Gyn Henrico Doctors'
Karen Knapp, MD, FACOG
Commonwealth Ob/Gyn Specialists
Henrico Doctors’ Hospital

Laura (not her real name) visits every year for her annual gynecologic exam. We have known each other for many years, but today, she is not herself. Laura’s periods have become less regular, and she has hot flashes some nights that disrupt her sleep. Some months she feels like her old self with regular periods, but other months, her periods are accompanied by severe cramps and breast tenderness. Laura is understandably distressed and wants to know what is happening.

Laura is experiencing the typical symptoms of perimenopause. This is when her periods become less predictable before eventually stopping at full menopause. This lack of predictability is from her brain’s response to the aging of the remaining eggs in her ovaries. To have a period and ovulate (pass an egg), a woman’s brain must send stimulating hormones to her ovaries. With ovulation, the ovary makes estrogen and progesterone, but as the ovaries age, the brain has to issue increasingly higher levels of its stimulating hormones, with the ovary not always responding. All of Laura’s symptoms are explained by this “waxing and waning” of her ovarian function. How do we help with her symptoms?

She needs to understand that it’s all normal, but understanding what may not be normal is just as important. Periods every 21-35 days during perimenopause are normal, while bleeding at intervals less than 21 days or bleeding more than eight days at a time is not normal, and indicates a need for further evaluation by a gynecologist.


Laura must also remember she is still at risk for pregnancy during perimenopause. Low-dose birth control pills or a progesterone intrauterine device are good choices for contraception as they also help regulate bleeding. If contraception is unnecessary, bioidentical progesterone can be used to regulate periods while soy and black cohash can help alleviate hot flashes. Laura decided she would just ride it out and see what happens.

Laura came back 8 months later having had no periods. Hot flashes, sleep disturbances, mood changes, and irritability had really begun to interfere with the quality of her life. Information from the internet and bookstores just confused her more. What does Laura do now?

Stages of Menopause

Menopause can be divided into “early” menopause (no period for six months) and “late” menopause (no period for one year). Laura is between, having had no periods for eight months. We know her stimulating hormones are elevated as her brain tries to get her ovaries to work, but they no longer produce eggs and only make low levels of estrogen. This combination affects the body’s “thermostat” and causes the hot flashes, leading to sleep disruption, fatigue, irritability, and mood changes. Low estrogen can also cause mood changes and increase susceptibility to anxiety and depression, with accompanying physical changes. Vaginal dryness, pain with intercourse, decreased libido, joint pain, and decreased elasticity of the skin can also be experienced. Fortunately, there are a variety of options to help alleviate Laura’s symptoms.

Hormone Replacement Therapy

Hormone replacement therapy was once the most commonly prescribed treatment, but we now know it can increase the risk of heart attack, blood clots, stroke, and breast cancer, regardless of the type of therapy used or its route of administration. Furthermore, contrary to popular belief, both bioidentical and non-bioidentical preparations carry these risks. Despite this, hormone replacement therapy is still the most effective way to alleviate menopausal symptoms, but it must be used with caution and with the understanding that the symptoms will return when the hormone replacement is stopped.

In 2013, the Food and Drug Administration (FDA) approved paroxetine (Brisdelle), a serotonin reuptake inhibitor anti-depressant, for the treatment of hot flashes. Neurotonin or gabapentin, long used for the treatment of chronic pain, can be helpful as well, but may be overly sedating at undesirable times. With mood changes, again, paroxetine may help, both as an anti-depressant and in promoting restful sleep. There’s a good chance that a full night’s sleep will help Laura’s mood improve.

Vaginal dryness, pain with intercourse, and decreased libido are also common during perimenopause. Bioidentical estrogen preparations for the vagina and vulva dramatically relieve the dryness and decrease libido by keeping estrogen levels in balance, and Osphena, an oral medication for vaginal dryness, has recently also been approved by the FDA.

Non-Drug Treatments for Menopause

Non-pharmacologically, numerous other treatments for the symptoms of menopause have been widely studied, but with varying results. These include vigorous aerobic exercise, yoga, hypnosis, paced breathing, mindfulness meditation, and acupuncture. As mentioned earlier, herbal supplements such as soy and black cohash may help, but dong quai, ginseng, kava, and evening primrose have not been found effective and can instead have serious side effects.

Laura decided to try a local estrogen supplement for her vaginal dryness and an anti-depressant for her hot flashes, and she increased her exercise. Six weeks later, her symptoms were not entirely gone, but she was managing them well and was much happier.

Menopause Richmond Virginia HCA Karen KnappOver the past 20 years, a better understanding of the physiologic changes of aging in women has led to vast improvements in menopausal medicine and the treatment of disruptive symptoms. To find the latest information on menopause and to locate a certified menopause practitioner, visit the North American Menopause Society website at menopause.orgKaren Knapp, MD, FACOG, is Richmond’s only female NAMS-certified practitioner. She is specially trained to help you through all the challenges of perimenopause and beyond.

For further inquiries about menopause management or general gynecology, contact Karen Knapp, MD, FACOG, of Commonwealth Ob/Gyn Specialists at 804-285-8806, or visit their website at

Could obesity be making it harder to breathe?

Hala Moukhachen Pulmonary Obesity
Hala Moukhachen, MD
Director of Pulmonary Diseases
MultiSpecialty Health Group
Spotsylvania Regional Medical Center

Obesity is strongly linked with respiratory symptoms and diseases, including exertional dyspnea, obstructive sleep apnea syndrome (OSAS), obesity hypoventilation syndrome (OHS), chronic obstructive pulmonary disease (COPD), asthma, and pulmonary embolism. Overweight and obese individuals are more likely to have respiratory symptoms than individuals with a normal BMI, even in the absence of demonstrable lung disease.

Respiratory muscle function has been shown to deteriorate in obesity, in a pattern similar to that seen in chronic respiratory disease like COPD. This may also be related to a reduction in the overall fat free mass (FFM – i.e., muscle mass).This deficiency may contribute to the additional oxygen demand required for ventilation and may heighten sensation of breathlessness in obese patients. Obesity is also recognized as an important risk factor for the diagnosis asthma and sleep apnea.

Obesity and Asthma

There may be implications of a genetic link between asthma and obesity. In general, all studies published so far show that weight loss in obese asthmatics improves asthma control. Conventional weight loss managed through diet and exercise, but more so surgically induced weight loss, results in significant improvements in asthma severity, use of asthma medication, dyspnea, exercise tolerance, and acute exacerbations of asthma, including hospitalizations due to asthma.

Overweight Woman Asthma COPDStudies have also shown that weight loss in obese asthmatics is associated with improvements in level of lung function and airway responsiveness to inhaled methacholine, whereas no significant improvements have been observed in exhaled nitric oxide or other markers of eosinophilic airway inflammation. Taken together, these observations therefore indicate that objective markers of asthmatic airway inflammation are not improved to an extent comparable to the improvements observed in symptoms and lung function. It is therefore probable that weight loss induced improvements in asthma control (which is the goal in asthma treatment) – defined as symptoms, level of lung function, and use of medication – occur due to a reduction in mass loading on the respiratory symptoms rather than improvements in asthma, per se.

Sleep Apnea COPD ObesityObesity and Sleep Apnea

People who have obstructive sleep apnea (OSA) have periods of sleep that are interrupted by apneas, or pauses in breathing. The causes of this are as varied as the patients who have it, but there is a definite link between sleep apnea and having extra body fat. When patients with sleep apnea lose weight, their sleep apnea improves.

In addition, some patients with obesity can develop a very rare form of sleep apnea called the obesity hypoventilation syndrome. These patients also have poor breathing while awake, which causes them to have low oxygen and high carbon dioxide. Those patients have headaches, have long term detrimental heart health effects, and altered functionality.

Obesity and Chronic Obstructive Pulmonary Disease (COPD)

There is a higher prevalence of overweight and obesity in the early COPD population compared with the general population, but a paradoxically lower BMI in moderate to severe COPD patients (GOLD stages 3 and 4). At these later stages of COPD, lower values for BMI (

Overweight Man Apnea Asthma COPD ObeseIn COPD and obesity, low-grade inflammation and arterial hypoxemia have been associated with a reduction in skeletal muscle tissue, a decrease in muscle fat oxidative capacity, a shift from muscle fiber type 1 (slow twitch) to type 2 (fast twitch), and a loss of respiratory muscle performance.

Physiological and metabolic factors related to COPD and obesity seems to jeopardize morbidity and mortality further when in association. Further studies are being undertaken to investigate the relationship.

In conclusion, the influence of obesity in respiratory diseases is complex and goes beyond the obvious mechanical and physical consequences of weight gain and its associated inflammatory and metabolic disorders. It is important to recognize it early and attempt all measures to treat it.

If you have further questions about the connections between obesity and respiratory diseases or general pulmonary care needs, contact Dr. Hala Moukhachen of MultiSpecialty Health Group at 540-423-6600, or visit her practice website at

If you’re interested in attending a seminar to learn about surgical weight loss options with Dr. Mohammad Jamal, call 540-423-6600 to sign up, or visit to learn more.

The Pill – It’s Not Just for Birth Control!

Catherine Bagley DO OB/GYN Richmond
Catherine Bagley, DO
Commonwealth Ob/Gyn Specialists
Henrico Doctors’ Hospital

In 1957, the medication now known as “the pill” was approved by the FDA for menstrual disorders. Coincidentally (or not), when the pill became available, thousands of women suddenly developed menstrual disorders. Three years later, the FDA officially approved the combined estrogen and progesterone pill for contraception. Today, over 100 million women are taking the pill worldwide and the question remains – are we taking full advantage of the benefits the pill has to offer?

The pill was the first medication approved by the FDA for long-term use in healthy patients and it still functions as a go-to drug for many different clinical situations. The pill works primarily through influencing the hormones that cycle in women naturally, estrogen and progesterone. There is a progesterone-only pill that works somewhat differently than the combined hormone pills and is an appropriate clinical choice for patients unable to take estrogen.

Estrogen stabilizes the uterine lining, reducing breakthrough bleeding and significantly lightening bleeding for each month that patients are on the pill. Eventually, researchers discovered that estrogen also inhibits the development of eggs and helps to prevent ovulation. This combination of effects resulted in a treatment for menstrual disorders as well as providing contraception. Today, there are many different combinations of the amount of estrogen as well as the amount and type of progesterone available in different medications, including a combination transdermal patch and a removable vaginal ring.

In the development of the pill, a hormone-free week was built into each month in order to provide the patient with reassurance that she was not pregnant. During this week, a patient may take placebo pills or no pills at all. Typically, she will bleed during this week, and some patients will mistake this for a period, when it is not. The hormones in the pill prevented ovulation and stabilized the lining of the uterus; the bleeding that may occur is merely the uterus responding to the withdrawal of the hormones. When I counsel adolescent patients about the use of the pill, I often answer questions from patients’ mothers about the safety of continuous dosing, i.e. avoiding the week of inactive pills built into a typical four week pill pack. Historically, that week of bleeding was considered normal, but continuous dosing is very safe and is an excellent option for many patients. Some of the newest versions of combined pills are designed to minimize bleeding, representing a shift toward recognizing not only the safety of continuous use, but the importance of giving women more control over their cycles.

iStock_000021759022_LargeFor many women, periods interfere with school, life, and/or social activities. Whether a woman suffers from heavy bleeding, painful periods, fatigue due to chronic anemia (because of heavy bleeding), headaches, or mood changes, the pill can often help alleviate those symptoms. Pelvic pain, either because of painful periods or other conditions, such as endometriosis or fibroids, is one of the leading causes of women missing school and work. Many patients who are treated with the pill are able to function at the level they were accustomed to prior to the pain. Continuous use of pills can resolve the symptoms of pre-menstrual dysphoric disorder for many patients.

Beyond controlling reproductive cycles, there are other benefits to the pill. These include: the potential to slow excess hair growth and acne because they suppress production of the male hormone, prevention of menstrual migraines, improving bone mineral density, normalizing irregular periods, and allowing women to avoid having their period at inconvenient times, such as during a business trip, vacation, or honeymoon.

The scientific evidence shows that the longer a woman uses the birth control pill, the lower her risk for developing endometrial and ovarian cancer later in life, up to 20 years after discontinuing use. The pill also seems to offer some short-term protection against colorectal cancer among current or recent users. Women using the pill for non-contraceptive benefits, generally return to fertility soon after discontinuing the medication. On the opposite side of the coin, women who have completed child bearing and may be entering the perimenopausal state can benefit from the hormone balance the combined pill provides. Because of recent legislative changes, most every financial barrier to the pill has been eliminated, which is terrific news for our patients.

All medications carry some degree of risk and it is important for patients to know whether or not the pill is safe for them. Early formulations of the pill contained high levels of hormones; the pills available today have approximately one third the amount of estrogen as the first version of the pill. Estrogen carries very specific risks that are increased in certain patient populations. Patients with a history of any bleeding disorders, especially venous thromboembolism (VTE), deep venous thrombosis (DVT), and/or pulmonary embolism (PE), are not candidates for combined pills. Patients who are over the age of 35 and are smokers are also not candidates for combined pills.  For these patients, the estrogen in the pill increases their risk of developing blood clots.

In addition to the medical risks that medications carry, there are typically side effects that can dictate whether or not someone is able to tolerate a medication that has been deemed clinically appropriate and safe for that patient.   Side effects of the pill are interesting because some of them are the very symptoms that the pill helps to improve.  They can include: nausea, vomiting, hypertension, headaches, mood changes, and alterations in libido. If patients fail therapy with the pill, there are other options. With advances in minimally invasive operative technology, in addition to procedures that have been performed for many years, definitive surgical treatment is available to some patients. However, not every patient is an ideal surgical candidate; for those patients as well as the patients who want to avoid surgery, a different version of the pill (or a different delivery method of the combined hormones) may be a viable alternative.

For further inquiries about the pill, contraception or general gynecology, contact Catherine Bagley, DO, of Commonwealth Ob/Gyn Specialists at 804.285.8806, or visit their website at

Quick Facts: What stroke factors cannot be controlled or changed?

Alan Schulman, MD Neurological Associates Henrico Doctors' Hospital
Alan Schulman, MD
Neurological Associates
Henrico Doctors’ Hospital

Age is the single most important risk factor for stroke overall. Stroke rates steadily increase after age 55. There is also a likely genetic component to stroke, which is an area of active research. The good news is that there are many known modifiable stroke risk factors. The most important one is hypertension, or, high blood pressure. Others include diabetes, atrial fibrillation, carotid artery disease, high cholesterol, obesity/physical inactivity, and excessive alcohol use.

If you have any questions about stroke treatments or diagnosis, general neurologic disorders, or would like to schedule a consultation with Dr. Alan Schulman, please call Neurological Associates, part of HCA Virginia Physicians, at 804-288-2742. 

Bringing Home Baby – Everything Your Doctor Wants You to Know

ThinkstockPhotos-148490276It is completely normal to feel both excited and scared about bringing your baby home from the hospital. Being prepared can go a long way in making you feel more confident and making your baby more comfortable. What will your newborn need? The essentials include food, clothes, diapers, and a quiet and safe place to sleep. Of course, your baby will also rely on you for love and attention.


Whether by breast or by formula, a newborn needs to be fed throughout the day. In the first few weeks, you should wake your baby to feed if 3-4 hours have passed since the last feeding. Unless they are premature or have special nutritional needs, you may not need to wake them up overnight, as they usually wake up on their own.

iStock_000013188397LargeIf you are breastfeeding, you will likely need to feed your baby every 2-3 hours. If you are feeding your baby formula, your baby may have 6-10 formula feedings (2-4 ounces each) per day. If you do decide to use formula, be sure to follow the product’s instructions for storing and warming it.

Essential Feeding Supplies:

  • Formula
  • Bottles and nipples
  • Bibs, washcloths, and towels
  • Breast-fed babies may need extra Vitamin D

*Mom Tip – There are many feeding resources available in the area. Check with your hospital for a list of lactation professionals, or for advice on the right formula and bottles for your baby. Your Ob/Gyn or Pediatrician can also be an excellent resource for feeding advice. Lastly, La Leche League and are fantastic online communities.


Dress your baby in comfortable clothes that make it easy for you to change diapers. Be sure that the clothes do not have anything hanging from them, like strings or ties, which can become a choking hazard. Also check to make sure that your baby’s sleepwear is flame-retardant. Newborns can sometimes have trouble regulating their own body temperature, and as a result, too much clothing can result in overheating, just as underclothing can result in heat loss. For room temperatures of 75°F (24°C) or less, use several layers of clothing. As a guideline, dress your baby in one more layer of clothing than you are comfortable wearing. In warmer weather, you can use a single layer of clothing.

Essential Clothing Supplies:

  • Receiving gowns
  • Footed sleepers
  • Undershirts and onesies
  • Blanket sleepers
  • Hand mitts (to keep babies from scratching themselves)

*Mom Tip – Have hand mitts on hand to place over your newborns hands. Their small fingernails can be sharp, and they can easily scratch their skin (or their face!) in the early days.

ThinkstockPhotos-178500338Diaper Changes

When you first arrive home, your baby will not have regular-looking stool. It will be thick and sticky and have a greenish-black color, and is called meconium. If your baby is breastfed, the stool will become more liquid in consistency, seedy, and yellow. For formula-fed babies, expect soft, pasty, and yellowish-brown stool. Hard or dry stools may be due to your infant not getting enough fluid or losing too much fluid due to an illness.

The frequency of bowel movements can vary greatly in infants. If your baby has many or infrequent bowel movements or if you have any concerns, call your doctor. Your baby should have at least 6-8 wet diapers per day. If your child looks to be in pain while urinating, let your doctor know, as this may be a sign of a urinary tract infection.

Essential Diapering Supplies:

  • Safe changing area for your baby—Have all of the supplies that you will need in the changing table’s drawers. Never leave your baby alone, and use the safety straps on the table to secure your baby.
  • Extra diapers
  • Baby wipes
  • Towels
  • Diaper rash ointment
  • Diaper pail and trash bags

ThinkstockPhotos-99678084Sleep Time

Your baby may sleep 12-20 hours per day in 1-3 hour intervals, and will develop a routine. It is common for your baby to wake up during the night for a feeding or a diaper change. When you place your baby down to sleep, always place them on his or her back, as this is the safest position. The baby should sleep in a place where you can hear and care for him immediately for the first few months of life.

Essential Sleeping Supplies:

  • A safety-approved crib or bassinet that has a firm mattress
  • Fitted crib sheets
  • Waterproof crib pads

Avoid having anything in the crib or bassinet that could restrict your baby’s breathing. Do not place pillows, quilts, comforters, stuffed animals, or other items in the crib. Also, do not use sleep positioners, as they can increase your baby’s risk of suffocation.

You can help your baby sleep better by keeping the environment calm and quiet during changing and feeding at night. Try to put your baby in the crib when he or she is drowsy but not yet asleep rather than waiting until he or she is fully asleep. This will help your baby to learn to fall asleep independently. If your baby is fussy, wait a few minutes to see if he or she falls back to sleep. If crying persists, try to determine if your baby is hungry, has a wet diaper, or is not feeling well.

*Mom Tip – Install a dimmer switch on a lamp in the baby’s (or your) room, so that you don’t have to turn on bright overhead lights during nighttime feeding, keeping the environment soothing for a fast return to sleep.

Other Day-to-Day Activities

Giving Your Baby a Sponge Bath

Your baby’s umbilical cord stump needs time to dry and fall off. Until that happens, you will need to give your baby a sponge bath, rather than a tub bath. Gently clean your baby girl’s genital area from front to back. For an uncircumcised baby boy, do not pull back the foreskin. This can cause swelling and other problems. If your baby has been circumcised, follow the doctor’s instructions for caring for your baby.

Essential Bathing Supplies:

  • Wash cloths
  • Towels
  • Mild bath soap
  • Cotton balls or gauze pads—Do not use soap on your baby’s face. Instead, use a wet cotton ball or gauze to gently wipe your baby’s eyes.

ThinkstockPhotos-469114023Taking Your Baby’s Temperature (Rectally)

It is good idea to have a rectal thermometer at home to take your baby’s temperature, in case they feel warm. These thermometers give the most accurate readings in infants, and your doctor will likely ask for it to be verified this way. Follow the product’s instructions for taking the temperature. Having a temperature greater than 100.4°F (38°C) may be a sign of an infection in babies younger than 1 month. If this occurs, call your baby’s doctor.

Traveling in the Car With Your Baby

Your baby will need a safety-approved rear-facing car seat. Some manufacturers make rear-facing convertible seats, which can be switched to a front-facing seat once your child has reached the height and weight requirements. Rear-facing seats placed in the back seat are the safest option for your baby. Be sure that the seat is strapped into your car properly and that your baby is buckled in correctly. On the National Highway Traffic Safety Administration’s website, you can find a local inspection station where the staff will check to make sure that the car seat is safely installed.

*Mom Tip – In Central Virginia, there are several fire stations around Richmond that will both install and check your car seat for you. They stay annually updated on the latest requirements and advice, and are the best private resource for you. Your baby will not be allowed to leave the hospital without an approved and installed car seat.

Taking a Walk With Your Baby

Just as with the car seat, you will want to buy a safety-approved stroller for your newborn. There are many options available, including ones that allow you to attach the car seat to the stroller. Never leave your baby alone in the stroller.

Some features to look for in a stroller include:

  • Five-point harness that is securely attached to the stroller
  • Brakes that lock and work well
  • Storage area located behind and low to the ground, so items will not fall onto your baby
  • Reclining back—If the stroller has leg-hole openings, be sure that you can close them when your baby is resting.
  • Canopy to protect your baby from the elements

Playing With Your Baby

You can help your baby to develop his brain and body by doing activities like:

  • Touching your baby—cuddling, holding, rocking, and massaging
  • Talking to your infant—Call out your baby’s name. Tell your baby what you are doing. Sing or read to your baby.
  • Showing your baby objects—While your baby’s vision will take time to develop, your baby will be able to see items that are close. Newborns like bright colors and patterned objects.
  • Moving your baby—If your baby is active, place him or her on his or her belly while supervised. Do not let your baby sleep in this position.

Some toys that your baby might enjoy include a brightly-colored stuffed animal, a rattle, or a book with lots of colors. Be sure that the baby’s toys are safety-approved for infants.

Soothing Your Baby

When your baby cries, it can be distressing. Crying is how newborns let you know that they need something, whether it is a diaper change, a feeding, or time in your arms. Over time, you will become better at understanding what your baby needs. Some newborns get upset by bright lights or loud noises. Their bodies are sensitive. Making their environment relaxing and quiet may help to reduce crying. Your baby may also be soothed by being wrapped in a blanket. Remember, it is normal for a newborn to cry for several hours throughout the day. If you think your baby may be sick, call the doctor right away.

If you ever feel that you are becoming aggravated or angry with your baby, ask for help from friends or family right away. Never shake your baby. This can cause brain damage or even death. Get support from your loved ones to help you care for your newborn. There are many people who will be happy to help you. If you find yourself feeling frustrated, remember there are always resources available for you. Call 1-800-CHILDREN (1-800-244-5373) 24/7 if you’re in urgent need of support, and dial 911 if there is a medical emergency.

ThinkstockPhotos-136484223Once your baby is home, you will soon develop a routine. Do your best, ask for help, and talk to the doctor or nurse if you have any questions or concerns about your new arrival.

HCA Virginia Physicians is home to the largest physician network of Ob/Gyn and Pediatric providers in Central Virginia, with more than 12 area locations specializing in newborn (and new mother!) care.

Visit for more information, or click THIS LINK to schedule an appointment online with a provider today.

8 Things You Should Know About Heart Valve Disease

Chiwon Hahn, MD, FACS Cardiothoracic Surgical Associates Henrico Doctors' Hospital
Chiwon Hahn, MD, FACS
Cardiothoracic Surgical Associates
Henrico Doctors’ Hospital

Many people will go their whole lives not thinking twice about the health of their heart valves, but for approximately 5 million Americans annually, Heart Valve Disease is cause for very serious concern.

What is a heart valve and how does it work?

Humans have four distinct heart valves – the mitral and aortic valves on the left side of the heart, and the tricuspid and pulmonic valves on the right side. The job of these valves is to move blood properly through the heart, preventing blood at different stages of circulation from mixing.

What causes heart valve disease?

There are several factors, both genetic and environmental, that can contribute to heart valve disease. Congenital heart valve defects are those that occur before birth, and are detected later in life. Environmental factors that increase risk include a history of rheumatic fever, infective endocarditis, heart attack, arrhythmia, or cardiomyopathy. Calcification of the arteries (arteriosclerosis) is also a risk factor, as plaque build-up narrows the arterial tubes delivering blood to the heart. Not only can this affect valve health, but also can increase a person’s risk for heart attack and stroke.

What are some common types of heart valve problems?

  • Aortic Stenosis: The aorta is the artery by which blood leaves the heart, exiting through the aortic valve. In aortic stenosis, this valve does not open fully, decreasing blood flow from the heart to the body. The primary cause of aortic stenosis is arterial calcification; it usually develops later in life, and mostly affects older patients.
  • Mitral Valve Prolapse (MVP): MVP is a condition that affects 1-2% of the population, by which the leaflets of the mitral valve enter the left atrium during the heart’s contractions. The tissues in the valve can stretch, causing the valve to leak. MVP usually is mild and does not require treatment.
  • Mitral Valve Regurgitation (MVR): If left untreated, MVP can lead to MVR, which is a leakage of blood backward through the mitral valve into the atrium. This backward flow can cause pressure and fluid volume to build, ultimately increasing pressure in the veins leading from the lungs to the heart.

What are the symptoms of heart valve disease?

375x321_heart_valvesSymptoms can range from severe to non-existent, depending on the type of valve disease. Patients who suffer from valve disease may feel abnormal shortness of breath, weakness, dizziness, palpitations or other chest discomfort, especially when subjected to activity or cold air. Edema (swelling of the ankles, feet, or abdomen) is also a possible indicator, as is rapid, unexplained weight gain in a very short period of time.

How is heart valve disease diagnosed?

Many heart valve issues are first identified by the presence of an atypical murmur in the heart’s normal beating pattern that your physician would hear during a routine stethoscope chest exam. Upon suspicion of an issue, your doctor would conduct a full physical exam, potentially an echocardiogram, a set of x-rays, an electrocardiogram (EKG), and a cardiac catheterization (angiogram), which is the insertion of a tube-like device into the heart through an artery in order to accurately define the valve issue.

What are the treatments for heart valve disease?

There are two main avenues for treatment – management with medication, and surgical intervention. If surgery is indicated, you will work with your surgeon to determine if your valve needs to be repaired or replaced, with normally only one valve being replaced at a time. New heart valves can be either synthetic or tissue-based from a pig, cow, or a human donor.

  • Balloon Valvuloplasty is a surgical repair option, and is a procedure done during a cardiac catheterization whereby an expandable “balloon” is threaded into the heart, placed inside the tightened valve, and then inflated in order to stretch open the valve, restoring proper blood flow.
  • Transcatheter Aortic Valve Replacement (TAVR) is a relatively new minimally-invasive procedure that inserts a new temporarily collapsed valve into the damaged valve, effectively replacing it. The surgeon then “inflates” the new valve, and as it expands, it assumes blood flow management going forward. TAVR is a procedure ideally suited for those who are unable to undergo a traditional open-chest procedure, as it can be completed through small incisions that do not disturb the chest wall. The cardiothoracic surgical team at HCA Virginia was the first to complete this procedure in Central Virginia, and recently celebrated their 100th TAVR operation.

Are the surgical options for treatment safe?

As with any surgical intervention, there are potential complications. Because heart valve surgery can be highly invasive, patients can normally expect a hospital stay of 2-5 days post-surgery, with intensive monitoring by a highly specialized staff. Because heart valve replacement surgery has been evolving over many years, most techniques are considered to be very safe and highly effective. There are some lifestyle factors that can increase complication rates such as smoking, a pre-existing heart or lung condition, advanced age, or a recent illness or infection. All of these factors would be assessed by the patient’s surgeon prior to operating.

How long does a heart valve replacement last?

The lifetime of the replacement valve depends on whether it is synthetic or natural. Manufactured mechanical heart valves are the most long-lasting replacement valves, but they can come with a lifetime of blood-thinning medications in order to prevent clotting and embolisms. Natural replacement valves, either from a human donor or animal tissue, generally last between 10-20 years and in many cases can be maintained without medication assistance.

There are more options today for safe and effective heart valve disease treatments than ever before, and surgeons continue to innovate in the field. As with any medical intervention, you should discuss all appropriate treatment options with your physician before pursuing any course of action.

For questions about heart valve disease, treatment options, or to schedule a consultation, contact Chiwon Hahn, MD, FACS, of Cardiothoracic Surgical Associates, at 804-320-2751 or visit

Pregnancy Immunizations – What You Should Know Now

Marijan Gospodnetic, MD Richmond Women's Specialists Johnston-Willis Hospital BOOK ONLINE NOW
Marijan Gospodnetic, MD
Richmond Women’s Specialists
Johnston-Willis Hospital

April 18-25th is National Infant Immunizations Awareness Week, and while that topic is of paramount importance, many women who study it don’t think about the period in their lives immediately prior – pregnancy – and the immunizations this delicate time can require.

Vaccines help keep pregnant women and their growing families healthy, and are necessary for the protection of your children and those in the community from vaccine-preventable diseases. Many terms are used when discussing this segment of preventive medicine, but the three main ones are: vaccines, vaccinations, and immunizations.

Vaccines are the products that produce immunity from a disease and can be administered orally, via injection, or through an aerosol spray. There are two types of vaccines, inactivated and live, and these present different indications after administration. Vaccinations are the act of administering the vaccine that produces immunity in the body against the organism. Immunization is the process by which one becomes protected from a disease. Vaccines cause immunization, and sometimes diseases can also trigger immunization after the individual recovers from the disease.

There are three distinct stages to a woman’s pregnancy, prenatal (before), perinatal (during), and postnatal (after). All of these have specific vaccine and immunization recommendations that should be followed.

Before Pregnancy

As you consider expanding your family, you should ensure that you are current on all routine vaccines as indicated by age and individual health factors. The vaccine statuses of which you should be aware are: Hepatitis A, Hepatitis B, Human Papilloma Virus (HPV) if you are age 26 or younger, Influenza (flu shot), Measles, Mumps, and Rubella – MMR (live), Tdap (Tetanus/Diphtheria/Pertussis), and Varicella – Chicken Pox (live). If you receive a live vaccine, you should refrain from conception for at least four weeks while establishing immunity.

During Pregnancy

Congratulations – you’re now expecting! Among all the health questions that arise, one of the biggest is: what medicines and vaccines are safe during this time? The most important vaccine during pregnancy is for influenza. The “flu shot” is given annually to combat the anticipated strains of flu circulating in that given year, and it is of paramount importance for pregnant women to receive the inactivated flu vaccine. Contracting the flu during pregnancy puts you at serious risk for complications and hospitalization, and symptoms can be detrimental to the pregnancy. You should also get the Tdap vaccine for tetanus, diphtheria and acellular pertussis during each pregnancy. Ideally, this will be administered between weeks 27 and 36 of your pregnancy, in your third trimester.

Some of a woman’s immunity to disease is passed along to their baby during pregnancy, protecting them from some diseases during the first few months of life, before the baby’s 2-month checkup, when initial vaccines are routinely administered. In addition to boosting your immunity during pregnancy, you should be cautious about travel to areas known to be common locations for vaccine-preventable diseases. Talk to your physician about any planned international travel and work together on a care plan if the trip is unavoidable. More information about travel vaccines can also be found at Center for Disease Control’s traveler health website:

After Pregnancy

It is safe for women to receive routine vaccines immediately after giving birth, even while breastfeeding. This is also an important time to begin educating yourself on childhood vaccination schedules for your new addition. If you haven’t received your Tdap vaccine during pregnancy, you should have it administered right after delivery. Also, women should receive the pertussis (whooping cough), MMR, and varicella vaccines to reduce risks to both her and her infant.

If you’re seeking additional resources about pediatric immunizations, the CDC has a fantastic chart (linked here) that details all of the vaccines your child needs from birth to age 6, and the stages at which they should be administered.

For further inquiries about immunizations, vaccines, pregnancy, obstetrics, or general gynecology, contact Marijan Gospodnetic, MD, of Richmond Women’s Specialists at 804.267.6931 or visit You can also schedule an appointment with him directly by clicking HERE.

Breastfeeding 101

Courtney Legum-Wenk, DO Commonwealth Ob/Gyn Specialists Henrico Doctors' Hospital
Courtney Legum-Wenk, DO
Commonwealth Ob/Gyn Specialists
Henrico Doctors’ Hospital

Breastfeeding is a very charged and often misunderstood topic in the world of women’s and infant health. Historically, breastfeeding has been the standard way to provide infant nutrition, and although there was a gap in the mid-20th century in breastfeeding rates, it has resurged as a dominant first choice for feeding by most families. Extensive information is available regarding breastfeeding from your OB/GYN, your pediatrician, and trusted official resources, but much misinformation also abounds. I’d like to take this opportunity to answer some of the most frequently asked questions about breastfeeding, and encourage you to talk to your healthcare provider in detail about anything not covered here.

What are the specific health benefits of breastfeeding for my baby?

The American Academy of Family Physicians recommends six months of exclusive breastfeeding for infants. Breastfeeding provides vital nutrients to your infant that change and develop as he or she gets older. Studies show that infants who are breastfed have less frequent instances of otitis media (ear infections), gastroenteritis, atopic dermatitis (eczema), lower respiratory infections, and SIDS. There are also links to obesity, type 1 and type 2 diabetes, and asthma for children who were not breastfed in infancy.

iStock_000020070767MediumAre there additional health benefits for the mother when exclusively breastfeeding?

Breastfeeding is associated with reduced instances of postpartum depression, type 2 diabetes, breast cancer and ovarian cancer for mothers. Many women have always heard that the “weight will fall off” during the postpartum period for those who are breastfeeding, but that link is unfortunately minor when compared with other factors. Breastfeeding can be one of the most unheralded difficult parts of the transition in becoming a new parent, but you will find that through all of the challenges, this is one of the best ways to bond with your new baby. This sense of accomplishment, both in providing exclusive nutrition for your child, and for persevering through the challenges posed by breastfeeding, is immensely beneficial to both mental and physical health.

breastfeeding babyAre there any dietary restrictions for breastfeeding mothers?

Many restrictions that existed during pregnancy still exist, to some degree, when breastfeeding. A good rule of thumb about alcohol consumption when breastfeeding is that if you’re sober enough to drive, then you can breastfeed. Alcohol affects infants in a magnified way because of their underdeveloped liver function, so consumption should always be monitored with care. Caffeine intake is another common concern, although most mothers can have it in moderation. Some infants are more sensitive than others to a mother’s caffeine intake, particularly if the mother avoided caffeine entirely during pregnancy. Cigarette smoking is universally unhealthy for both mothers and infants, and should be avoided. Babies who are exposed to cigarette smoke have higher incidences of respiratory distress, ear infections, eye irritation, croup, colic, and SIDS.

What if I have trouble breastfeeding, or am not able to produce enough milk?

Although most breastfeeding-related problems can be corrected by addressing a few simple procedural issues, a small subset of the population can experience Primary Lactation Failure (PLF), a condition occurring when the mother’s body fails to produce enough milk to supply her infant’s nutritional needs. PLF can be due to various factors, notably previous thoracic or breast surgery severing vital nerves or ducts, hormonal imbalances, and/or insufficient glandular tissue (IGT), which can also be referred to as Hypoplasia or Tubular Breast Syndrome. Many options exist for proper infant nutrition outside of breast milk, including many different types of formula. Your pediatrician can best guide you on which type of formula will work best for your infant, and can help you adjust if you experience issues transitioning.

What are some resources online where I can find more information?

The best medical resources for individual research are the American Academy of Family Physicians and the American Congress of Obstetricians and Gynecologists. La Leche League International, KellyMom, and BabyCenter are also excellent online resources.

For further inquiries about breastfeeding, pregnancy, obstetrics, or general gynecology, contact Dr. Courtney Legum-Wenk of Commonwealth Ob/Gyn Specialists at 804-285-8806 or

Does it actually matter “how” you run?

Jonathan Wilson, DPT HCA Virginia Sports Medicine Chippenham Hospital
Jonathan Wilson, DPT
HCA Virginia Sports Medicine
Chippenham Hospital

Finally, the RVA can wave goodbye to winter and open our arms to embrace spring. Spring time in Richmond means buds will appear in Maymont and Lewis Ginter Botantical Garden, your car will turn yellow with pollen, allergies will destroy your sinuses, and it also means more runners will be hitting the streets and trails outside to run. This seems like a good time to discuss running mechanics and form, and their relationship to injuries.

Most running injuries result from repetitive stresses causing tissue breakdown and ultimately tissue failure. For every mile we run, we take roughly 750 steps with each leg. That’s 1,500 combined foot contacts per mile. If we could make small changes to our running from that would decrease the load with each step, you could have a significant change in overall stress our body endures for a given run.

Research with real time feedback from force plates have enabled us to see the stress and loads created during running. We know there is a spike representing an increase in loading rate which is thought to correlate to increased tissue breakdown and increased risk of injury. Some runners have this spike, while others do not. Runners who make contact out in front of their center of mass, or over stride, have this spike of increased loading rate. What if we could change our running mechanics to get rid of the increased loading rate? The good news is that we can!

iStock_000057793344_LargeSome people associate heel striking with over striding. They blindly believe heel striking is always bad, whereas midfoot striking is always good.  It’s not this simple. Jay Dicharri has a great post on the topic. Often times, heel striking does accompany over striding. However, Jay Dicharri explains why a heel striker can have smaller force loading rate compared to that of a runner landing at midfoot. Instead of getting completely focused on foot striking pattern, let’s focus on landing close to our center of mass.

In research, and the clinic, stride rate manipulation (increasing your cadence) has shown to successfully help a runner land closer to their center of mass. Runners typically choose the most efficient and comfortable pace to run. However, often times this leads to a low cadence. Cadence is the amount of foot contacts a runner makes per minute. 180 steps combined (90 each foot) is considered the “ideal cadence.” With this said, 180 is dependent on pace. Research shows increasing cadence by 5-10% can help bring a runner’s foot closer to their center of mass. However, if you increase your cadence by more than 10%, you risk increasing your cardiac output, becoming less efficient.

Seiko-DM50S-Clip-Digital-MetronomeFirst, you need to find your cadence. I suggest using a treadmill so you can maintain a steady pace. You will also need a metronome, or an app on your smart phone. Count how many times you’re right leg makes contact with the treadmill for one minute. Double this number and you now have your cadence. Multiply this number (your cadence) x .05 (round up if you get a decimal) and you now have your target cadence. Enter your original cadence into your metronome and run till you fall in sync with the beat. At this point, increase the metronome to your target cadence and run till you again fall in time to the beat.

Second, work on feeling the difference between the two cadences as you maintain the same speed. Once you feel like you have the timing of your target cadence remove the metronome. Run for a few minutes and then bring the metronome back to check yourself. How close were you? It will take a few sessions per week of training with a metronome until the new cadence feels normal.

It is important to remember to run loose, even when working on increasing your cadence. You do not want to become so focused on your cadence that you tightening your upper body or become mechanical. Gait manipulation takes time, as you are retraining your body to run in a new way. Don’t get frustrated. Remember, run loose, run soft, and always enjoy your run.

For further inquiries about running injuries or performance, contact Jonathan Wilson, DPT, at HCA Virginia Sports Medicine’s Boulders location, at 804-560-6500, or like us at