Gynecologists handle all conditions of the female reproductive system. As the obstetric and gynecologic fields are closely related, many physicians generally practice these two specialties together. Mt. Auburn Obstetrics and Gynecologic Associates, Inc. physicians are trained in both specialties; however, we do have physicians that practice in the area of gynecology only. A number of women choose to “follow” the physician that delivers their baby through the continuum of their gynecologic care.
Your Gynecological Exam
What will happen at your first gynecological appointment?
It’s normal to feel nervous, but there is really nothing to worry about. Your first appointment is usually very simple, and your doctor will spend time getting to know you. The doctor will ask about you and your family’s medical history and your sexual health.
What are gynecologic exams?
There are four types of examinations that you may have during your visit. Each type depends on the length of your first appointment, your age, your sexual history and whether or not you have any particular symptoms.
If you are going to have any tests, the doctor will explain them first so you don’t have to be anxious. The doctor will instruct you to go to the bathroom or a changing room to undress in private and put on a gown. Here’s what to expect:
- General physical examination. As with any medical examination, your weight, height and blood pressure will be measured.
- Breast examination. Your doctor will gently and quickly feel the breast tissue to check for lumps or abnormalities.
- Pap smear
- Pelvic examination: This test is not performed on all women unless they’ve had sex or have certain symptoms in their vagina or abdomen.
Premenstrual Syndrome, commonly referred to as PMS, is a term used to describe the symptoms many women experience one to two weeks before the beginning of their period. Physical symptoms, accompanied by mood swings and depression, are the classic signs. Thirty to forty percent of American women have symptoms severe enough to interfere with their daily lives, while three to five percent have symptoms severe enough to be incapacitating.
PMS symptoms can occur any time after ovulation, approximately two weeks after the beginning of your period.
What Are the Symptoms of Premenstrual Syndrome?
The following is a list of both behavioral and physical symptoms commonly associated with PMS. All PMS symptoms should disappear rapidly once menstruation begins.
- Increased irritability
- Feeling anxious
- Crying spells
- Cyclic depressive symptoms
- Difficulty concentrating
- Breast swelling or tenderness
- A bloated feeling or temporary weight gain of a few pounds
- Nausea or constipation followed by diarrhea at the start of menstruation
- Swelling of hands or feet
- Increased appetite or thirst
- Food cravings
- Fatigue or insomnia
What Causes Premenstrual Syndrome?
PMS has been described as far back as Hippocrates. Modern investigation of PMS began in the early 1930?s when it was called premenstrual tension. For many years, research has focused on two hormones produced by the ovaries, estrogen and progesterone. Other investigations have centered on serotonin levels (a neurotransmitter in the brain,) deficiencies of endorphins, defects in the metabolism of glucose or B6, low concentrations of zinc, magnesium or calcium, and an imbalance in the body’s level of acidity.
No conclusive evidence has been found to support any of these theories. Research has found though, that PMS responds to a variety of treatments.
How Is Premenstrual Syndrome Diagnosed?
There are no diagnostic tests for PMS. It is generally diagnosed through a process of elimination. To aid in diagnosis, you should keep a diary for several months of symptoms; when they appear, their severity, and when they subside. You and your physician can review your record in order to determine a treatment plan.
How Is Premenstrual Syndrome Treated?
Premenstrual Syndrome may be treated through a modification of lifestyle and change in diet, or through medications.
Lifestyle and Dietary Changes
- Decrease Caffeine: Caffeine can exaggerate certain PMS symptoms, such as irritability, anxiety, insomnia, and nervousness.
- Avoid salt: Many women gain a few pounds in the second half of the menstrual cycle due to water retention. Avoiding salty foods can help decrease the bloating. Since brain cells can also retain fluid, decreasing salt may also help relieve headaches and aid in concentration. Along with the sodium reduction it is important to drink at least 8 to 10 glasses of water a day. Water acts as a natural diuretic, along with its normal role in cellular function.
- Avoid sugar: Eating sugary foods can set off a vicious cycle of sugar cravings. Blood sugar swings can cause a disruption in hormonal production and distribution.
- Stop smoking: Nicotine can exaggerate PMS symptoms much the same as caffeine.
- Decrease alcohol intake: Alcohol can intensify PMS symptoms because it depletes the body of B vitamins, disrupts the metabolism of carbohydrates, and affects the liver?s ability to process hormones.
- Add Calcium: Taking 1200 mg of chewable calcium carbonate a day can decrease PMS symptoms by as much as 50%. Improvements may not be apparent until the third cycle of treatment.
- Exercise: Women who exercise regularly have milder PMS symptoms. You should participate in some type of aerobic exercise for 20 to 30 minutes at least 3 times a week.
- Add Magnesium: The intake of 200 mg of Magnesium a day may reduce fluid retention, breast tenderness and bloating by 40%. Improvements may not be realized until completing the second cycle of treatment.
- Over the counter PMS preparations: There are a number of over the counter PMS medicines available which contain a medication for headaches and pain along with a mild diuretic.
- Oral Contraceptives (Birth Control Pills): Taking birth control pills, or changing prescriptions if already on the pill can decrease PMS symptoms for many women.
- Spironolactone: This is a diuretic that has been shown in some studies to decrease bloating and mood-related symptoms.
- NSAIDs (Examples of NSAIDs available over the counter are Advil, Motrin, Aleve, and Nuprin): NSAIDs are prostaglandin inhibitors. They work best if taken before the onset of PMS symptoms. They work on headaches, cramping, and may reduce the amount of blood loss.
Human Papilloma Virus (HPV)
More than 60 viruses make up what is known as Human Papilloma Virus (HPV). These viruses can cause warts anywhere on the human body. The HPV types that attack the genital tract are sexually transmitted.
HPV is currently the most common sexually transmitted virus in our country with a 1,000 percent increase in HPV patients since 1987. Because it is a non-reportable disease, the actual number of patients infected with HPV is unknown. It is believed more than 50 million Americans are currently infected with the virus, with the number growing by almost a million every year.
Venereal warts, known as genital warts or condylomata, are the clinical form of this infection because they can be easily seen and diagnosed. Venereal warts look like a fleshy bump of tissue on the labia, clitoris, or around the anus.
The sub-clinical version of venereal warts is more common. The infection resides under the skin and cannot be seen. The sub-clinical varieties have been linked to cancers of the genital tract so it is important for sexually active women to have yearly Pap tests to detect pre-cancerous changes.
What are the Risk Factors for getting HPV?
You are at risk for HPV if you have had sex with more than one partner, or have had sex with a person who has had more than one partner.
What are the Symptoms of HPV?
Whether there are symptoms of HPV depends on the strain present. If there are warts, you will notice a raised, fleshy area. If left untreated, the wart may disappear or it may grow and merge with other warts to take on a cauliflower-like appearance. Some people complain of burning or itching and occasionally a wart may bleed if irritated. You may see warts from one to eight months from exposure, or they may appear many months or years later. It may be difficult or impossible for you to determine when you were exposed.
HPV infection on the cervix usually has no symptoms at all. Evidence of a sub-clinical infection may first show up on a Pap test. Your test may show HPV changes or dysplasia (pre-cancerous cells).
How is HPV Diagnosed?
Diagnosis of warts is usually made by sight. If a suspected wart is flat and difficult to see, your doctor may look at the area with a Colposcope (a binocular-like instrument).
Warts or HPV infection on the cervix is usually revealed through a Pap test. Definitive diagnosis is usually made with a colposcopic exam and biopsies.
There is a test available that can identify HPV DNA called the Virapap. This test will only tell us if you are shedding the HPV virus when the test is performed, a negative result does not necessarily mean you have not come into contact with the virus.
What is the Treatment for Venereal Warts?
Like with other viruses, there is no cure for HPV. Warts can be treated as they appear so you may have to return to your doctor for repeat treatment. Over time though, the warts usually stop developing on their own.
- Trichloroacetic Acid (TCA): This is a strong chemical painted on the warts to destroy them. The application may cause some burning and should be applied by your physician.
- Podophyllin: This is a drug that has been long used in the treatment of venereal warts. It is painted on the warts to destroy them. Because it must be carefully washed off a few hours after it is applied, and cannot be used in pregnancy, Podophyllin is rarely used any more.
- Interferon: This is a new drug that can be injected directly into the wart itself.
- Prescription Drugs for Home Use: There are two medications, Condylox and Aldara, your doctor can prescribe for use as home treatment for venereal warts. Your doctor will show you how to apply them. They can cause burning and inflammation.
What Are the Risk Factors for Osteoporosis?
A number of factors determine the risk of developing osteoporosis, including:
- Gender: Women have lighter, thinner bones than men.
- Age: With menopause, estrogen decreases resulting in a decrease in bone mass.
- Race: Caucasian and Asian women have 5 to 10% lower bone density than African-American women. The lighter the complexion, the higher the risk for osteoporosis. Women with very fair skin, freckles, and blond or reddish hair are at the highest risk for osteoporosis.
- Build: A smaller frame, or weaker bones, increases the risk for bone fracture. Overall muscle tone can play a role in the likelihood of experiencing a bone fracture.
- Age at Menopause: Early menopause causes reduced levels of estrogen over a longer period of time than when menopause occurs later.
- Heredity: Having a mother, grandmother, or sister with osteoporosis increases your risk.
- Medication use: The use of steroids, diuretics, anti-convulsants will increase your risk for osteoporosis.
- Alcohol use and smoking: Both smoking and alcohol use are risk factors for osteoporosis.
- Medical conditions: Anorexia, Celiac disease, diabetes, chronic diarrhea, kidney or liver disease are risk factors for osteoporosis.
How Can I Prevent Osteoporosis?
- Exercise: Exercise increases bone mass before menopause resulting in a decrease in bone loss after menopause.
- Diet: Calcium intake is most important in three age groups. The earliest age group is from childhood through the mid-20’s when bones are growing at the fastest rate. Postmenopausal women experiencing rapid bone loss should monitor calcium intake. Calcium intake is also important in the elderly population.
- Hormone Replacement Therapy (HRT): Replacing estrogen after menopause improves calcium absorption and has been shown to prevent osteoporosis in 70 to 80% of women.
Hormone Replacement Therapy (HRT)
Hormone replacement therapy (HRT) consists of using two hormones, estrogen and progesterone, to relieve the symptoms of menopause. Menopause is a naturally occurring event in the lives of all women. One third of your life will probably happen after menopause.
Hormone replacement therapy remains a viable treatment option for the treatment of menopause. Your physician can discuss with you the latest findings related to the benefits and risks of HRT.
Your decision to initiate HRT should be based on a number of factors including:
- The severity of your menopausal symptoms and how they are affecting your life.
- Your individual risk for osteoporosis and heart disease.
- Your individual risk for cancers of the breast and reproductive system.
If you have had your uterus surgically removed, then you will only need to take estrogen. For those with a uterus progesterone is added to cut the risk of uterine cancer that exists with unopposed estrogen (estrogen without progesterone).
What Are the Benefits of HRT?
Hormone replacement therapy may:
- Help to prevent osteoporosis, and can even reverse bone loss that has already occurred.
- Help protect against heart disease HDL (high-density lipids, the so-called good cholesterol) levels increase, LDL (low density lipids, the bad cholesterol) levels decrease.
- Relieve menopausal symptoms including hot flashes, insomnia, vaginal dryness and atrophy.
What Are the Risks of HRT?
If you have a uterus, taking estrogen without progesterone increases the risk of endometrial cancer.
There is the possibility of a slightly increased risk of developing breast cancer with prolonged hormone replacement therapy. Many studies have shown no increase in risk. For long-term use, the incidence of breast cancer may rise from 10 per 10,000 women a year to 13 per 10,000 women a year.
What Is Menopause?
Menopause technically means the “end of menstruation.” The transition time, when estrogen levels are decreasing, is known as perimenopause.
The levels of estrogen and progesterone produced by your ovaries declines beginning in your early 30’s. This decline escalates when you enter perimenopause – usually three to five years prior to menopause. The levels of estrogen and progesterone drop so low you stop menstruating. You know you have passed menopause when you have not had a period for 12 months.
When Can I Expect to Enter Menopause?
The average age of women entering menopause is 51, although the normal age range is from 45 to 55. Often women begin and end their menstrual life about the same age as their mother or sisters did.
What Can I Expect with Menopause?
The diminishing amount of estrogen produced by your ovaries produces changes in your body. These changes occur slowly over time and are different for everyone. Some women notice very little change while other women find it difficult to cope with the dramatic symptoms caused by these changes.
Some symptoms include:
- Hot Flashes – Hot flashes are the most common symptom of menopause. As many as 75% of women experience hot flashes. A hot flash is a sudden rush of heat that spreads over the upper body and face. Some women experience a simple warming; others have acute flashes with perspiration.Hot flashes can occur any time of the day or night. They usually last from thirty seconds to several minutes. Some women have hot flashes for a few months; other women may experience them for several years. Some women do not have hot flashes at all.
- Sleep Difficulties – Many women complain of problems with sleep as they enter menopause. Some women find it difficult to get to sleep or to stay asleep. Sometimes hot flashes cause women to wake from a deep sleep.
- Vaginal and Urinary Tract Changes – Some women experience vaginal problems during the perimenopause, while others don’t have symptoms until they are well past menopause. The loss of estrogen causes changes in the walls of the vagina. The vaginal lining becomes thinner, drier, and less elastic as you age. You may have burning or itching. Some women have bleeding or burning with intercourse.The bladder and urethra can lose muscle tone with lower levels of estrogen. This can lead to a loss of bladder control. You may notice leakage when you sneeze, cough, laugh, or exercise.
- Bone and Body Changes – Lower estrogen levels due to menopause can result in osteoporosis. Your bones lose density and become fragile. Older women are more likely to break bones. The hip, wrist, and spine are the bones most likely to break.The increased risk of heart disease after menopause is thought to be related to decreased estrogen levels.
- Emotional Changes – Mood swings can occur with the changes associated with menopause. Contrary to prior belief, studies show there is no increase in serious psychiatric disorders in women entering menopause. The emotional change felt by most women can be accentuated by sleep disturbances and hot flushes. Normal stress is more difficult to cope with while experiencing menopausal symptoms.
How Will Menopause affect My Sexuality?
Many women find sex to be more rewarding after menopause. They no longer have to worry about birth control and may now have more time to spend with their partners. However, some women find that changes caused by menopause do impact their sexuality. They may have vaginal dryness or may lose interest in sex. Hormone Replacement Therapy and vaginal lubricants can help return moisture and elasticity to the vagina and make intercourse more comfortable. There are many vaginal lubricants or moisturizers that can be bought over the counter. If you have been having sexual intercourse on a regular basis, you may not notice vaginal changes with menopause. Regular sex may help the vagina retain its natural elasticity.
A decrease in libido, or sexual drive, can occur with menopause. Lower hormone levels may decrease your sex drive or may affect your ability to have orgasm. Hormone replacement therapy can help some of these changes. Trying different positions and engaging in longer foreplay may also help. Be sure to talk to your doctor about your concerns.
How Do Diet and Exercise Affect Menopause?
Eating a balanced diet will help you stay healthy before, during, and after menopause. It is important to eat a variety of foods to make sure you get all the essential nutrients. As you enter menopause, you should pay close attention to the amount of calcium you are receiving in your diet. The calcium is important to help build strong bones. Women over the age of 50 should be getting 1,000 mg of calcium each day if they are on hormone replacement therapy, 1,500 mg each day if they are not.
Exercise is very important as you get older. Regular exercise slows bone loss and improves your overall health. Walking and aerobics are good weight-bearing exercises.
Monthly Breast Exam
When Should I Examine My Breasts?
If you have periods, you should do the exam seven days after your period begins. Your breasts are least likely to be tender and swollen at this time. If you no longer have periods, choose a day each month for the exam, such as the first of the month.
How Do I Examine My Breasts?
You may examine your breasts in one of three ways.
In Front of a Mirror
Inspect both breasts with your arms at your sides. Next, raise your arms over your head. Look for any changes in the shape of each breast swelling, puckering, dimpling, or scaling of the skin. Gently squeeze your nipple and look for a discharge. Report any discharge to your doctor. Next, put your hands on your hips and press firmly to flex your chest muscles. The left and right breasts will not exactly match this is normal. Any change in contour should be reported to your physician.
In the Shower
As you shower or bathe press the sensitive pads of your fingers flat against the outer part of the breast. Gently move over every part of each breast. Start at the nipple and go around in a circular motion, enlarging the circle each time you reach the point where you began. Completely examine the breast and chest area from your collarbone to the base of a properly-fitting bra, and from your breastbone to your underarm.
Repeat this the breast exam while lying flat on your back. Place your left arm over your head and a pillow or folded towel under your left shoulder. This position flattens the breast and makes it easier to examine. Repeat on the other side.
Birth Control Options
Choosing a birth control, or contraceptive method, is a very personal decision. You and your partner should review the several birth control options available and decide the best method for you. Many people change their birth control method several times throughout their reproductive years. There are a few considerations to keep in mind when choosing a contraceptive method.
- How effective is the method?
- How likely you are to use it? Will you use it if you have to put it in place every time? Can you remember to take a pill every day?
- How safe is the method?
- Is it affordable?
- Is the method permanent or can it be reversed?
Most contraceptive methods require an ongoing, consistent commitment. Make sure you understand the method you have chosen.
Click on any of the links below to learn more about the various birth control options available to you.
Birth Control Pills
What are the Side Effects of Birth Control Pills?
There are some minor side effects associated with the birth control pill. These include:
- breakthrough bleeding (bleeding between periods)
- breast tenderness
Many of these side effects decrease during the first three months of usage.
What are the Advantages of Birth Control Pills?
There are some advantages to the birth control pill over other methods of contraception. It does not interrupt sexual activity and allows for spontaneity. It offers protection against ovarian, endometrial, and colo-rectal cancers. The pill decreases menstrual bleeding and cramping. The pill decreases the risk of pelvic inflammatory disease, (PID.) The pill can shrink some benign ovarian cysts and can decrease reoccurrence. It is an easily reversible birth control method. Just stop taking them.
What are the Disadvantages of Birth Control Pills?
There are some disadvantages to taking the birth control pill. If offers no protection against sexually transmitted diseases (STD’s.) It can be expensive. The pill must be taken consistently every day. It can cause mood changes. It can cause rare, but dangerous complications.
Who Should Not Take Birth Control Pills?
Not all women are good candidates for the birth control pill. You should not take the pill if you are over 35 and smoke. You should not take the pill if you begin getting migraine headaches after starting the birth control pill. Women who have a history of blood clots or stroke, have heart disease, or high blood pressure, have had breast cancer, have liver problems, have kidney problems or have active gallbladder disease should not take the pill.
The diaphragm is a flexible rubber cup-shaped device you fill with contraceptive jelly and insert into the vagina up to six hours before any act of sexual intercourse. The diaphragm, when properly inserted, covers the cervix (the opening of the uterus). The diaphragm itself acts as a physical barrier against sperm, while the contraceptive jelly kills any sperm that happens to get past the device. It must be left in place for six hours after intercourse.
How Effective is a Diaphragm?
The effectiveness of the diaphragm is 84-94% when used with spermicide. Using condoms along with the diaphragm increases the effectiveness to almost 99%.
What are the Advantages and Disadvantages of a Diaphragm?
You must be comfortable touching your body though, to insert the diaphragm. There is also an increased risk of urinary tract infections with diaphragm use. Once the diaphragm is inserted, more contraceptive jelly or cream must be inserted into the vagina with each additional act of intercourse.
The diaphragm must be fitted by your doctor. The size should be rechecked after the birth of each baby, and if you have a significant weight loss or gain.
In order to reverse this method, simply stop inserting the diaphragm.
A condom is a thin shield placed directly over the man’s erect penis. It catches the sperm released during ejaculation, thereby preventing the sperm from entering the woman’s vagina. Most condoms are made from rubber (latex), but some are made from animal tissue. They may be lubricated or treated with a spermicide.
What are the Advantages of Using a Condom?
The condom is convenient, inexpensive, and easy to obtain. They can be purchased without a prescription. Latex condoms, especially those treated with a spermicide, can protect both partners from sexually transmitted diseases; therefore they are good choice if either partner is not monogamous.. They can also increase the effectiveness of other forms of birth control.
What are the Disadvantages of Using a Condom?
The disadvantages of condom use are a reduction in sexual spontaneity and sensation, along with the possibility of the condom breaking or leaking.
The female condom is a lubricated, plastic sheath with rings on each end. One end is open and remains outside the vagina. The other end is closed and looks like a diaphragm. It is placed inside the vagina so that it covers the cervix, preventing sperm from entering the uterus and fertilizing an egg.
What are the Advantages and Disadvantages of a Female Condom?
The female condom offers protection against sexually transmitted diseases, but it is cumbersome to use, more visible, and less comfortable than a male condom. It is not available in all areas of the country.
Sterilization involves blocking or cutting the woman’s fallopian tubes so no eggs can travel to the uterus to be fertilized. It is generally an outpatient procedure and normal activities can be resumed within a few days. Sterilization, a permanent form of birth control, is 99.6% effective. Voluntary sterilization is the most popular birth control method worldwide.
What are the Advantages and Disadvantages of Sterilization?
Many couples choose sterilization because they will no longer have to think about birth control.
The risks with sterilization are the same as with any type of surgery. On rare occasions women may have complications from anesthesia, internal bleeding, injury to the surrounding internal structures, or infection.
Intrauterine Device (IUD)
An IUD is a small, T-shaped piece of plastic that is inserted into the uterus by your doctor. The effectiveness is about 99%. Once the IUD is inserted, protection lasts for: Skyla – 3 years, Mirena – 5 years, Paragard – 10 years.
What are the Side Effects of an IUD?
The most common side effect of the IUD is heavier bleeding* and cramping with your period. There are serious complications that can arise from using the IUD. These include: infection, tubal pregnancy (pregnancy located in the fallopian tube), and perforation of the uterine wall. *Not common with Skyla or Mirena
What are the Advantages of an IUD?
IUDs are probably one of the easiest contraceptive methods to use. You do not have to think about it every day. Once the IUD is in place, you only need to check the string at least once a month. In order to reverse the method, have the IUD removed by your physician.
Who Should Not Use an IUD?
Not everyone is a candidate for the IUD. If you and your partner are not monogamous, the IUD is probably not for you. You should not use the IUD if you are having a problem with unexplained, abnormal uterine bleeding, have a history of endocarditis, have severe menstrual cramps or heavy periods, have problems with blood clotting, are allergic to copper*, or are anemic. *Copper allergy possible with Paragard
An arm implant that gives you the option of up to 3 years of continuous pregnancy prevention.
What are the Side Effects of an Nexplanon?
The most common side effect of Nexplanon is a change in your normal menstrual bleeding pattern. Other frequent side effects that cause women to stop using the implant?include:
- Mood Swings
- Weight Gain
- Depression Mood
What are the Advantages of Nexplanon?
Once inserted, NEXPLANON is over 99% effective, just like the pill. But there’s a difference with NEXPLANON, you don’t have to remember to take it every day.
Who Should Not Use Nexplanon?
You should not use NEXPLANON if you are pregnant or think you may be pregnant; have or have had blood clots; have liver disease or a liver tumor; have unexplained vaginal bleeding; have breast cancer or any other cancer that is sensitive to progestin (a female hormone), now or in the past; and are allergic to anything in NEXPLANON.
Spermicides are over the counter contracptions which come as a cream, jelly, foam or suppository. The spermicide kills sperm, preventing the fertilization of an egg.
How Effective are Spermicides?
Alone, spermicides are only 79% effective. When used with condoms, the effectiveness increases to 99%.
What are the Advantages and Disadvantages of Spermicides?
Spermicides are convenient, portable and relatively inexpensive to use. It is necessary to insert the spermicide an hour or less before intercourse, and it must be reapplied with each additional act of intercourse.
A Depo-Provera injection is a shot which contains progestin, a hormone which suppresses ovulation. Injections are given every 90 days, four injections a year. They are 99% effective for birth control.
What are the Side Effects of Depo-Provera?
The side effects of Depo-Provera include bleeding irregularities, weight gain, headaches, decreased sex drive and a delay in the return of fertility. Some women stop having periods after a few months.
What are the Advantages and Disadvantages of Depo-Provera?
Many women prefer the injections because they only have to think about birth control four times a year. Women with menstrual cramps or heavy bleeding enjoy the amenorrhea-absence of periods- that accompanies the injections.
Depo-Provera injections do not offer protection against sexually transmitted diseases.
Natural Family Planning
Natural family planning is based on fertilization occurring just before, during, and after ovulation. By monitoring yourself daily, you may be able to determine when you are ovulating. In practice, the effectiveness of natural family planning is only 30-70%.
What are the Advantages and Disadvantages of Natural Family Planning?
Natural family planning is inexpensive and has no health risks involved. It is more effective for women with regular menstrual cycles who keep good daily records and are dedicated to the method.
Natural family planning is only 30-70% effective, therefore it is not the most reliable form of birth control.
Our experienced physicians offer a wide range of care using state of the art diagnostic and treatment techniques for many conditions.