Internal Medicine Blog

What is the difference between ThermiVa and O-Shot?

By: Allison Andrews, WHNP

What is the ThermiVa®?

ThermiVa® is a non-surgical, safe and effective procedure that uses radiofrequency heat to tighten loose, sagging skin and increase blood flow and nerve sensitivity in the vaginal area. 

What are the benefits of the ThermiVa®?

Ø  Vaginal and labial laxity 

Ø  Vaginal dryness

Ø  Urinary incontinence and overactive bladder

Ø  Painful sex 

How is it performed?
During the procedure, a small wand is slowly moved over the areas of concern, gradually heating the tissue.  The procedure takes less than an hour, during which most women report feeling only a warm sensation and no pain.  There is no down time once completed, women can return to exercise and sexual activity immediately. 

What is the O-Shot®?
The O-Shot® is a non-surgical, minimally invasive procedure that can help improve a woman’s sexual desire and orgasm, decrease urinary incontinence and treat a chronic skin condition called lichen sclerosus.   Up to half of women experience low sexual desire and many others experience issues with arousal, lubrication and orgasm.  The O-Shot® uses platelet-rich plasma (PRP) that contains growth factors from the woman’s own blood, and is injected into the clitoris and vaginal wall.  This increases the blood flow, nerve sensitivity and collagen formation in the area, leading to improved sexual function.

What are the benefits of the O-Shot®?
This injection can increase a woman’s sexual desire and arousal, as well as improve the number or quality of her orgasms.  In addition, this procedure can help with

Ø  Leaking urine

Ø  Painful sex

Ø  Vaginal dryness

Ø  Decrease symptoms and long-term consequences of lichen sclerosus

How is it performed?

Blood is drawn from the patient and then using a special double-spin process the red blood cells are removed, leaving the plasma which is full of growth factors.  Numbing cream is then placed onto the areas that will be injected, and a lidocaine injection is performed to ensure there is minimal to no discomfort during the procedure.  The PRP is then injected into the clitoris and vaginal wall.  The procedure takes less than an hour.  

If you would like to learn more about these procedures, schedule a consultation with one of our Women’s Health providers.

PTSD Awareness Month: Treatment with Medical Marijuana

By: Bruce Saltzman M.D.

June is post-traumatic stress disorder (PTSD) awareness month.

PTSD is a severe, potentially chronic and disabling disorder that develops in some persons following exposure to a traumatic event involving actual or threatened death, serious injury, or sexual assault. Some common symptoms include intrusive thoughts, nightmares and flashbacks of traumatic events, avoidance of trauma reminders, hypervigilance, and sleep disturbance. These symptoms can be highly distressing and substantially impair social, occupational, and interpersonal functioning. The intensely distressing and impairing symptoms of traumatic stress are highly prevalent immediately following traumatic exposure and dissipate over the following days and weeks in most people. Persistence beyond one-month post-trauma suggests PTSD [1].

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition stipulates that for an individual to be diagnosed with posttraumatic stress disorder, he or she must have experienced or witnessed a life-threatening event and reacted with intense fear, helplessness, or horror. The traumatic event is persistently reexperienced (e.g., distressing recollections), there is persistent avoidance of stimuli associated with the trauma, and the victim experiences some form of hyperarousal (e.g., exaggerated startle response). These symptoms persist for more than one month and cause clinically significant impairment in daily functioning. When the disturbance lasts a minimum of two days and as long as four weeks from the traumatic event, Acute Stress Disorder may be a more accurate diagnosis.

The prevalence of PTSD in the U.S. population is approximately 8%, with incidence as high as 17% in primary care patients. PTSD can become chronic in as many as 40% of cases [2]. 50% of women in the United States have experienced a traumatic event, with the majority reporting trauma exposure also reporting two or more traumatic events. The National Comorbidity Survey Replication estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%. Current past year PTSD prevalence was estimated at 3.5%. The lifetime prevalence of PTSD among men was 3.6% and among women was 9.7%. The twelve-month prevalence was 1.8% among men and 5.2% among women. However, PTSD only develops in 10% of those exposed to trauma, a finding that has prompted intense research efforts in identifying risk factors and early intervention to prevent or reduce the development of PTSD [2]. Populations at risk for PTSD include refugee victims of torture, combat veterans, persons released from incarceration, victims of sexual assault, and adults who endured repeated sexual or physical abuse as children">[4].

Explanatory models of PTSD have been proposed to better understand psychotraumatization processes and PTSD. Explanatory models of PTSD have been proposed to better understand psychotraumatization processes and PTSD. [5] These perspective models include:        

1.     Disease/Illness Perspective [6-11]-

2.     Dimensional Perspective

3.     Cognitive-Axiologic Perspective [12,13][6]

4.     Behavioral Perspective [6]

5.     Spiritual/Transcendental Perspective [14]

6.     The Narrative Perspective [15]

PTSD is viewed as a maladaptive response to a traumatic stressor, characterized by altered fear-related learning (fear conditioning) and extinction, behavioral sensitization and kindling, and alterations in brain regions and neurotransmitter systems closely linked to these processes. The hypothalamic-pituitary-adrenal (HPA) axis is the primary system activated as a stress response and a potential source of vulnerability to trauma-related psychopathology such as PTSD. Normal response to stress exposure initiates a neuroendocrine cascade in the HPA axis, leading to adrenal gland hypersecretion of the glucocorticoid cortisol. HPA axis activity is tightly controlled through complex regulatory mechanisms of glucocorticoid negative feedback. Glucocorticoids regulate the secretion of hypothalamic corticotropin-releasing factor (CRF) and pituitary adrenocorticotropic hormone. HPA axis activity is also regulated by glucocorticoid receptors (GRs) in the hippocampus and prefrontal cortex [[16,17] HPA stress response pathways are intimately linked with neurotransmitter systems and key brain regions in PTSD. The neural circuitry that mediates fear memory involves complex interactions among three brain centers: the hippocampus, involved in short-term memory and contextual fear; the amygdala, involved in conditioned fear response; and the medial prefrontal cortex, which mediates suppression of subcortical (e.g., amygdala, hippocampus) responses. Several neurotransmitter systems serve as chemical messengers in this neurocircuit. Alterations in these transmitter systems reflect a dysregulated stress response and substantially impact conditioned fear response and the consolidation and retrieval of traumatic memories [18,19].

Treatment of PTSD is aimed at interfering with this persistence of traumatic memories. The treatments of PTSD are varied and diverse including:

1              Psychosocial

2              Rehabilitation

3              Somatic and Alternative Therapy

4              Pharmacotherapy

In 2002 Marsicano found that the CB1 receptors in the amygdala are required for the extinction of fear memories [20]. A further study by Hillard in 2015 showed that following chronic stress signaling in the endocannabinoid system (ECS) is downregulated [21]. This downregulation impaired reversal learning (the ability to be trained differently to two stimuli based on reward or punishment response) in mice and as anticipated induced perservatory behaviors.  The study also found that the effects of chronic stress were reversed when an exogenous CB1 agonist was applied.  Hill found Reductions in circulating endocannabinoid levels in individuals with post-traumatic stress disorder following exposure to the World Trade Center attacks [22]. These studies showed that there may be a scientific rational behind the use of marijuana by veterans to reduce PTSD. Medical marijuana has been shown to be an effective adjuvant in the treatment of PTSD. It may even be possible to treat PTSD without the side effects caused by THC.

If you think that you might have PTSD or would like to discuss the possibility of Cannabinoid therapy, please speak with me or your primary care physician.

1.       American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association Press; 2013.Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey.Arch Gen Psychiatry. 1995;52(12):1048-1060.

2.       National Center for PTSD. How Common is PTSD? Available at Last accessed February 16, 2018.

3.       Phoenix Australian Centre for Posttraumatic Mental Health. Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder. Available at Last accessed February 16, 2018.

4.       Jakovljević M, Brajković L, Jakšić N, Lončar M, Aukst-Margetić B, Lasić D. Posttraumatic stress disorders (PTSD) from different perspectives: a transdisciplinary integrative approach. Psychiatria Danub. 2012;24(3):246-255.21. McHugh PR, Slavney PR. The Perspectives of Psychiatry. 2nd ed. Baltimore, MD: John Hopkins University Press; 1998.

5.       22. Tyrer P, Steinberg D. Models for Mental Disorders: Conceptual Models in Psychiatry. 3rd ed. Chichester: John Wiley & Sons; 1998.

6.       23. Summerfield D. Cross-cultural perspective on the medicalization of human suffering. In: Rosen GM (ed). Posttraumatic Stress Disorder: Issues and Controversies. Chichester: John Wiley & Sons; 2005: 233-245.

7.       24. Frueh BC, Elhai JD, Kaloupek DG. Unresolved issues in the assessment of trauma exposure and posttraumatic reactions. In: Rosen GM (ed). Posttraumatic Stress Disorder: Issues and Controversies. Chichester: John Wiley & Sons; 2005: 63-84.

8.       25. Herbert JD, Sageman M. First do no harm: emerging guidelines for the treatment of posttraumatic reactions. In: Rosen GM (ed). Posttraumatic Stress Disorder: Issues and Controversies. Chichester: John Wiley & Sons; 2005: 213-232.

9.       26. Friedman MJ. PTSD and related disorders. In: Stein D, Friedman M, Blanco C (eds). Post-Traumatic Stress Disorder. 1st ed. Chichester: John Wiley & Sons; 2011.

10.   27. McNally RJ, Frueh BC. Why we should worry about malingering in the VA system: comment on Jackson et al. (2011). J Trauma Stress. 2012;25(4):454-456.

11.   28. McNally RJ. Conceptual problems with the DSM-IV criteria for posttraumatic stress disorder. In: Rosen GM (ed). Posttraumatic Stress Disorder: Issues and Controversies. Chichester: John Wiley & Sons; 2005.

12.   29. Reivich KJ, Seligman MEP, McBride S. Master resilience training in the U.S. Army. Am Psychol. 2011;66(1):25-34.

13.   30. Maguen S, Litz B. Moral injury in veterans of war. PTSD Res Q. 2012;23(1):1-6.

14.   31. Amendolia RA. A Narrative Constructivist Perspective of Treatment of PTSD with Ericksonian Hypnosis and EMDR. Available at Last accessed February 16, 2018.

15.   Morris MC, Compas BE, Garber J. Relations among posttraumatic stress disorder, comorbid major depression, and HPA function: a systematic review and meta-analysis. Clin Psychol Rev. 2012;32(4):301-315.

16.   George SA, Stout SA, Tan M, Knox D, Liberzon I. Early handling attenuates enhancement of glucocorticoid receptors in the prefrontal cortex in an animal model of post-traumatic stress disorder. Biol Mood Anxiety Disord. 2013;3(1):22.

17.   Ressler KJ, Mayberg HS. Targeting abnormal neural circuits in mood and anxiety disorders: from the laboratory to the clinic.Nat Neurosci. 2007;10(9):1116-1124.

18.   Rauch SL, Shin LM, Phelps EA. Neurocircuitry models of posttraumatic stress disorder and extinction: human neuroimaging research—past, present, and future. Biol Psychiatry. 2006;60:376-382.

19.  Neumeister A, Corsi-Travali S, Green CR. The role of BDNF-TrkB signaling in the pathogenesis of PTSD. J Depress Anxiety. 2013;S4:006

20.  G Marsicano, CT Wotjak, SC Azad, T Bisogno. The endogenous cannabinoid system controls extinction of aversive memories. -Nature volume 418, pages 530534

21.  Maria Morena, Sachin Patel, Jaideep S Bains & Matthew N Hill. Neurobiological Interactions Between Stress and the Endocannabinoid System. Neuropsychopharmacology volume41, pages80–102 (2016)

22.  Hill MN1, Bierer LM, Makotkine I, Golier JA, Galea S, McEwen BS, Hillard CJ, Yehuda R. Reductions in circulating endocannabinoid levels in individuals with post-traumatic stress disorder following exposure to the World Trade Center attacks. Psychoneuroendocrinology. 2013 Dec;38(12):2952-61

23.  George Fraser, M.D., F.R.C.P.C., The Use of a Synthetic Cannabinoid in the Management of TreatmentResistant Nightmares in Posttraumatic Stress Disorder (PTSD). CNS Neuroscience and Therapeutics. 2009 February 13; Volume15, Issue1 Pages 84-88

5 Ways to Spring Clean Your Health

By: Lauren O’Brien, MD

The sun is shining, the birds are chirping and spring has (finally!) arrived. This is the season of renewal, so what better time to clean up and refresh your health. Here are 5 easy ways to get started today!

1)      Get outside!

These warmer temperatures are just calling for a walk at lunchtime, a run down the Schuylkill River Trail, or a picnic in Rittenhouse Square. Though being active is important, just getting out into the fresh air can lead to greater happiness. Maybe give gardening a try. Even small city balconies can grow veggies in pots and containers and people who garden have reduced stress, get increased amounts of vitamin D and can have improved mental clarity. Plus, they tend to eat more fruits and veggies, which leads us to our next tip.

2)      Clean up your diet

With fresh fruits and veggies more readily available this time of year, it is a great time to embrace “clean eating”. This means incorporating fresh, real, whole foods into the diet and limiting overly processed foods with long, indecipherable ingredient lists. Ways to achieve clean eating include: increasing your intake of fresh fruits and veggies, eating the least processed grains (such as quinoa, wild rice, steel cut oats), avoiding added/refined sugar and going light on meat products. Choosing grass-fed/pasture raised options when you do eat meat is overall better for your health and the health of the environment.

3)      Clean out your medicine cabinet

You likely have medicines stored from old prescriptions that might be handy “someday”. This is a good time to get to work clearing out all of those medications that have outlived their use. Be sure to check expiration dates. Many meds lose efficacy after this date and some can become toxic. A good rule of thumb is to toss any prescription medicine that is over a year old. For safety and environmental reasons, it is best not to toss medications directly into the trash or down the toilet. Your local pharmacy, police station or DEA may provide opportunities to safely dispose of medications. If not readily available, you can place meds in a sealable bag (add water if pills or solid medications are present to dissolve them fully). Then add kitty litter, coffee grounds or saw dust to the bag. This makes the package less appealing to children and animals. Finally seal the bag and place in the trash. Be sure to remove all labels of medication bottles that are thrown away.

4)      Clean out your makeup bag

I know you might be very attached to that perfect shade of lipstick you have had for years, but old makeup can carry bacteria that can lead to infection. Here are some guidelines on when to toss those products: eyeshadow:3-6 months, Blush/bronzer: up to 2 years, Lipstick: up to 1 year, Mascara: 3 months. Be sure to also clean your brushes and make up bag regularly.

5)      Finally, if you have not done so already, make an appointment for your annual physical. At this appointment we can guide you with recommendations on diet and exercise and be sure you are up to date on all of your recommended screenings.

Happy spring, everyone!


By: Dana Shanis M.D.

Intrauterine devices (IUDs) have become an increasingly popular form of contraception in the US due to their convenience and effectiveness. However, the cost of these devices has been a barrier to some women. The Liletta is the first IUD created by a non-profit organization to provide a more affordable option that still has all the benefits of the more costly IUDs.

At Rittenhouse Women’s, we have decided to offer this IUD not only for the benefit to our patients, but also to the community. Liletta provides devices to the local health centers at almost no cost to help protect underprivileged and at-risk women from unintended pregnancy. We believe that better access to this device can improve lives and should be an option for all women.

Why choose the Liletta?

The Liletta is more than 99% effective at preventing pregnancy and can decrease the amount of bleeding and cramping you have with your periods. It is placed in the office in only a few minutes and can be removed at any time. Once removed, your ability to get pregnant returns right away. There is a low risk of complications during placement or significant side effects from the device. While newer than most other IUDS, Liletta has been evaluated in the largest IUD trial that has ever been conducted in the US. This study showed Liletta was also safe and effective for women who have never been pregnant before.

How does it work?

Liletta releases a small amount of progestin hormone in the uterus. This small amount of hormone thickens the mucus inside the cervix, which creates a barrier that sperm cannot penetrate. The progestin also may thin the uterine lining and slow movement of sperm through the fallopian tubes. Very little hormone gets into the blood stream, so most women continue to ovulate.

How long does it last?

Currently, Liletta is approved for 4 years of use, but can be removed any time sooner if desired. The device is currently being studied for longer use, and likely will get the 5 year approval in the near future. Ongoing studies are being performed and the device may be approved for up to 7 years in the future.  

What are the risks and side effects?

The most common risk is expulsion, or the IUD falling out on its own and the Liletta has similar rates to other IUDs for this issue. Also similarly to other IUDs, there is a small risk of uterine perforation (making a hole in the uterus) during insertion. This risk is extremely low and is unlikely to cause long-term damage if it occurs.   If you have an STI, such as gonorrhea or Chlamydia, during placement, there may be an increased risk of the infection going into the pelvis. However, once the IUD has been in for more than a month, it is likely the risk of pelvic inflammatory disease may actually decrease.

Most women will experience some spotting after placement, which can last up to 6 months or occasionally longer for some women. Some women will no longer have periods, which is a desired effect for some. Hormonal side effects are uncommon, but can occur.

There are many forms of contraception, including several options for long-acting reversible contraception we offer, so there is a good chance there will be an option that will work for you. It is important to discuss your medical history, periods, and experience with other forms of contraception in the past with your provider to find the right fit.

Scheduling Preventive Versus "Problem" Appointments

By: Monica Duvall, M.D.

At Rittenhouse Internal Medicine, we recognize that the health care and medical insurance industries can be confusing to navigate for many of our patients.  Our goal is to make the process of seeing a provider as smooth and as simple as possible.  Part of that process is ensuring that you, our patients, are aware of the different appointment types that we offer so that the proper appointment is scheduled to fit your needs at a given time.  We also recommend reviewing your insurance policy, so that you can be aware of how/if the different appointment types are covered ahead of time to avoid surprises (and large bills!).

"Annual Physicals", also called "Routine Medical Exams", "Health Maintenance Exams" or "General Checkups", are preventive health exams that are typically covered by an insurance provider no more than once a year.  The purpose of the annual physical is to is to review a patient's health history, family history, and social habits, to make sure she is caught up on routine vaccinations and recommended age-appropriate health screenings such as colon cancer screening, cholesterol testing, mammograms, etc.   It is also an opportunity for the provider to make specific recommendations that would reduce a patient's risk of poor health outcomes down the road--such as advising an increase in certain types of exercise, or cutting back on the amount of alcohol a patient is drinking.   The goal of this appointment type is to prevent disease by identifying factors in a patient's history/lifestyle that could put their health in jeopardy if not addressed and modified. 

The "Annual Gynecological Exam", also called a "GYN Exam" or "Women's Health Exam", is another type of preventive visit.  This type of appointment is also typically covered by insurance providers no more than once annually.  It differs from the Annual Physical in its more narrow focus; the exam exclusively focuses on preventing adverse gynecological health outcomes.   Items addressed in an annual gyn exam may include cervical cancer screening (the Pap smear), breast cancer screening, birth control/family planning, or preventing/screening for low bone mass.  

All visits that do not fit into the above categories are classified as "Problem" visits.  Most insurance companies do not put a limit on the number of problem visits that can be scheduled in a calendar year; but they typically will require you to pay a copay for each of these visits (even if the problems are addressed during a preventive visit--which we discourage, due to time constraints).   Problem visits (which may be referred to as "Follow up visits", "Sick visits" or "Annual medication checks", depending on the reason for the appointment) are made to address one or more specific health issues or symptoms.   Problem visits are not preventive health exams, and they are scheduled separately from preventive visits to allow adequate time for evaluation and management of the symptoms prompting the appointment.   These may be new, acute symptoms--such as a sore throat, a new rash, or a vaginal discharge--or chronic issues, such as high blood pressure, depression, or managing thyroid medication.   Additional testing or medication may be advised; these may or may not be covered by your insurance company (again, reviewing/knowing the details of your insurance plan coverage ahead of time is advised, as we are not privy to these details).  

Hopefully this is a helpful guide to scheduling your next appointment with us; our call center staff is always available to help you schedule the correct appointment type if you have any questions or need further clarification.

March is Patient Safety Month!

By: Maria Daly, Practice Manager

As March is patient safety month we wanted to share a few ways we work to ensure patient safety in our practice!
Although we are just a little internal medicine office and not a huge hospital, there are still plenty of steps we take to try and keep our patients safe.

  1)      Employee Training: All of our employees receive various trainings on an annual basis. We provide our staff with training on HIPAA so that they become highly familiar with how to treat private health information. We also host a CPR training for our staff so that we always have employees who are able to provide emergency care. On an as needed basis, our MAs also receive refresher courses on best practice for venipuncture and any other procedures.

  2)      Processes: As a medical practice we have a few processes in place to ensure patient safety. All of our MA stations have label machines connected to our EMRs that allow our medical assistants to print legible labels for any laboratory samples collected at our practice. This is the best way to reduce any possibility of mislabeled specimens and potentially giving patients incorrect lab results. We also have specific sterilization processes for our different instruments – weather they need to be packaged or cleaned at a different temperature – these processes ensure that instruments we use in the office are not a source of infection for our patients.

  3)      Equipment: You may have noticed that we have gloves available in all of our exam rooms – gloves are an important barrier to keep our patients safe as well as keep our staff safe! We also have hand sanitizer available all over the building which is our go-to, especially during flu season!

  4)      Building Safety: There are a few safety measures we have taken to make our facility safer for patients also. Our entryway steps now have treads which makes them much easier to walk on in wet weather; the same goes for our carpeted staircase. During snowstorms, our staff regularly shovels and salts the sidewalk in front of our building and we try to mop our waiting room regularly also to get up any water that had been trekked in so that there are no slips in our waiting room.

Although a lot of these items may seem obvious, they all go a long way in ensuring the safety and well-being of our patients. We review these processes regularly and consider employee and patient input to find any problems or improvements that can be made. Please know that we are always doing our best not only to treat you but also to keep you safe physically and psychologically whenever you visit our practice. Thank you for being our patient and have a safe and happy March!


By: Dana Shanis, MD

ThermiVa® is a non-surgical, safe and effective procedure that uses radiofrequency heat to tighten loose, sagging skin and increase blood flow and nerve sensitivity in the vaginal area.  This procedure is used to treat many common vaginal complaints, including:

1·  Vaginal and labial laxity

Stretching of the vaginal tissues and muscles is common after childbirth and can occur with normal aging.  This can cause decreased sexual satisfaction, discomfort with exercise and bothersome urinary symptoms.   The labia (external lips around vagina) also experience sagging over time, which can cause rubbing and irritation and cause many women to feel self-conscious.  ThermiVa® can be used both internally and externally for these concerns.  The heat applied during the procedure causes the tissues to contract and increases the amount of collagen in the area.

2·  Vaginal dryness

Many medications, as well as the normal aging process can cause vaginal dryness for many women. This dryness often becomes severe after menopause or cancer treatments, causing daily discomfort and making sex painful.  Without exposure to hormones, the ThermiVa® procedure increases blood flow in the area which increases vaginal moisture and lubrication during sexual activity.

3·  Urinary incontinence and overactive bladder

Urinary complaints are common in women of all ages, most commonly incontinence (leaking urine) and overactive bladder.  The radiofrequency applied to the vaginal tissues during the ThermiVa procedure can help tighten the tissue under the urethra, which decreases the rate of leaking with cough, sneeze or exercise.  The procedure also increases nerve growth around the bladder, which can decrease bladder irritation that causes the urgency experienced in overactive bladder.

4·  Painful sex

ThermiVa® helps reduce muscle spasms in the pelvic floor that are commonly a cause of pain with sex.  Many women also report an improvement in their desire, arousal and ability to orgasm after the treatment.  Due to the small probe size, most women report little to no discomfort during the procedure even if they are unable to tolerate penetration during sex due to pain.

How is it performed?

During the procedure, a small wand is slowly moved over the areas of concern, gradually heating the tissue.  The procedure takes less than an hour, during which most women report feeling only a warm sensation and no pain.  There is no down time once completed, women can return to exercise and sexual activity immediately.  A total of three treatments, scheduled a month apart, are recommended for optimal results.

When will I see results?

While each woman’s experience may differ, many women notice a difference within hours to days after their first treatment.  For some women it takes longer or multiple treatments.  The effects of the treatments continue to improve for several weeks and lasts up to one year on average.  A touchup session is often needed after a year to maintain the effect.

Is it safe?

Over 50,000 procedures have been performed with this technology worldwide, and no burns or significant adverse outcomes have been reported.

If you are dealing with any of these issues, you do not have to live with the discomfort any longer. Schedule a consultation with one of our Women’s Health providers to review your concerns, discuss alternative treatment options and determine if you may benefit from this procedure.  

January is National Blood Donor Month

By: Monica Duvall, MD

The start of the new year heralds the American Red Cross's annual effort to raise awareness of the critical need for blood and blood products through the winter months. Blood donations typically go down during this period, due to illness of potential donors, cancellations of blood drives due to inclement weather, and other reasons.   It is estimated that 38% of the US population is eligible to donate blood, but less than 10% of that eligible population donates, according to the Red Cross.  National Blood Donor Awareness month aims to remind the public that the need for blood is real, and to motivate first-time and previous donors to give blood or support blood donation efforts in other ways.

Over 20 million blood products are transfused in the US annually; 40% of these products come from volunteer donors to the American Red Cross.   Every 2 seconds, someone in the US needs blood, and an average transfusion requires 3 pints of blood.  A victim of a car accident may need as many as 100 pints of blood!  A typical blood donation takes about a pint of blood out of the approximately 10 pints in the average adult body--plenty for a healthy adult to spare.  Each donation can help multiple people, as components of whole blood can be separated out for different uses.  Red blood cells carry oxygen to tissues in the body, and are used in trauma, surgery, and in the treatment of severe blood loss.  Platelets are cell fragments that help with clotting--these are used in surgeries and cancer treatments.  Plasma is a clear liquid that contains proteins and clotting factors; it is commonly used in burn patients and bleeding disorders.   Although donors of all blood types are needed, certain blood types are usually in shorter supply because their blood products can be used for patients of any blood type (critical in emergency situations, when a patient may need blood before his/her blood type is known); these are Type O negative, the "universal donor" for red blood cells, and type AB positive, the "universal donor" for plasma.  Only 7% and 3% of the US population, respectively, has these blood types.

Giving blood is safe for most healthy adults, and a single donor can give blood multiple times annually.  General eligibility requirements are that donors must be at least 17 years of age, and weigh at least 100 pounds.  Additional eligibility/exclusion criteria can be found on the American Red Cross website.  To donate blood, you can download the ARC blood donor app, visit, or call 1-800-RED-CROSS (733-2767).   If you do not meet current eligibility criteria, you can still support blood donation efforts by spreading the word about Blood Donor Awareness month, by donating to the Red Cross, or by hosting a blood drive through your workplace or community group (such community efforts provide about 80% of Red Cross blood donations!).   Giving blood is giving the gift of life to someone in need--please consider donating this winter.

Is Medical Marijuana right for you?

By: Bruce Saltzman M.D.
Board Certified Anesthesiologist

At Rittenhouse, we believe that medical marijuana may be useful in the treatment of the following conditions and you should be discussing these conditions at your visit:

·         Amyotrophic Lateral Sclerosis
·         Autism
·         Cancer
·         Crohn’s Disease
·         Damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity
·         Epilepsy
·         Glaucoma
·         HIV (Human Immunodeficiency Virus) / AIDS (Acquired Immune Deficiency Syndrome)
·         Huntington’s Disease
·         Inflammatory Bowel Disease
·         Intractable Seizures
·         Multiple Sclerosis
·         Neuropathies
·         Parkinson’s Disease
·         Post-traumatic Stress Disorder
·         Severe chronic or intractable pain of neuropathic origin or severe chronic or intractable pain in which conventional therapeutic intervention and opiate therapy is contraindicated or ineffective
·         Sickle Cell Anemia

The State of Pennsylvania has legalized the use of medical marijuana.  Starting sometime next year, dispensaries will be opening and patients with the following serious medical conditions will be able to get medical marijuana. To purchase medical marijuana, a patient will need to be under the continuing care of a physician who is registered with the Department of Health. The physician may then provide a signed certification to the patient stating that the patient has a serious medical condition. The patient must then apply to the department for an identification card. Once the patient receives an identification card, he or she can purchase medical marijuana at an authorized dispensary.  In the upcoming months we will be discussing many of the below conditions and how medical marijuana may be useful in their treatment, and how to obtain the patient certification from our practice.
Cannabis, also known as marijuana is a psychoactive drug from the Cannabis plant used medically and recreationally.  The main psychoactive chemical of cannabis is tetrahydrocannabinol (THC) (THC); one of 483 known compounds in the plant, including at least 65 other cannabinoids.   Cannabis can be used by smoking, vaporizing, within food, or as an extract.    As early as 2737 B.C., the mystical Emperor Shen Neng of China was prescribing marijuana tea for the treatment of gout, rheumatism, malaria and poor memory.   The criminalization of Marijuana by the Harrison act inhibited medical research on the plant.  The new research on marijuana in the 21st Century has led to the characterization of two receptors for cannabis in humans, CB1 and CB2. These receptors work through a unique feedback  mechanism on G protein–coupled receptors(GPCRs), again too complex for this setting.  GPCRs, which transduce extracellular signals into intracellular effector pathways, include about 900 members and represent the most prominent family of validated pharmacological targets in biomedicine.  Advair and Abilify are among the drugs that work with this receptor.  ~4% of the protein coding genome is devoted to these receptors. 

Dr. Saltzman’s background in Pharmacokinetics and the dynamics of medications has led to him researching the significant benefits of medical marijuana and he has received his certification from the state of Pennsylvania and will be seeing patients at our office for medical marijuana evaluations.

Preconception tips for optimal fertility and a healthy pregnancy

By: Dana Shanis, Gynecologist

Trying to conceive is an exciting time and a little preparation can help improve your experience and the likelihood of a healthy child. Good health before and during pregnancy will ensure the safest environment for your baby to grow. Here are some tips that can help prevent problems that may affect you or your child’s future health:


One of the best things you can do to help your long-term health, including during pregnancy, is to exercise. This decreases inflammation, reduces stress levels, and has been shown to decrease the risk of pregnancy complications, such as gestational diabetes or hypertension. Physical activity does not increase your risk of miscarriage, a low birth weight baby, or early delivery. If you have any medical problems, it is important to discuss with your provider what types of exercise may be suitable for you. 

Balanced diet and vitamins

Eating a well-rounded diet including adequate fruits and vegetables will help prevent a nutrient-deficiency, such as iron or vitamin D, which can cause problems for you in pregnancy. Most women are able to get adequate nutrition in their diet. For women with a modified diet, like gluten-free or vegan, it may be beneficial to supplement other nutrients and should be discussed with your healthcare provider or a nutritionist. In the month prior to attempting pregnancy, regardless of diet, it is helpful to start supplementing 400 micrograms of folic acid daily, which has been shown to decrease the likelihood of neural tube defects in the baby.   

Healthy weight

Maintaining a healthy weight is important to optimize your reproductive system. Obesity has been shown to decrease fertility and increase the risk of pregnancy complications for both mother and child. Underweight women also experience effects on fertility and increase the risk of a low birth weight baby, who is at risk for problems during labor and may have behavioral or health problems that last through childhood. Your provider can offer recommendations to help you reach a healthy weight range.

Control stress

Stress hormones can affect your menstrual cycle and have been shown to decrease fertility. In addition, studies have shown women in stressful jobs, have higher rates of preterm delivery and preeclampsia, a potentially dangerous complication of pregnancy. While it is impossible to remove all sources of stress, learning how to limit and physically handle stressors can decrease their impact. 

Limiting caffeine

Significant caffeine intake can increase your heart rate, lead to dehydration, and increase stress hormone levels. In small doses, likely less than 200mg or 12oz of normal strength coffee, these changes are unlikely to affect your health or the pregnancy. Spacing out the caffeine intake and drinking enough water can help prevent issues.

Work to stop drinking, smoking or other drugs

Pregnancy can be a great motivator to decrease use of harmful substances, as many have been shown in studies to cause adverse outcomes in pregnancy. There is no level of alcohol use that has been proven to be safe in pregnancy so it is recommended to abstain. Alcohol use can also decrease both male and female fertility for some. Smoking cigarettes while pregnant can increase the likelihood of having a low birth weight baby and other adverse events. 

See your healthcare provider

Most women would benefit from a preconception visit with a healthcare provider. This visit can help assess any medical problems, medications, personal or family history that could affect your pregnancy or your ability to get pregnant. Your provider will help to determine what testing, vaccinations, and medication changes may be recommended, as well as any other risk factors that require intervention. She can also review your menstrual cycle and determine the best time for you to discontinue your current contraception or time intercourse to promote fertilization.

Optimizing your health prior to trying to conceive will give you the best chance for a healthy mother and child, and our providers are here to help get you ready.

NCQARittenhouse Internal Medicine™ has received the highest recognition from the National Center for Quality Assurance (NCQA). What this means for our patients

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