Category Archives: Gynecology

Sterilization by Laparoscopy BISALP

Let’s talk about permanent sterilization or getting a “BISALP”

There has been a lot of discussion lately on social media platforms regarding this. On Reddit/Facebook/Instagram there are many threads on “getting your tubes tied.” I would like to share my support and present reliable information regarding this on our website as well for you. 

I have placed my name on a list of physicians who are willing to perform sterilization procedures on women despite the number of babies they’ve had or their marital status. As always done in my practice, I will counsel you on all the options of contraception including the risks/benefits of female sterilization. We can discuss the option of vasectomy for your partner and where I would recommend to go for this outpatient procedure. We can discuss the option of placing a LARC contraceptive to help with heavy periods while also completing permanent sterilization if desired. 

If after our discussion about even the risk of regret and the usual risks of laparoscopic surgery etc, you would still like to have surgery, then I am happy to walk you through that process. I operate at Adventist Shady Grove Hospital. 

Please call and speak to my office staff if you would like to come in for a consult. You may bring a friend/family member to the consult for support if you choose. 

Here is a thorough FAQ list about permanent sterilization for men and women:

-Dr. Mishra

COVID-19, an OBGYN Perspective

COVID-19 map.png

COVID-19 was first recognized in Wuhan China. It started in December 2019 with one case and by the end of two months it had grown to over 70,000 cases. As of early March it has been diagnosed in over 100,000 people and has killed 3300. Currently it is most prevalent in China, South Korea, Iran, Italy, France, Germany and the US, which is ranked 7th in the amount of cases.


Patients who get sick with COVID-19 have cough and fever, sometimes with muscle aches or chills. In the more severe cases patients can have viral pneumonia. In the worse cases patients develop a syndrome called ARDS which is a pulmonary syndrome and is similar to that seen with a different virus called SARS which was prevalent in 2002.


Some patients’ symptoms can also be GI symptoms such as nausea, vomiting or diarrhea. In China approximately 80% of those infected developed mild symptoms and did not require any medical intervention. About 15% required hospitalization and 5% required critical care.


The overall mortality rate of the disease is difficult to calculate because of the different ways it is being diagnosed around the world. We find severe cases first so there is probably an over-representation of those cases and the mortality rate is probably lower than current estimates. The more that we do diagnosis, the more we diagnose mild cases. In South Korea with the greater availability of testing, the mortality rate was found to be 0.6%, which is probably more accurate than the numbers from China. The risks are substantially higher in people who are older than 70. At present, it does not appear that pregnancy increases your risk.


The virus has a 1 to 14 day incubation period, with the average incubation of about 5 days. The virus is spread by respiratory droplet with close contact, usually within 6 feet. In China as many as 20% of cases have no symptoms which makes it more challenging to identify it and contain it.

In China they took major interventions to contain the virus such as closing cities, canceling mass gatherings, closing of travel routes, closing of businesses, closing schools and confining people to homes.


The US has moved to increase capacity for testing to make tests available for any patient with symptoms who needs it. The government is proceeding with making drive through testing centers available in all communities. Local government and hospitals are gearing up to make testing and treatment available in our community.


Our practice plans to stay open and continue to see our OBGYN patients. To help us help you, please do not come to our office if you have symptoms of this infection, such as fever, chills, cough, muscle aches, or recent exposure to someone who did. Feel free to reschedule your non-emergent gynecology visit.


If you want to be tested for the virus, Montgomery County has a hotline to find out where to go: 240-777-1755. You can also find out up to date information about the virus at the COVID-19 Johns Hopkins site.  If you have further questions about whether or not you should come in for your visit, please call our office before coming in.




Closing the Orgasm Gap

This image has an empty alt attribute; its file name is Screen-Shot-2019-01-06-at-12.28.58-PM-1024x571.png

Statistically, women report fewer orgasms than men. A study in orgasm frequency of US adults showed heterosexual men usually orgasmed during intimacy (95%) followed by gay men (89%), bisexual men (88%), lesbian women (86%), bisexual women (66%) and heterosexual women (65%). Women who orgasmed more frequently were more likely to receive more oral sex, have longer duration of sex, be more satisfied with their relationship, ask for what they want in bed, act out fantasies and express love during sex. Women were more likely to orgasm if their last sexual encounter included deep kissing, manual genital stimulation and oral sex in addition to vaginal intercourse.

Why the Orgasm Gap Exists

There are theories as to why women don’t orgasm as much as they’d like to. There is too much emphasis on penetrative sex. Our Western culture is goal oriented. For men the goal is to orgasm, and then the fun stops. Biologically, it’s more difficult for women to achieve orgasm from penetrative sex alone. According to sex experts 80% of women do not orgasm through intercourse alone. Most need direct clitoral stimulation to experience orgasm.

Female Orgasm During Intercourse

Fortunately there are ways to ensure women experience mind-blowing orgasms during sex. Penis in vagina intercourse is just one type of sex. Using your hands and mouth to arouse one another should be a central part of your sex life. Start with lots of full body touch. We recommend female orgasm or high arousal before penetration. Using your fingers in the vagina before inserting a penis can help warm her up. Emphasize clitoral stimulation before and during intercourse. The clitoris is the anatomical match to the penis, so just imagine men trying to reach orgasm without touching their penis and you’ll get a sense of how essential clitoral stimulation is to female orgasm. It can be easiest for her to keep touching her clitoris once intercourse has started.

The first moment of penetration can be exquisite and set the tone for the entire time. Make sure to not penetrate until she is ready. Try holding still and letting her slide onto the penis at her own pace, or going in one inch at a time.  Wetness is not a good indicator of arousal. Women can be aroused but not wet, or wet but not aroused. Whenever it is needed, use good quality lube.  Explore different depths, rhythms and speeds. Ask her what works well for her. Experiment with sensible sex positions. Focus on comfort and the ability to thrust and move easily. Take turns being the more active one. Try making sex last longer with foreplay, more attention to her pleasure, and gaining control over ejaculation. Have fun with extras such as holding still while she squeezes and releases pelvic muscles, make and hold eye contact, using full body touch during intercourse to maximize skin to skin contact. Adjust your erotic attitude from sexual scarcity to sexual abundance.

Four Ways to Close the Orgasm Gap

Explore the many, different kinds of female orgasm.

This image has an empty alt attribute; its file name is screen-shot-2018-11-24-at-9-46-48-pm1.png
This image has an empty alt attribute; its file name is screen-shot-2018-11-24-at-9-41-03-pm1.png

The Clitoral orgasm is from the clitoris, a small organ filled with nerve fibers that is derived from the same tissue in utero as the penis. It becomes erect and engorged with blood during sexual arousal. There are 2 sex positions that allow for more direct stimulation of it, the CAT (coital alignment technique) and the Reverse Cowgirl.

The Reverse Cowgirl sex position is one of the more well-known positions out there. Your man first needs to start by lying down on his back. You then get onto your knees, with one on either side of him, and lower yourself down on him while facing toward his feet. You lean against his upper thighs and grind against him to stimulate your clitoris. The CAT position is great if you like clitoral stimulation. You lie on your back with your legs open while your man is on top of you. But instead of thrusting in and out, you man moves forward so that the angle of the penis is more pointing downward so that his pubic bone will come into contact with your clitoris. It can also be performed with a strap-on.

The G-spot orgasm is from a sensitive area in the front wall of the vagina. When stimulated correctly, many women report intense orgasms that are different from clitoral orgasms. To stimulate the G-Spot curl two fingers into the vagina and press them into the upper wall in a come hither motion. Or slide 3 fingers into the vagina and sweep them back and forth like windshield wipers against the upper wall. The more you take the time to get to know your G-spot and what type of stimulation feels good, the more pleasure you’ll be able to derive from this erogenous zone.

The Blended orgasm is a combination of two or more different types, such as from stimulation of clitoris and nipple.

Anal orgasm involves intense pleasure from stimulation of nerves in the vagina and rectum. So for vagina owners, it may be possible for sexual arousal to occur from rectal stimulation. This definitely needs extra lubrication!

The Nipple orgasm can occur from breast stimulation as the nipple is an erogenous zone for many people and can lead to incredible orgasms. For men and women, nipple play is rewarding foreplay. A study showed that nipple stimulation enhanced sexual arousal in 82% of women and 52% of men. Nipples attract women, just like they do men. A University of Nebraska study found that women and men follow similar eye patterns when looking at women. They quickly look at breasts before moving on to other areas of the body. Piercing? In a study from 2008 94% of men and 87% of women polled about their nipple piercings said they’d do it again. They liked the look of it.

The Fantasy orgasm is possible if your brain is powerful enough to take your daydreams into orgasm territory with nothing more than naughty thoughts!

If you’re a fitness junkie, a Coregasm might be for you. Also known as exercise-induced orgasms, they occur during workouts, and may be due to vibrations from the abdominal and pelvic muscles.

Masturbate More

This image has an empty alt attribute; its file name is screen-shot-2018-11-24-at-9-26-39-pm.png
This image has an empty alt attribute; its file name is screen-shot-2018-11-24-at-9-25-52-pm.png

It doesn’t take two to have an exciting empowering sex life. Masturbation is good for your health and for improving your sexual encounters with your partner. There are numerous health benefits such as a boost of endorphins, reduced anxiety, a better sex life and increased blood flow to the vagina, which can reduce dryness and be especially helpful as you become older. Friction can cause discomfort, so using a lubricant (see pictures of two good brands) can help. For clitoral, try lying on your back.  With a pillow under your head, spread your legs and start to rub your clitoris with whatever feels good. For vaginal, try squatting. Squatting makes it easier to find your G-spot, whjch is about 2-3 inches inside your vaginal canal. Slide your fingers or toy inside your vagina, moving deeper as you go. For anal, try face-down doggy style. The position gives you room to insert your fingers or toy in your behind with one hand while rubbing yourself with the other. For the combo, try the pretend lover. Think of the pretend lover as the cowgirl for one. Put your favorite dildo or vibrator on your bed, and lower yourself down until you find a sensation you like- either penetration, clitoral or both. Ride your toy as fast or slow as you want. At the same time rub your clitoris or play with your nipples. If you want to get your other senses involved, erotic stories can let you discover your sensual and sexual side. Check out for some femme-friendly stories. If you’re more visual, watching porn can increase your libido and relieve stress in a safe way. If you like listening, has steamy audio books. Masturbation is a fun, sexy and safe way to explore your desires and learn what turns you on.

Sex Toys Can Help Erase the Orgasm Gap

This image has an empty alt attribute; its file name is screen-shot-2018-11-24-at-9-24-56-pm.png

Some people think sex toys are for solo sex only, but using toys in the bedroom can be a shared experience, and can help take some pressure off when it comes to helping your partner orgasm.  Toys come in all shapes and sizes, and many of them emit a range of vibrations that you can adjust to your need and desire. Three companies who sell sex toys are We-VibeLelo and Tantus.

Communicate with Your Partner

This image has an empty alt attribute; its file name is screen-shot-2018-11-24-at-9-21-22-pm.png

To better communicate,  demand you get what you need. Women are less likely than men to verbalize their sexual desires or speak up when they are not satisfied during sex. As for men, they assume that women all want the same thing in bed. All women are different with different wiring, different anatomy and different responses.  If you feel awkward stating your desires during sex, you can start beforehand. Not sure what to say? Here’s a list:

The orgasm gap does not have to exist. Women deserve just as much pleasure as men. With a little attention to detail and more focus on female pleasure, you can narrow the gap for good, and that’s something worth getting excited about!

Are Hormones for Menopause Safe?

I recently attended the American Congress of Obstetricians and Gynecologists Annual Clinical Meeting and heard an excellent talk from one of George Washington University’s Professors, James Simon MD. The talk was inspirational! He spoke about a very important topic, “The Status of Hormone Replacement Therapy.”

By way of background, in the past many women were treated for symptoms of menopause with hormones, but in 2002 a report came out, called the “Women’s Health Initiative,” which changed everything by painting a very negative picture about the harm that hormones could cause. As a result, many women, all over the world, were scared into stopping hormones, and some of that fear persists to this day, despite much evidence to the contrary. Years later we have gradually discovered that the study was deeply flawed.

Dr Simon described this as an example of a  “Zombie Idea,” an idea that should have been killed by evidence, but refuses to die! This actually is similar to the current situation involving fear of vaccines, which was originally based on a fraudulent and discredited study, but still lingers on despite overwhelming evidence of vaccine safety.

Similarly, the WHI Study from 2002 was also flawed and following its recommendations has caused harm.

We now know about the “timing hypothesis” that the safety of starting hormone replacement therapy depends on when it is started in relation to menopause. Studies show a much decreased risk of complications such as stroke or heart attack if the woman starts treatment within 10 years of menopause.

Transdermal patches as a way of receiving hormones appear to decrease the risk even further, according to an extensive French study.

Re-analysis of the old WHI data shows no effect of hormones on causing breast cancer.

A Finnish nationwide study showed a decreased chance of death from breast cancer if hormone therapy with either estrogen or estrogen with progesterone was used.

To make it even more definite, a review of 17 studies looking at the risk of recurrence of breast cancer in women who had previous breast cancer, showed that 16 of the 17 studies had either no change or a reduction in recurrence of cancer if they were on hormone therapy.

Another review showed women lived longer if they received hormones starting at age 50-59. This looked at death from all causes, death from cancer, and death from stroke or heart attack.

The risk of Alzheimer’s disease or dementia was decreased by use of hormones.

How do hormones compare with other medications? Surprisingly, recent  studies found an increased risk of breast cancer from taking statins, which are often prescribed for high cholesterol levels. Medicines prescribed for improvement of bone density such as Pioglitazone showed an increased risk of breast cancer of 88 per 10,000.

Surprisingly, analysis showed one of the most dangerous medications causing breast cancer is Vitamin D, which caused 70 per 10,000 additional cases of breast cancer.

What was the aftermath of stopping hormonal therapy based on the WHI report when it came out in 2002? A study in 2009 showed a significantly increased number of bone fractures. Another study in 2011 shows more hip fractures in women who stopped hormonal therapy compared with those who continued it.

Was there an increased risk of death from stopping estrogen therapy? A study in 2013 showed over a 10 year span, starting in 2002, a minimum of 18,000 and as many as 91,000 US women died prematurely because of the avoidance of estrogen therapy.

The conclusions are that hormone therapy risks are rare, and even more rare when started in women who are less than 60 years old and/or within 10 years of beginning menopause. Starting it at a younger age does decrease the risk and increase the benefit.

The degree of risk, when it does occur, is similar to that of many commonly used medications or vitamin supplements. Hormone therapy significantly reduced the risk of bone fractures and is the most effective treatment for reducing the worst symptoms of menopause including hot flashes and atrophy of the vulva and vagina. If you have any symptoms of menopause, talk with us about being treated for it!


  1. Benefits and Risks from WHI – Initiation of HT in Women 50-59 Years of Age: Manson JE, et al. JAMA 2013;310:1353-1368.
  2. Timing Hypothesis: Hodis HN, et al. J Am Geriatr Soc 2013;61:1005-1010, 1011-1018.
  3. CHD Events Associated with HRT in Younger and Older Women: Meta-analysis of 23 Randomized Controlled Trials: Salpeter S, et al. J Gen Intern Med 2006;21:363-366.
  4. Are Transdermal Preparations Safer? Canonico et al, BMJ 2008; 336 (7655);1227-1231.
  5. WHI E+P Trial: No Effect of E+P on Risk of in situ Breast Cancer: Chlebowski RT et al. JAMA 2003; 289(24):3243-3253.
  6. Finnish Nationwide Study – Risk of Breast Cancer Mortality in Women after Different Exposure Times to Estrogen: Mikkola TS, et al. Menopause 2016;23:1199-1203.
  7. Mortality Outcomes During the 18-Year Cumulative Follow-up in 50-59 Year Old Women: Manson JE, et al. JAMA 2017;318:927-938.
  8. Alzhemier’s Disease or Dementia Mortality During the 18-Year Cumulative Follow-up: Manson JE, et al. JAMA 2017;318:927-938.
  9. WHI-E in Perspective: RUTH. New Engl J Med 2006;355:125-137.
  10. Relative and Absolute Risks of Commonly used Medications and Supplements: Li Ci et al. JAMA Internal Medicine 2013;173:1629-1637. SPARCL Investigators N Eng J Med 2006;355:549-559.
  11. Relative and Absolute Mortality Risks of Commonly used Medications and Supplements: Hodis HN, et al. J Am Geriatri Soc 2013;61:1011-1018.
  12. WHI E-Only and E+P Evolving Conclusions 2017: Manson JE, et al JAMA 2017 Sep 12:318(10):927-938.
  13. Aftermath of WHI – Fracture Data: Karim R. Menopause 2011;18:1172-7
  14. Mortality Toll of Estrogen Avoidance: Sarrel PM, Njike YY, Vivante V Am J Public Health 2013;`03:1583-1588



Introducing Dr. Jennifer Jagoe!


We are very pleased to announce that our practice has grown. As you can see in the picture, we now have four doctors in our practice!

Dr. Jennifer Jagoe, pictured on the left in the above image,  has joined our practice. She has a strong background in Obstetrics and Gynecology. She served as an OBGYN physician at the Naval Medical Center San Diego, the Naval Hospital Guam, the Naval Hospital Bremerton, Washington, the Madigan Army Medical Center, Tacoma, Washington, and the Walter Reed National Military Medical Center in Bethesda, MD.

She recently worked as an Assistant Clinical Professor of Obstetrics and Gynecology at the University of Maryland School of Medicine. Her work included being a preceptor for medical students, being a member of the Perinatal Advisory Council, and a member of the Maryland Patient Safety Center.

We are very fortunate to have her joining our group!

Dr. Jagoe is available to see patients at our Rockville office on Tuesday, Thursdays and Fridays, and at our Germantown office on Mondays and Wednesdays.

Finding Breast Cancer

One in eight women in the United States will be diagnosed with breast cancer. The longer someone has breast cancer before it is detected, the more difficult the treatment becomes and the worse the odds of survival. One of the best ways to find breast cancer earlier is by self-exam.

The Worldwide Breast Cancer organization has come out with a nice campaign using photos designed by a breast cancer survivor to help increase awareness of how to find breast cancer.


This campaign gets the point across effectively and can be used in social media posts to help spread the word. The original photo has been shared nearly 35,000 times and seen by more than 3 million people. Just think about how many lives can be saved!

If you find anything like this in your breast self exam, please let your doctor know about it!

Chronic Vaginal Infections

I’m at the 2016 ACOG Clinical meeting!

I recently heard an informative lecture at the 2016 ACOG Annual Clinical Meeting about new research and treatment of chronic vaginitis. Dr Chemen Tate from the Indiana University School of Medicine spoke about the different causes of chronic vaginal infections. While most people associate vaginal infections with yeast, the actual leading cause of vaginal infections is Bacterial vaginitis, which comprises 50% of infections, compared with only 25% for yeast.

Bacterial vaginitis causes an increased discharge with a bad smelling odor. It is usually not associated with inflammation. There is found to be a reduction of the amount of lactobacilli, which usually serve to protect the vagina. (Those are the same helpful bacteria that are found in yoghurt). BV can weaken the body’s defenses and promote other infections including herpes, chlamydia, trichomonas, HIV and gonorrhea. It is highly recurrent, and 30% of women who are treated for it will have a return of symptoms within 3 months, or 3 to 4 episodes a year. This can be very distressing. Return of symptoms may be due to reinfection or a failure of treatment. Why does this happen?

Research has determined that bacterial biofilms are organized microcolonies on a surface that create a protective mode of growth allowing for survival in a hostile environment. For example, electron microscopy of the surfaces of infected medical devices have shown the presence of large numbers of slime-encased bacteria. Tissue taken from chronic infections have shown the presence of biofilm bacteria surrounded by a protective exopolysaccharide matrix. Other examples of biofilm infections include dental carries, prosthetic device infections and cystic fibrosis lung infections.

Biofilm infections are resistant to antibiotics and host defense mechanisms. Antibiotic therapy typically reverses the symptoms caused by the infection but may fail to kill the biofilm. Bacterial Vaginosis is a biofilm infection. An adherent vaginosis biofilm persists on the vaginal epithelium after standard treatment with oral metronidazole. What new treatments can be successful against this resistant infection?

We should council our patients that in many cases bacterial vaginitis is chronic and will come back. When the infection returns treatment needs to be adjusted to be more effective. New recommended treatment is longer treatment, and includes Metrogel, oral metronidazole, tinidazole, or clindamycin vaginal for two weeks. For a patient who has a previous history of long term symptoms, the two week treatment is to be followed by once weekly Metrogel, or twice weekly oral metronidazole or tinidazole for six months. Using the appropriate treatment for this chronic problem can be expected to cure it 80% of the time. Investigation is ongoing in this field and future therapies that attack biofilms directly may show even better results.