Check Your Gas Tank Meter…It Might Be Time to Refuel: The Thyroid

In many ways, the thyroid is like the man behind the curtain. You have never seen him and are not really sure what he does, but you know he’s there. You’ve heard about him, blamed him for your weight gain and for sleeping through your alarm clock, and considered that errors in his way are keeping you from getting pregnant. But how he is masterminding all of this remains unclear.

While the intricacies of the thyroid are more delicate than a lace shirt, the basics come down to a simple Goldilocks type of situation: the thyroid is working too fast, too slow, or just right. When it’s really off, you usually feel really off. Simply stated, when your thyroid is running on empty or very close to it (think flashing red light telling you to pull over ASAP), you will feel like a car without gas, putt putt puttering through your day, being tired, cold, and constipated, with dry skin and hair loss, to name a few.

On the flip side when your tank has been topped off just a bit too much, you feel like you had one too many shots of espresso. You experience insomnia, diarrhea, palpitations, hot flashes/sweating, anxiety…

However, sometimes the deviations are subtle, and your thyroid is just slightly off (medically termed subclinical). But you may not know it unless a doctor checks. While the subclinical part will usually not cause you any noticeable symptoms, it can increase your risk of miscarriage and infertility and lead to negative pregnancy outcomes. Bottom line: if your thyroid is off, it’s not only your bottom line that will suffer but also your plus one.

As a result, fertility MDs are somewhat fixated on hitting the thyroid hormone level sweet spot! We check it on nearly all of our patients pre-pregnancy and then again during pregnancy. We are somewhat OCD in getting it to the perfect point and will labor over when to start some additional medication, when to increase or decrease it, and when to stop it.

What and where is this elusive “gas producer”? The thyroid is a small butterfly-shaped gland that sits at the base of the neck. In most women who are free from thyroid disease, the thyroid is small and cannot be felt. The thyroid produces thyroid hormones (T4 and T3); these hormones travel through the blood throughout the body to target organs. Almost all of your vital organs are target organs in desperate need of a little thyroid juice! The ovaries and the uterus are also quite “thirsty.”

Thyroid hormone plays a role in regular ovulation, pregnancy implantation, and miscarriage. Additionally, babies don’t start to produce their own thyroid hormone until about 13 weeks of age (in utero). Therefore, for the first trimester of pregnancy, babies rely exclusively on their mothers. If you are borderline low making thyroid hormone, they will be super low. And given that thyroid hormone is essential for brain development, this is not an area you want to be lacking in! It is for this reason that doctors will frequently start a thyroid supplement early before the situation hits rock bottom.

While your thyroid may not be to blame for all of your problems, it’s under (termed hypothyroidism) or over production (hyperthyroidisim) may be the cause of some serious ailments. And like most autoimmune conditions (where the body basically attacks itself), women are about six times more likely to be diagnosed with thyroid disease; most of those diagnoses will be made in the reproductive years (30s and 40s).

Not only is the thyroid important for pregnancy and fertility, but the start of it’s decline often occurs during the reproductive years.  So while your tank may be running on empty because you’re burning the candle at both ends, it is always a good idea to have your thyroid level checked, particularly when contemplating pregnancy. Who knows? You may just need a little refueling to help put an end to those annoying symptoms!

The Most Unwelcome House Guest: Endometriomas

When you can’t find your keys, what do you do? Most of us go to the “hot” spots and start searching. Hot spots are those places that you usually, on most days, drop your keys: on the kitchen counter, in the hallway, hanging on a hook in the garage. By hitting those high-traffic key spots, we are pretty likely to find a match.

When looking for evidence of endometriosis, we go to those hot spots, and the ovaries are the hottest of the hot spots. Endometriosis that implants on the ovaries and forms a cyst is called an endometrioma. News flash: endometriomas and the ovaries are not friends; in fact, they are not even frenemies. They are unwelcome guests that can make the ovaries incredibly unhappy. And here’s why.

Intruders are not fun in anyone’s house. This is particularly true in the ovaries that are already dealing with a limited supply of goods (a.k.a. eggs). Endometriosis on the ovaries can range from mild (a few spots) to major (a whopping 10cm, plus a cyst). Usually, the bigger the cyst, the bigger the problem. And although this may be hard or disturbing to picture, what’s inside the cyst bears a close resemblance to chocolate. While we hope that didn’t destroy your love of everything Hershey’s, Nestle, or Godiva, that is what the brown fluid that leaks out of the cyst looks like.

And while it may look like chocolate, it’s more of an inflammatory soup; factors and mediators lurking in this fluid are not pleasant. They’re irritants. They can damage the ovary and eat away at your egg supply—as well as your quality of life. It is for this reason and others that women with endometriosis often experience infertility.

The walls of endometriomas were not built in a day. They are usually quite tough and scarred. In many cases, the ovary-plus-cyst complex is stuck like glue to surrounding abdominal organs (intestines, uterus, etc.). This can make taking them out pretty challenging. Fortunately, surgeons that specialize in endometriosis surgery have a lot of weapons in their armamentarium.

You want to make sure the good guys are fighting for you, and for this reason, make sure you vet your endo surgeon well. Unlike those keys that you couldn’t find, you can’t just get a new ovary copied. If you lose it, it is forever lost. For this reason, you want to make sure whomever you are trusting to “hold them” knows what they are doing.

The good news about endometriomas is that the hot/cold/found-it game is pretty easy. An ultrasound is pretty spot on in identifying what is likely an endometrioma and what is not. On ultrasounds, the cyst/mass will look greyish/white and solid, and it usually has a lot of blood flow. If your doctor is still on the fence about what is plaguing your ovary or needs more information before surgery, an MRI is usually their go to. With these tools in our pocket, we can decide if surgery is needed, what the best approach for surgery is, and how major the surgery will be. It is important to take good before pictures (say cheese!) prior to surgery so that you have a good idea about what the after should look like.

Unfortunately, the recurrence rate of endometriomas is pretty high, especially when the surgeon does not remove the cyst wall in its entirety. Simply draining the cyst doesn’t do all that much for you or for your chances of being cured.

Word of advice…make sure to ASK your surgeon how he or she plans to remove the endo before signing that consent form. The reason for the high recurrence rate of all things endo is that estrogen is fueling its fire. If estrogen is around, endo will grow—sort of like, if you build it they will come. It is for this reason that, for women who do not have babies on the brain (because they are not ready or they are done), we recommend shutting the reproductive system down (pills, Lupron etc.) after undergoing surgery.

Cold, hot, hotter, hottest—you found it! Endometriomas are often a pretty good giveaway for underlying endometriosis. They have no game face, and when present, you can pretty easily guess what’s causing those unpleasant symptoms. While they may not need to be treated unless causing pain or contributing to infertility, they do shed some major light on what may be hiding in the dark in your pelvis. It may be the key to what you experience in the future—make sure you know where you put it!

Who Doesn’t Want Half and Half in Their Coffee? IVF Stimulation Medications

Calories, shmalories… We like our half and half! In fact, the lighter the better (sweet is good, too!). Half and half gives coffee that creamy taste that is not replicated by any amount of whole or skim milk. The same can be said for ovarian stimulation medications—the ovaries of most women like half FSH and half LH. In many cases without this combo, the response is bland and lackluster.

But before we go any further, let’s take it back to the “beans” (a.k.a. the basics). While FSH and LH are hormonal medications used in IVF, they are also hormones produced naturally in the brain. It is the steady production of FSH and LH throughout the menstrual cycle that results in egg production and ovulation.

Because in a natural cycle you never see FSH without LH, many fertility doctors prefer to keep this dynamic duo intact when selecting IVF stimulation medications. As a result, combined protocols (as we call them in fertility medicine) are definitely leading in the fertility polls. Most of us have seen better ovarian response, better egg quality, and hence, better embryo development when the two are mixed. But taking it back to the beans (a.k.a. the basics), FSH and LH are two hormones that are normally made in the brain.

Great, now they want me to take two shots? Unfortunately, yes, we do. And while we would love to minimize the number of times you have to stick yourself, doubling up will likely do your ovaries wonders. When we stimulate ovaries for IVF, as unnatural as it feels, we are trying to mimic a natural cycle as much as possible. Nature happens for a reason! By giving both FSH and LH together, we are coming closer to what happens when we are not there. These two were paired together before we got there—it seems silly to separate them!

Yes, there are certain women who do better with straight whole or skim milk or even black coffee. For example, women who suffer from hypothalamic amenorrhea (no periods due to low hormones from the brain) need LH. Their ovaries will sit on the runway all day without a blast of LH. On the flip side, women with the real deal PCOS do better with minimal LH in their stimulation. Their ovaries see LH all the time (been there, done that), so it’s better not to put fire on an already flammable situation.

The debate over whether to use FSH alone or FSH + LH has gone on longer than the Coke vs. Pepsi debate. There is evidence on both sides to support combo protocols vs. straight FSH or LH. While doctors may have a preference for one (and can certainly find evidence to support it), most large reviews have demonstrated that (like us) two are better than one. When sitting down with your doctor, before you start the shots, ask them what you are getting, why they are giving it to you, and why they like this for you. Asking questions will quell some of the confusion and anxiety that those bags of needles and boxes of medicines bring upon their arrival.

Your choice of cocktails is very personal. Trust us, we get it. While some of us are vodka soda fans, others like to mix with cranberry juice. And then we have the more elaborate amongst us who go for Cosmos, Long Island Iced Teas, and Mojitos. (Watch out the next day: sugar hangovers are the worst!) Whatever you like to mix with your alcohol, you probably have a reason for it. Same goes for your ovaries and us. Everything we do has a purpose. The difference is, we’re helping make babies, not Bellinis. Here’s to your success, your health, and your fertility. Cheers!

Cervical Mucus: A Marker for Ovulation and a Must for Pregnancy?

For many of us, there is nothing more off-putting than the thought of tracking your cervical mucus day after day, month after month. It’s not easy knowing what you are looking at, why you are staring at your underwear, how long this exercise needs to go on, and what you will do with this information.

Egg white versus watery, creamy versus sticky. Are we baking a cake or making a baby? While in many ways, it’s sort of a little bit of both, tracking your cervical mucus is not a prerequisite for detecting ovulation or having a baby. The changes that occur over the course of those approximately 26 to 36 days can provide helpful hints on both if and when you are ovulating. However, while it is important and does serve as a reservoir for sperm, it is much lower on the fertility pecking order.

The cervix is the lower part of the uterus (a.k.a. the womb); it is the conduit between the uterus and the vagina. When not pregnant, the cervix measures about 2 to 3 cm. During pregnancy and particularly as its end is near, the cervix begins to shorten, thin out, and ultimately dilate. Think of the cervical mucus as the pond at the base of this conduit. It serves as a reservoir for sperm by providing it with nutrients and safety for several days (up to five, to be exact!). While the majority of sperm is in the tubes minutes after ejaculation, the pond holds on to the stragglers. Over the course of about three to five days, sperm is released into the uterus and the tubes, hoping to meet its mate and make an embryo.

Much like the variability in the uterine lining during the approximately one-month-long menstrual cycle, the cervix and its mucus also go through a host of changes. After bleeding has stopped, the cervical mucus is usually scant, cloudy, and sticky. This lasts for about 3–5 days. What comes next is the stuff that you are taught to look for.

In the three to four days leading up to and after ovulation, the mucus changes to clear, stretchy, and fairly abundant. Following ovulation, the cervix becomes somewhat quiet, and cervical discharge remains scant. The “stage hands” behind the curtain setting the scene for the changes observed in cervical mucus are estrogen and progesterone production. Altering levels of estrogen and progesterone results in major modifications in mucus content and production.

If the cervix falls short on producing and maintaining its reservoir (a.k.a. mucus), problems can arise. However, while cervical factor infertility used to be considered a serious and real problem, today the cervix and cervical mucus production are hardly ever the cause of infertility (only about 3% of infertility cases are due to the cervix). Because of this, tests to evaluate the cervix/mucus are no longer needed.

Traditionally, a postcoital test (nicknamed the PCT) was performed to seek out cervical dysfunction. Now, picture this: fertility doctors used to obtain a sample of cervical mucus before ovulation and after intercourse and check it out under the microscope. They were looking for the presence (or absence) of moving sperm. Although this is sometimes used in couples that cannot have a formal sperm check, it is otherwise one for the ages. The subjectivity, poor reproducibility, and very inconvenient aspect of it have eighty-sixed the PCT in the land of fertility medicine.

In cases where the cervix has been previously cut, burned, or frozen, a narrowing of the cervical canal can arise (medically called cervical stenosis). Cervical stenosis can make procedures that require access to the uterus difficult (picture trying to pass something through a really narrow hole—it doesn’t fit!). Therefore, prior to undergoing any fertility treatment, a cervical dilation (that is, a widening of the cervix) may be required. This allows your doctor to then put sperm or embryos back into the uterus.

However, while the narrowing can make infertility procedures somewhat more challenging, the width is not what’s causing the entire problem. Cervices that have been exposed to trauma like surgery can have difficulty producing mucus. No mucus equals not much of a place for the sperm to hang out (cue IUI or IVF).

While the cervix may not be playing the feature role in the fertility play, it does serve as an important role. In addition to providing a respite to sperm, it also helps maintain a pregnancy to term. When a cervix shortens or dilates before time’s up, it can lead to a snowball of negative events: preterm labor and preterm delivery, to name a few. Bottom line, it’s not only a reservoir but also a roadblock. Until that nine-month mark has passed, it should not let anything out that front door!

Think about your cervix and cervical mucus but don’t drive yourself nuts. Yes it is a way to confirm ovulation but no it’s not the only way. While we are advocates of knowing your body and being aware of what’s going on with your cycle, obsessing over what’s going on won’t change what’s coming out. We have ways to get the sperm to meet the egg even if the cervix isn’t cooperating!

Let’s Play Pill! Controlling the timing of your cycle.

For all of you blackjack and poker fans out there, you probably get the “Let’s play some cards” reference pretty quickly. And while you may have never put the words birth control pill and pack of cards together in the same sentence, there are some similarities. Think about it…both come in a pack, both have two colors, and both can be purchased at most local drugstores. And it doesn’t end there. In fact, the biggest similarity between these two “packs” is the way you can manipulate them to make things a little more interesting. If we lose, you don’t despair. We will lay all our cards on the table and talk you through this.

Although as GYNs we are pretty partial, in many ways, OCPs are science’s greatest gift to women. It gives us flexibility, it gives us choice, and it gives us control. It also takes away cramps, minimizes bleeding, and puts a stop to acne and unwanted hair growth. Not bad! And while it does require a daily thought (we recommend combining it with brushing your teeth!), most of us can handle that. On top of these pluses are some plus + pluses (a.k.a. contraception).

And if that wasn’t enough, the pill can now be used to adjust when and if you see red. By extending the active pill pack and skipping the placebo (sugar pills), you can avoid that un-fun time. The constant dose of estrogen and progesterone will keep the inside of the uterus (the lining) from shedding. And while it may sound like we have lost our minds, you can live in this steady state of estrogen and progesterone for many months, even years (truly, you can!). It won’t hurt your body or your future chances of having a baby.

Sometimes you just don’t like the hand you are dealt. Luckily, you are not in Vegas and can reshuffle your cards. In fact, counting cards is what we GYNs do best. By looking at your pill pack and your calendar, we can come up with a period schedule that not only works for your body but also for your life. Let’s face it,getting your period on your vacation, wedding day, or honeymoon is just not fun.

But don’t count your cards before the game is over. While altering the pill schedule usually works to avoid bleeding on big days, sometimes your body has a mind of its own. Breakthrough bleeding can occur despite continuous OCP use—and although it’s a big bummer, it’s not a big deal (medically speaking).

So if you play your cards right, you might just be able to avoid taking tampons on your next trip. It requires some planning, but with your ace up your sleeve (a.k.a. your OB/GYN), you can plot out your next move. While most card players are taught to keep their cards close to their chest, in this game, to win you have to let a couple of people in. Don’t worry; we won’t tell the dealer!

5 + 5 = 2? The Difference between Follicle Count and Embryo Number

Numbers are no strangers to fertility medicine; success rates, dosages, and egg/embryo counts are all things we count. And despite our tenuous personal relationship with math, over time, we have become quite comfortable with statistics, percentages, and probabilities (disclaimer—as they relate to IVF only)!

However, the number that often eludes us, and the question on so many patients’ minds, is the following: What is the follicle to egg to embryo to viable (able to make a baby) embryo conversion rate? Simply stated, if I have 10 follicles will I have 10 eggs, and if I have 10 eggs will I have 10 good embryos? The short answer, without any derivatives, formulas, or equations is no…You will very likely not. And here’s why.

Human reproduction is an incredibly inefficient process; think the DMV on a bad day! While we start with over a million eggs, a very small percentage of them actually have the potential of making a baby. So while a woman may ovulate every month, many of these months the egg that is released won’t put you on the path to pregnancy. Now, while in most natural un-medicated cycles only one egg is released per month, there are actually a group of eggs that are vying for the ovulation “trophy.”

Think of egg /ovulation selection as a horse race. At the beginning of the month, several horses (a.k.a. eggs) are racing to become the egg that will be ovulated. Ultimately, one breaks free, garners enough receptors to capitalize on the available hormones, and wins the ovulation race. When we are young, there may be 30 or 40 “horses” that enter this race. Although there will still only be one winner at the finish line, the race is more robust. As a result, there is a much higher chance that your winner will be fast, strong, and able to get the job done.

As we age, the number of “horses” lining up at the gate declines until we are left with only a few weaker, slower, scrawnier participants. There will still be a winner, but you may not get very many calls from interested breeders!

Let’s stay with the horse-racing metaphor for a moment. One of the primary goals of an IVF cycle is to ensure that all of the horses that start the race finish it; in this race, we don’t want a winner. As fertility doctors, we give hormones to ensure that there is enough juice to get every follicle/egg to go the distance and cross the finish line. We want all of the eggs in that month’s cohort to grow and develop at the same rate and ultimately achieve maturity.

However, even with the strongest of cocktails we are limited by the number of entrants. If five horses enter the race, we can have no more than five horses finish it. Think of the first ultrasound in an IVF cycle as the race check-in. If the doctor sees five follicles (remember, eggs are microscopic so we count follicles that hold the eggs) there are likely to be no more than five eggs extracted at the time of the retrieval.

Unfortunately, IVF is not as simple as horse racing, and the follicle number seen at the start does not always translate into the egg number you have at the end. There is a very large attrition rate as you move throughout an IVF cycle. The race is longer than a couple of laps around the track, and therefore, the numbers drop off quickly.

And the situation only becomes more complex as women age. As the years rise, the baseline follicle count falls, and you lose your cushion. With a diminished starting follicle count at the outset comes a decline in egg number at the conclusion. Fewer eggs equal fewer embryos. Fewer embryos mean fewer viable embryos.

No matter how young or old you are, there will always be a noticeable decline in the follicle to embryo equation. It is a function of human reproduction. However, if you are going to fall, you hope that there is a cushion below you to break that fall.

I’m Pregnant. Now What?

Month after month of unhappy faces, single lines, and not-pregnant responses… When you finally see a smiley face, a double line, and/or (likely and, because most of us take about 20 tests to make sure it’s right) a pregnant message, you almost pass out. After the excitement, shock, and joy subside, anxiety, confusion, and uncertainty set in. What do I do now? And while we may not be on your speed dial, we can share with you a few of the pointers we point out to those that are!

First things first, take a deep breath. There is a lot that will happen over the next nine months, and you want to try and remain as calm as possible. (Good energy is transferred through the placenta!) After a few good, deep breaths, a bunch of OMGs this might actually be happening, and a call to your plus one (or best friend), the next step is to purchase a prenatal vitamin (if you aren’t already on one). Generic or brand, it really doesn’t matter. You just want to make sure that your body is chock full of nutrients and essentials to start nurturing that little one. If you haven’t already been taking one, there is no need to stress. You have not caused any damage or done any harm.

Additionally, if you have had a few cocktails, colored your hair, or partook in any activities that are off limits during pregnancy, don’t sweat it. The first weeks between ovulation and early pregnancy are what we OB/GYNS call the “all-or-none” interval. Your actions will either have absolutely no impact on the pregnancy, or they will result in a non-pregnancy/miscarriage type of situation. Simply stated, there will be no long-term effects on the fetus!

While the “all or none” gives you a get-out-of-jail-free card, you do want to start to alter your habits. Hang up your love of unpasteurized cheeses, your obsession with tuna (that one was hard for us, too!), and your passion for cold cuts. While you can still eat cheese, tuna, and cold cuts, the quantity needs to be reduced and the way they are cooked slightly altered. For example, cold cuts should be warmed before eating.

But don’t obsess about what you are eating in those first few weeks. Nausea is at its peak during this time, and whatever you can keep down is all you and your baby needs. Don’t stress if only grilled cheese, bagels with butter, and saltines are all that you are craving. Your lack of greens, veggies, and fruits won’t harm your little one. Your tastes will change shortly, and you can stock up on good things at that time.

It’s also a good idea to buy yourself a water bottle and make sure you are constantly sipping. The changes in blood volume that occur during pregnancy can make you dehydrated pretty quickly. To avoid that “Oh no, I am going to pass out” feeling, drink lots of fluid. And while we are on the drinking subject, it’s totally cool to continue with caffeine. A cup or two a day is definitely not a no-no. Furthermore, the occasional glass of wine, flute of champagne, or bottle of beer is not a big deal. While there is no safe amount of alcohol that can be consumed during pregnancy, a few drinks (over the nine months, not one day!) is certainly not going to do any damage.

From food, we transition to fitness. For all of you die-hards out there, pregnancy does not mean you have to hit pause on your fitness habits. Exercise in pregnancy is totally okay. You may need to tailor your exercises and taper the intensity, but staying active is A-ok. With that being said, the only things we are not fans of are the activities performed in 100 degree-plus heat (e.g., hot yoga). That temperature is not only going to seriously dehydrate you but also may not be so good for your baby’s developing organs. It is always a good idea to let your exercise instructor know that you are expecting. Most studios/fitness clubs have done a good job at training their teachers on how to modify and be mindful of moms to be.

After food and fitness, most women usually want to know about sex and personal grooming. Here’s the deal: sex is okay. Unless you start bleeding, there is really no reason to go on pelvic rest (aka- no sex). If bleeding should occur, we usually recommend resting (no sex, no exercise, and nothing in the vagina) until you are blood free for about 48 hours. After that, it is okay to give it another go. Most bleeding after sex is from the cervix or from the development of a tiny blood clot around the placenta, neither of which routinely cause a miscarriage.

In terms of personal grooming, continue pushing forward: bikini waxes, manicures, pedicures, facials, and massages are all good. Hair coloring is the only questionable practice on the list. We usually suggest sharing your news with your colorist and asking him or her to switch to a more suitable dye for pregnancy.

And finally, we arrive at family (a.k.a. whom should you tell and when). The telling part is totally up to you. While we always recommend that our patients share their news whenever and with whomever, remember that a positive test does not equal a baby. You may not want your 300+ Facebook friends to know that you just peed on a stick and saw a smiley face. However, you probably do want to tell your parents your sister and your BFF should anything go wrong and you need support. In general, most women wait until the one-third mark (about 12–13 weeks) before telling their employer and their Instagram. But bottom line is that this is a personal decision. Do what is right for you.

Make friends with a good Internet source (like Truly, MD!), buy a good book, and make sure you like your OB. He or she will serve as a guide during the next several months. You want to be comfortable and confident with your baby team. If someone or something is not working for you, kick them off, quickly! Your OB/GYN is like the coach of this team, so if you are not jiving with the coach, start looking for another team captain. This game is a big deal. These nine months, even for those of us who are not pregnancy lovers, are sort of sacred. There are only so many times in women’s life that they will be pregnant. So relish the good stuff—the first time you hear your baby’s heartbeat, the first time you feel movement, the first time you see your baby on the ultrasound, and the first time you hold your baby. You are in for a lot of firsts. Let us be the first to say congratulations on your pregnancy!

Is Testosterone the End All-Be All for Sexual Dysfunction?

Whether it be for our skin, our hair, or our vaginas, we are always in search of the Fountain of Youth. You know, that product or device that will keep everything looking and feeling young. In the land of sexual dysfunction, testosterone was thought to be just that. The magic medication that would keep us like our 20-year-old self—need we say more? And while it certainly can do the trick for some women, it has probably gotten much more press than it deserved. Let us explain…

As women age, androgen levels decrease. As androgen levels decrease, so does sexual desire. This connection led scientists to study the impact of androgen replacement treatment on sexual dysfunction, specifically hypoactive sexual desire disorder (Sexual Dysfunction). And like all good competitions, the results were split. Some studies showed improvements in sexual functioning, and others showed no change. And because there was no good tiebreaker for the long-term use of testosterone to treat sexual dysfunction (a.k.a. a prospective randomized controlled study), doctors were hesitant to prescribe it.

Furthermore, due to the limited data, the FDA was not willing to put their stamp of approval on testosterone treatment. For this reason, transdermal testosterone is only used to treat hypoactive sexual disorder in the short term, that is, no greater than six months. Long-term use is not recommended, no matter how hypoactive your sexual desire is.

We tread lightly when using testosterone because it is teeming with negative side effects. Think acne, facial hair growth, deepening of your voice, and cardiovascular complications. Not fun. Additionally, some researchers have noted an association between testosterone use and breast cancer. While the link is loose, it is another reason to opt for the short-term rather than long-term use of testosterone.

When it comes to hormones, testosterone is not the only game in town. While testosterone has gotten a lot of attention, it seems to work best on hypoactive sexual disorder (a.k.a. I am just not that interested).

When the desire is there but vaginal dryness is holding you back, cue estrogen. Low estrogen (think menopause and breastfeeding) leads to a loss of vaginal lubrication. Vaginal dryness equals vaginal discomfort, and collectively, these symptoms are a common culprit in sexual dysfunction. Vaginal estrogen (tablets, gels, creams, and rings) can be particularly helpful in alleviating vaginal dryness (picture a hose in a desert).

Oral estrogen can also add some water to the well but is generally not as effective as vaginal estrogen for the treatment of vaginal dryness. Going straight to the source is way more effective! Last, adding vaginal lubricants or moisturizers (Astroglide, Replens, etc.) will help to turn up the power on that hose and further reduce the dryness.

Hormones are certainly helpful in hampering sexual dysfunction. However, they are only the half of it. Treatment will generally take on many other forms, such as the addition or subtraction of other medications, counseling, and physical therapy. So, while our Fountain of Youth remains dry (no pun intended), the combination of treatments may just do the trick. It may not fill up that well, but it’s worth a shot!

Variety, Variability, and a Very Good Surgeon: The Many Flavors of Removing the Uterus

As if reaching a decision about if and when you want to get your uterus out is not enough, you now must also decide how much and in which way your uterus will come out. Unbeknownst to many, the uterus can come out from above (a.k.a. abdominal), below (a.k.a. vaginal), or a little of both (laparoscopic assisted or robotic). But it’s not so cut and dry (no pun intended). Imagine you are standing on line at your favorite ice cream shop. In those minutes before you give your order, you run through the options and the pros and cons of the various choices—chocolate with sprinkles, vanilla with chocolate chips, or maybe toffee crunch with nuts. Although whatever gets you to go with chocolate over vanilla is not so memorable and fairly insignificant, what makes you choose a vaginal hysterectomy versus an abdominal hysterectomy or doctor A versus doctor B should be unforgettable. So, as your favorite ice cream scoopers, here’s what’s on the menu—step by step.

Flavor (Is my uterus coming out?)

The first decision that must be made (whether on the ice cream line or in the hysterectomy process) is the most basic one: are you going to remove your uterus? This decision is a big one, and when making it, you must be comfortable and clear on why you are doing what you are doing. Is it because of pain, pressure, bleeding, or cancer? And have you tried medical or non-surgical treatments before moving on to surgery? Whatever the reason there must be a reason and a reason that does not have any other solution. And while we are not knocking vanilla ice cream, your reason for taking out your uterus should not be “vanilla!”

Cone or cup: Are you going to take out all of it (a complete hysterectomy) or a part of the uterus (a.k.a. a supracervical hysterectomy?)

After you decide what flavor you are choosing, you must decide how to eat it. Translate that into your uterus. After you decide if you are going to take your uterus out, you must decide if you want to remove your uterus and cervix (total hysterectomy) or just your uterus (supracervical hysterectomy). There has long been a suggestion that women who take out their cervix will suffer sexual consequences, dysfunction, and urinary incontinence. However, more recent data have debunked these theories, and most women opt to take the cervix out with the uterus to reduce the risk of cervical cancer. And while you have a lot of say in what you are going to leave and what you are going to remove, your doctor will also be a big part of this decision.

Toppings (Is my uterus coming out abdominally, vaginally, laparoscopically, or robotically?)

Even for us GYNs, it’s sometimes hard to believe how many different ways there are to remove the uterus. Long gone are the days of it’s abdominal or bust. Depending on things like the size of the uterus, the pathology (problems) affecting the uterus, the shape of the vagina, the presence of other medical conditions (think things like heart and lung disease), past surgical history (previous abdominal/vaginal surgeries), and the need for concurrent procedures (removing your ovaries as well as your uterus), one way may be recommended over another.

While there are pros and cons to each approach, research shows that, in most cases, the safest way to remove the uterus is vaginally. And while you may not be a candidate for a vaginal hysterectomy (the uterus is too big or you have had 3 C-sections in the past), it’s important to ask your MD why she is recommending a certain route and why you are not a candidate for another. It’s your uterus, and you deserve answers. And remember, the answer should never be because that is what the surgeon is most comfortable with…it should always be what you are most comfortable with.

With a cherry on top (Whom are you selecting as your surgeon?)

Deciding who is going to do the “scooping” (a.k.a. your surgeon) is a big decision. Not all “scoopers” were created equal. Some of us scoop daily, while others scoop no more than once a year. And as you can imagine, the more you do it (otherwise known as operate), the better you are at it. Make sure to ask about the surgeon’s experience, surgical outcome data, and training. It can make a huge difference in how your procedure goes.

While this is no ice-cream parlor and you may not be lining up to get your uterus out, if done in the right way, for the right reasons, and with the right surgeon, you will be enjoying an ice cream cone in no time. A hysterectomy may not be the treat you were dreaming of, but it will likely take care of many of your problems—at least when it comes to your female organs. So start building your perfect “hysterectomy sundae.” It can bring you sweetness and satisfaction for years to come!