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!

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!

The Low Down on the Low-Dose Oral Contraceptive Pills

Loestrin, Mircette, Yasmin, Yaz, Ortho-Tricyclin, Ortho-Novum, and Alesse—the list goes on and on. Many of us have sampled more pills than flavors at our local ice cream shop (even when the sign says one per customer). And no, it is not all in your head; different pills make you feel differently! Who is the culprit, or the Oz, making your body and maybe even mind feel different on Ortho-Tricyclen vs. Yasmin? Drum roll, please: it’s the progesterone!

While almost all oral contraceptive pills share the same type of synthetic estrogen component (ethinyl estradiol, a.k.a. EE) the progesterone content can vary significantly. Some may make you feel good, even great, while others can make you feel down right crummy. In order to understand the difference in progestins, we want you to picture your family tree. Hone in on four consecutive branches, or generations: from great grandma right down to you. And as with most families, generational changes are huge—think landline to the iPhone, black and white TVs to flat-screen monstrosities, a quarter to ride the subway to a whopping $2.50 per ride.

Similar changes can be seen in the generational changes of synthetic progesterone. The first-generation crew was not so specific in whom they “mated and connected with.” Therefore, they would bind to both progesterone and androgen receptors alike. Their affinity for the androgen receptors resulted in some unwanted side effects: think hair, acne, and bloating. Oh, what a joy! Such side effects made them somewhat unattractive and unpopular.

However, over the next several years, scientists found ways to alter the synthetic progesterone component and reduce the androgenic properties; this translated into way less negative side effects and even some positive ones! Such alterations made pills way more appealing and widespread in their use. Bottom line, if one type of pill (a.k.a. progesterone) doesn’t agree with you, try another. There are many “branches” to climb!

Now, while the progestin component varies, the synthetic estrogen component is pretty much always the same—think of the menu at Applebee’s. It’s just not going to change! However, while the estrogen content is always the same, the dose will differ. And what makes the modern-day pills low dose or, even better, low, low dose is the very low dose of estrogen that each pill contains.

Today, most pills have between 20–35 mcg of EE. This is in contrast to traditional pills (circa 1960), which contained about 50 micrograms of estrogen in each pill. The past 50 years have shown us how low we can go on the estrogen—minimizing clots, strokes, and a slew of negative side effects—while maintaining the efficacy. So although lower dose EE = lower negative side effects, lower dose ≠an increased chance of pregnancy. Currently, we are, taking it back to the limbo reference, as low as you can go without giving up on efficacy.

While intuitively, it seems that the lowest would be the best, this is not the case for everyone. Sometimes the low-low versions cause lots-lots of breakthrough bleeding; this can often be fixed by raising the estrogen dose. So just because low-low seems to be the “in thing” to do, it may not be right for your uterus. A slight bump up in the estrogen dose won’t take you back to the doses seen in the 1960s, but it will give your body just enough estrogen to maintain the lining and maintain your sanity.

You might be wondering what is up with the Tri and even Bi part in the name of some pills (e.g., OrthoTri-Cyclen vs. Ortho-Cyclen). For all of you number fans who can’t wait to travel back in time to middle school math class, tri means three, bi means two, and mono means one. The number part of the name describes the number of phases or changes in hormones that will occur throughout the cycle (a.k.a. the pill pack). Monophasic pills (Loestrin, Ortho-Cyclen, Yaz, Yasmin, Seasonale) contain the same amount of estrogen and progestin in all of the active pills. Biphasic pills (two-phase pills; e.g., Mircette, Ortho-Novum) alter the level of estrogen and progestin twice during the active pack. Last, triphasic pills (three-phase pills; e.g., Ortho Tri-Cyclen, Enpresse) have three different doses of estrogen and progestin in the active pills; the dose changes every seven days during the first three weeks of the pack. These triphasics were the original pills. Scientists were doing their best to mimic the natural cycle. However, research soon showed us that we didn’t need to vary the dose each week. Slow and steady could also win the race! In fact, monophasic pills are equally as effective and in many ways more tolerable. The consistency of the dose translates into less side effects and less breakthrough bleeding.

We have covered doses, phases, and progestins. Last but certainly not least is the number of active pills contained within the pill pack. Traditionally, pill packs contained 21 active pills and seven inactive (a.k.a. placebo or sugar pills). This, like the triphasic pills, was designed to mimic the natural cycle. However, newer formulations have increased the number of active pills to 24 and reduced the number of inactive pills to four. By altering the balance and pushing the pendulum a bit further to the right, there are fewer days off the active pills. Fewer days off the active pills means fewer days of bleeding. In fact, some women skip the placebo pills all together every month and only take the active pills. This does no harm to them or their fertility. It merely removes the need to buy tampons or pads.

Believe it or not, the pill has benefits beyond contraception. It can reduce the risk of ovarian and endometrial cancer, improve acne and unwanted hair growth, regulate the menstrual cycle, decrease heavy menses, reduce the size of fibroids and painful periods, treat PMS symptoms and menstrual migraines, and offer symptomatic relief to women with endometriosis. The list is long, and the benefits variable. Simply stated, the pill can do a lot more than prevent pregnancy!

However, with every peak there is always a valley, and with every pro, there is also a con. Even with the best medications, you must read the fine print. Although the pill has a lot of benefits, there are some of us for whom the glass slipper just doesn’t fit. Certain medical problems preclude women from even trying to shove their foot in! Such conditions include women with a history of blood clots (or a family member who harbors an inherited clotting disorder), impaired liver function, smokers older than 35 years, elevated blood pressure, migraines with visual aura (think flashing lights), and markedly elevated cholesterol/triglycerides. Before starting you on the pill your doctor will likely take a thorough medical and family history to make sure you are a good candidate.

You will likely not marry the first person you date or say yes to the first dress you try on. Don’t quit after one bad month on OCPs; just because one didn’t agree with you it doesn’t mean the dozen others will too. OCPs are a great form of birth control and come with a lot of other benefits. As long as you can remember to take it daily (put it by your toothbrush or face wash!), it’s worth giving it a go. You’ll find something that fits!

Pap Smears, Pelvics, and Plenty of Good Advice

Most of us associate Pap smears with the OB/GYN. A light goes off in our head, usually around the same time every year, that says, “You need a Pap.” After you make sure to get a bikini wax and shave your legs (we do it too, but we promise your GYN does not care!), you book your appointment, and off you go. When you get there, you might be surprised when your OB/GYN, or GYN-O, as we know many of you like to call us, conducts nothing more than a pelvic exam, a physical exam, and a good old-fashioned chat. You may be thinking, has she/he developed a case of memory loss and forgotten that I need a Pap? And although we may be super tired from that delivery the night before (yes, we work a lot of nights!), no, we have not lost our minds. Pap smear guidelines have changed a lot over the past 10 years, and most women no longer require yearly Pap smears. Pap smear recommendations change faster than Kim K changes husbands. It’s sort of hard to keep up. And we don’t expect you to. But what we can tell you is that things have loosened up a lot (unlike Kim K’s clothes!). We are less aggressive with what we biopsy and what we remove. We Pap less frequently, and we watch and monitor a lot more. And while we want to see you and hear what’s up in your life, we want to see your cervix a bit less.

For starters, we no longer perform Pap smears on anyone under the age of 21 (regardless of when they started to have sex). While it is a good idea to visit a GYN at about 15 years of age, Pap smears are no longer part of this visit. Data demonstrated that testing such young women did more harm than good (meaning invasive procedures due to abnormal results that would have gone away on their own). Furthermore, after the first Pap smear (if all looks good), we won’t invite your cervix back for another three years. Pap smears can be performed every three years in women between the ages of 21–30 if they are totally negative. And get this: if you are between the ages of 30–65, your Paps are normal, and your HPV (human papillomavirus) test is negative (called co-testing), then we don’t need to see that cervix for five years! If you opt for just the Pap smear, then we need to see you every three years. While we still want to see you and dish on what happened last year, we don’t need to do a Pap smear if the above guidelines are met. Once you start to collect Social Security (age 65), if you have never had any high-grade cervical abnormalities (HGSIL), you can say adios to another Pap smear. The only time the above rules don’t apply (at all) are women who are HIV+ or have severely weakened immune systems. Furthermore, if your Pap smear has been abnormal and your biopsies have come back abnormal, you will be on a totally different plan.

The screening intervals have been spaced out, not because insurance companies are trying to save money (although that is usually the right answer) but because, in reality, most cases of cervical cancer occur in women who were never screened or who were not screened well—not women who were screened by guidelines. If you follow the rules, it’s very rare that you will get burned. Cervical cancer development is slower than the slowest tortoise in a tortoise-and-hare race. It usually takes years and years and years (about 10) for an HPV infection (the most common precursor) to develop into cancer. In many ways, HPV and cervical abnormalities/dysplasia/cancer are the opposite of the chicken and the egg. While both are always seen together, in this case, we know who came first! HPV, specifically subtypes 16 and 18, cause the majority of cervical issues, including cancer. Interestingly, while most of us will contract HPV in our teens/early 20s (about 70% of sexually active college-age women have or have had HPV), most of us will clear it by the time we hit our middle to late 20s and 30s. Most women younger than 21 will clear the HPV infection in eight months. In fact, the majority of HPV infections have said hasta luego two years after they landed on your cervix.

It is when we hit the big 3-0 that things start to change and the HPV infections that are there are more likely to stay there. It is for this reason that HPV co-testing is only done in women older than 30; by this point, if it is still present, we are way more concerned. HPV testing can also be used to sort out if a mildly abnormal (medical term “ASCUS” on the Pap smear report) needs to be investigated further. If the HPV is positive, the situation is way more serious than if the HPV is negative.

Many of us are grade obsessed, number fanatics, and goal oriented. We are not much different when it comes to our health. So here is what those grades mean. Generally speaking, Pap smear reports can be thought of as negative (a.k.a. normal) or abnormal. This may be the one time you want to be negative! The abnormals are like college kids living in New York City after they graduate. That one-bedroom apartment is subdivided in a million different ways to house many and cut costs. Pap smear reports will report on a bunch of things. However, what you are most likely to hear about are the squamous cell abnormalities (these are the main cells that make up the cervix and can become cancerous!). Squamous cell abnormalities can fall into one of the following categories:

  • Atypical squamous cells (ASCs of undetermined significance = ASCUS or ASC. We cannot rule out more serious abnormalities)
  • Low-grade intra-epithelial lesions (LGIL or CIN 1)
  • High-grade intra-epithelial lesions (HGSIL or CIN 2 or CIN 3).

As you walk up the stairs, the abnormalities become more significant. You are climbing closer and closer to cancer. It is for this reason that the interventions become more and more serious; you may go from an office-based biopsy (medically termed colposcopy) to a procedure where we cut out a portion of the cervix (LEEP or cold knife cone). While Pap smears have the ability to tell you even more than we listed above (such as cellular changes suggestive of an infection, the presence of endometrial cells and glandular cells), these are much less likely. We have backed off big time with the screening, not because we want to see more badness, but because we want to prevent badness. Excisional cervical procedures increase the risk of preterm labor/preterm delivery. The cervix is there, at the end of the uterus, to keep things closed until it’s go time. If there is only a sliver of cervix left, it is going to have a hard time doing its job. By avoiding unnecessary procedures in young women who will most likely clear the HPV infection and the cervical cell abnormalities, we avoid future fertility issues.

Breaking news: if you are young enough (we are not!) to have received the HPV vaccine, that does not mean you don’t need Pap smears or cervical screening. HPV vaccine is like a really good insurance policy. However, it doesn’t mean that you can’t be caught in a bad flood or have a house fire. You still need cervical screening and should follow the same age-appropriate guidelines.

The yearly trip to the OB/GYN is usually met with the same feeling we have when going to the dentist. Yes, you have to do it but are always a little afraid to hear what they have to say. Most of the time, it’s good. You get the all clear and don’t need to worry until the next year. Even if you don’t need that Pap smear, you do need to go to the doctor. While we don’t clean teeth, we don’t check your vision, and we don’t check your hearing, we do make sure that your female organs are A-ok. Make sure when you do get a Pap smear you write down the results and keep it with your most treasured items (Grandma’s earrings, Mom’s ring, your first lock of hair). That way you will not only know what’s up, but also if you move or move away from your OB/GYN, you will know what happened in the past. You don’t need to understand the grades or know when Kim gets divorced and remarried (that is, the Pap smear guidelines change), but you should be the master of your own medical records. It will cut down on a lot of unnecessary testing.

Emergency Contraception: What to Do When You Are in a Big, Big Bind!

Accidents happen to the best of us. Let’s face it: we all make mistakes. When owned and recognized early, they can frequently be fixed. Contraception (or lack thereof) can fail. Pills can be forgotten, condoms can be broken, and timing can be off. Luckily, emergency contraception is available and if used appropriately can effectively prevent pregnancy in the majority of cases. Emergency contraception comes in two basic forms—oral and intrauterine (the Copper T IUD). As the oral form was the original and is available over the counter for women above the age of 17, it is the form that is much more well-known. In fact, it’s fair to say that most women are unaware that there is even another option out there!

Furthermore, the IUD (a.k.a. the “other” form) requires a visit to your OB/GYN as it must be placed in the uterus by a medical professional. But common things being common, the most commonly used oral emergency contraception is either a combination estrogen and progesterone pill or a progesterone-only pill. One regimen requires two doses administered twelve hours apart, and the other, just a one-time dose. These medications are currently available to almost all in need at the nearby CVS or Duane Reade; where the medications will be placed (over-the-counter vs. pharmacist) is dependent on age. The line in the sand has been drawn at 17; women younger than 17 require a prescription to get the goods, while women 17 and older can pick up the medication without a prescription.

When the medication is taken or placed (in the case of the Copper T IUD) is key; the success of the drug is dependent on how soon in relation to the “event” (a.k.a. unprotected sex or contraception failure) it is taken. After 120 hours (five days), emergency contraception is virtually ineffective. Simply stated, you can take it, but it won’t work. If taken within 72 hours, the chance of success is really high—here are the stats. Data from research done by the WHO (World Health Organization) show that, if taken with 24 hours, 95% of pregnancies are prevented, if taken in 25–48 hours 85% of pregnancies are prevented, and if taken within 49–72 hours 58% are prevented.

After that, we still see success but at a much lower rate. Not surprisingly, an IUD placed for emergency contraception works almost in overtime; less than 1% of women who use the IUD get pregnant. And with the IUD, the hits just keep on coming. It not only works for that act of unprotected intercourse but also serves as excellent contraception for the future. While side effects do exist, they are generally mild and fairly tolerable. The most common include nausea, vomiting, and irregular bleeding. The medications can throw off your menstrual cycle, causing irregular bleeding. Both are transient and will resolve fairly quickly. If the nausea is bad, an anti-nausea pill can be taken to help you keep things down.

Emergency contraception can be taken more than once in the same cycle and, if need be, again in future cycles. The medical data do not show that multiple doses are unsafe. However, keep in mind that emergency contraception is best used in emergency situations. Additionally, it is less effective at preventing pregnancy than almost any other form of contraception, and therefore, if you continually find yourself scouring the aisles of your local drugstore, you are overdue for a visit to your OB/GYN to discuss a reliable form of contraception. Just to make sure we are all on the same page, emergency contraception is not the same thing as an abortion. An abortion terminates or ends an existing pregnancy. Emergency contraception prevents a pregnancy from happening. If an embryo has already burrowed its way into your uterus and has begun to grow, emergency contraception won’t work.

No one really wants to take the morning-after pill or have an IUD emergently placed. But stuff happens. There are ways to prevent an unwanted pregnancy that have a really good chance of working. Go the drugstore, call your OB/GYN—take action. While you may be ready for a baby in the future, today is likely not the day. Know what’s available to you, know how to safely get what you need, and know that you are not alone. You are not the first person this has happened to, and you certainly won’t be the last!

Our Yearly Date: We Name the Place, You Name the Time

When your Google calendar and iPhone reminder flash GYN appointment, time to get a bikini wax, you probably think to yourself, Ugh, maybe I can come up with an excuse to cancel. And after a couple times of “I have a cold. I have a work event,” and simply, “I totally forgot,” you finally force yourself to come in and see us. The annual GYN exam is sort of like jury duty. You can run, but you can’t hide. At some point, your GYN needs will catch up with you, and you will have to sit in our “chair.” And while we are certainly not asking you to judge anything, we are asking you to recap your past year(s) and think about your future. Am I ready to have a baby? Should I be on contraception? Do I need a Pap smear, STD screening, or a breast exam? We want to break it all down and make sure that you are doing the best things for your body.

First things first. Your trip to the GYN should be yearly (at the least). Although acute issues (UTI, vaginal discharge, vaginal itching, abnormal vaginal bleeding) may require an immediate trip, the routine stuff doesn’t need to be dealt with more than yearly. And while this yearly meeting may no longer include a Pap smear, it should most certainly include a discussion on previous Pap smears and future Pap smear screening. The recommendations have been modified, and women in their 20s and 30s without a history of abnormal Pap smears may no longer need yearly cervical checks. However, that doesn’t mean you don’t need to check in with your OB/GYN. Despite the common misconception, we GYNs do a whole lot more than Pap smears!

This annual aloha should first and foremost include a lot of talking. We will discuss eating habits, exercise, sleep patterns, work-life balance, stressors, medications (both prescription and supplements), and relationships. Have your parents, siblings, or grandparents acquired new diseases? Have there been new genetic findings in the family? Additionally, it is super important to address all things sex: sexual health, sexual orientation, and sexual activity (nothing is off limits with your GYN!). We also need to address drinking, smoking, and partying behaviors. While we are totally down with you having a good time, we want to make sure that you are safe. Lastly, no visit to the GYN would be complete without a period pow-wow. What’s going on with your period? What’s the cadence of the bleeding? Are you spotting, and are you having crazy cramps? Abnormalities in your period can shed a lot of light on what’s going on with your ovaries and uterus.

When it comes the exam part, it’s important to have your blood pressure checked and your height and weight measured every year. We also recommend a yearly breast and pelvic exam. For those who are sexually active, STD screening is a good idea (age and risk factors are used to determine whom to screen, for what disease, and how frequently). In women with a strong family history or a personal history of a particular condition, we may consider checking certain blood levels such as cholesterol and lipids (fat). If other symptoms arise—problems hearing, seeing, or headaches—we will address them with the appropriate tests. In many ways, the visit is a debrief, a review of what went well and what didn’t go so well the year before. Together, we can plan on how to attack your next year head on.

Without trust, you won’t be comfortable bearing it all—which is big-time important in making sure you stay healthy. Like all good partnerships, your relationship with your GYN of choice needs to be built on trust. Unlike the jury you may be called to sit on, we are totally not judging you (for what you do/did or if you waxed/shaved!). We want to take the evidence you present us with and make sure you are not doing your body or your brain any harm. Some actions can stay on your permanent record, no matter how good your lawyer is. Let us make sure your record stays clean!

Inflammatory Soup with a Side of Adhesion Bread: Endometriosis

There are certain subjects in school (think calculus, physics, and for some of us, poetry) that just make you want to go, “Ugh.” Looking at formulas or sonnets makes you want to rip your hair out. No matter what you do, you just don’t get it. In many ways, the same can be said for endometriosis (a.k.a. endo). It is sort of like that black box in gynecology and infertility. We know it hurts. We know it can cause infertility, and we know it can cause problems. But we’re still a bit unclear on the hows and whys. How does it get there? Why does it get there? How does it cause pain? Why does it cause pain? While many of these questions have the start of an answer, they lack a conclusion. The unknown can make them hard to diagnose, to manage, and to treat.

Welcome to Endo 101. Here, we will give you the abridged version. Endometriosis is the implantation of endometrial tissue (that is, the tissue that is supposed to stay inside your uterus and only your uterus) in other places. How these cells break free from their uterine jail is as much of a mystery as how El Chapo escaped from jail. However, once the inmates (or cells) have been released, it’s tough to get them back in.

Many of us in the biz or in the know refer to endometriosis as “endo.” The shortened nickname does not mean the symptoms and the negative side effects that its presence brings are in any way short. In fact, this laundry list is quite lengthy. Women often report symptoms ranging from pain (including pain with periods, intercourse, defecation, and urination), infertility, diarrhea/constipation, and a no-joke impact on one’s quality of life. Symptoms can even be as vague as back pain, chronic fatigue, or abnormal bleeding.

The degree of pain and even infertility can be mild, or it can be severe. And the worst part of it all is that the extent of disease doesn’t equal the degree of symptoms (it’s sounding even more like calculus!). The trickiest part about endo is that, to diagnose it, you must operate on it. Symptoms and even visuals (ultrasound images) can’t make the call (although they can come pretty darn close). You must go to the operating room and have the tissue sent to the pathologist for a diagnosis. Although you can be nearly certain that the diagnosis is endometriosis, you can’t prove it without a reasonable doubt until the eyes of your pathologist friend sees the evidence. The judge and jury here are pretty small.

If you are suffering from endometriosis, you have probably thought on many a night, “Why me?” How did I win this unlucky lottery? Endo is no $200 million Powerball—it is actually fairly common. In women undergoing surgery for pelvic pain, up to 30% will have endometriosis. It’s nearly impossible to know how common endo is in the general population because many women will have it but won’t even know it. Bottom line, it is likely way more common than we know.

What makes someone more likely to hit the “un-lottery” lottery has not been fully worked out. While we know that there is definitely a genetic component, the endo gene(s) have not yet been identified. However, if your mom, grandma, and sister have it, there is fairly good chance you will, too. Other likely originators of endo include:

  • Changes in the immune system,
  • Retrograde menstruation (when the blood goes backwards through the fallopian tubes into the pelvis rather than out of the cervix into the vagina), and
  • The passing of endometrial cells through the lymphatic system (think lymph nodes, which are actually located not just in your throat but throughout your whole body!).

Who will win a game of Roulette is anyone’s guess, but our money is on a mixture of all three. Additionally, women are less likely to have endo if they have had multiple children, breastfed for a long time, or got their first period later.  On the flipside, women are more likely to have endo if they have not had children, got their periods early, went through menopause late, bleed for longer duration with their periods, have more frequent periods, and variations in their reproductive anatomy (called Mullerian anomalies). While you may have gotten it without any of the above, we as fertility MDs are definitely more likely to look for it in certain women.

The thing about endometriosis is that it only makes a peep when estrogen is around. If there is no estrogen (hence hormonal contraceptives, Lupron, or menopause), endo is quiet as a mouse! Because it can’t act without estrogen, it pretty much only impacts women during their reproductive years (late teens to 40s). For this reason, most of the treatments center on shutting down the production of estrogen. It’s like taking the logs out of the fire. Without fuel, nothing can burn! While this sounds all well and good, most of us can’t be without fuel for our whole life. At some point, you might want to get pregnant. This will require adding fuel back to the fire. For this reason, it’s not a bad idea to see a fertility specialist before you stir things up.

Endo plays a pretty bad game of hide and seek. (Basically, we can see it coming from a mile away!) When the decision is finally made to go into the operating room and take a look, the disease is often pretty easily spotted. While the most characteristic appearance consists of the blue/brown “powder burn” spots, the look of endo can be very Houdini-esque. Endometriosis can look like brown spots, red patches, yellow-brown discoloration, or white spots.

To know for sure what’s up, the tissue must be sent to the pathology lab for a thorough onceover. The most common places for endo to hang out are on the ovaries, on the tubes, in the pelvis, on the ligaments that hold up the uterus and the ovaries, in the colon, and on the appendix. Where it makes its home often translates into the symptoms that you have. Again, this is not always the case. Some women can have endo painting their ovaries, their tubes, their pelvis, and their colon and experience no symptoms.

While surgery is required to make a diagnosis, not everyone needs surgery. A good history, physical, and sometimes imaging can give us enough info to convict (a.k.a. start treatment). The treatments are plentiful (think Thanksgiving Day dinner) and will be passed around to see which “tastes” best for your body. Women who are trying to get pregnant ASAP will have to opt out of most of the dishes (although options still exist). The silver lining with endo is that, for almost all women, the symptoms disappear during pregnancy. While we don’t recommend getting pregnant simply for an endo time-out, it will make matters way better.

Unfortunately, endo is the gift that keeps on not gifting (or re-gifting things you don’t want!). And unlike a good gift giver, there is no receipt and no return policy. If it is yours, it’s yours for life. There are many ways to tailor that shirt or tighten those pants so that you can live with them. Same goes for endo. We can do a lot to make you pain free if we know what’s putting you out. It’s definitely a bumpy ride. You may need several fittings, but we know a pretty good tailor. Just make sure to be completely honest with your doctor, and do your research before committing to any treatment.

8 Symptoms That Suggest You May Have Endometriosis

Most of us have never even heard of endometriosis (a.k.a. endo) before our GYN throws it out there as a possible reason for those wildly unpleasant symptoms that wake you up every 30 or so days. When getting your period feels like getting hit by a sledgehammer, you very well may be suffering from endo (the implantation of uterine tissue on other organs in the pelvis/body). Here are some other red lights that should flash “endo” in your head.

  1. Painful Painful Painful Periods
    For most of us, no period is a fun period. Those three to five to seven days are never anyone’s idea of a good time. However, for women with endometriosis, these days can be debilitating (and they can start about 1–2 days before your period even begins)! The pain that comes with your periods can put you on the sidelines from work, from exercise, from socializing, and from life. Lying in your bed doubled over in pain is nobody’s idea of a good time. Medically painful periods are called dysmenorrhea. We GYNs ask about it all the time because it gives us a better idea about what you are going through when you get your period. It is the most common symptom associated with endometriosis (nearly 80% of women with endo report it). Therefore, if you are one of the unlucky ladies who languishes on the couch during your time of the month, it’s time to share this info with your doctor.
  2. Chronic Pelvic Pain (a.k.a. Pain All the Time)
    When you are singing the “pain, pain go away, come again another day” song, without any relief in symptoms, no matter where you are in your cycle, there is a pretty good chance that you have endometriosis. The pain can be sharp or dull, focal or diffuse—bottom line, it can be pretty variable. Chronic pelvic pain is seen in about 70% of all women with endo. It can cause a serious roadblock in one’s ability to function both at home and in the office and therefore needs to be cleared ASAP.
  3. Pain with Intercourse
    Women who have endo complain of pain with intercourse (medically termed dyspareunia) fairly frequently (about 45% of women with endometriosis report this symptom). The pain reported is generally a sensation of pain in the pelvis with intercourse (not pain with insertion or vaginal pain). As expected, it can have a serious impact on a woman’s quality of life, and while many women hold back in talking to their GYNs about sex, this is something you should definitely share.
  4. GI Distress
    Endometriosis is not picky in whom she decides to annoy. Lesions are not only limited to the reproductive system but also set up shop on the bowel (intestines). Where they lay their roots dictates what symptoms are felt. GI symptoms include diarrhea, constipation, bowel cramping, and difficulties going to the bathroom. Bleeding from the rectum can also occur. For some women, the GI symptoms can be worse than the GYN ones; it can be pretty intense.
  5. Infertility
    One of the biggest criminals in the infertility battle is endo. Endo can have a seriously negative effect on a woman’s ability to conceive—it can be a pretty formidable challenge for us in the Land of Fertility. The good news is that our treatments can also throw a pretty strong punch, and they can usually knock it out. Pregnancy is most certainly not impossible in women who have endo.
  6. Ovarian Cysts
    The most common site for endo to set up shop is in your ovaries. While the implants can be superficial and select, they usually form a cyst(s). The cyst (medically termed endometrioma) can cause some serious pain. It can also eat away at your eggs and reduce your egg quantity; this translates into what we call diminished ovarian reserve (low egg quantity). While surgery can help with cyst size, it can further hamper your egg reserve. Make sure that you consult with a surgeon who is skilled in endometriosis surgery before you make a date for the operating room. There is no frequent flyer program for surgery. Therefore, you want to limit the number of times you go to the operating room.
  7. Pain with Urination
    Although this may come as a shock, endometriosis can hang out in your urinary tract system. When it pitches a tent, it can cause urinary frequency, urinary urgency, urinary pain, and even retention. Not fun. These symptoms can be scary and confusing, especially when you are totally in the dark about the connection between the urinary system and the GYN system. The two are pretty close, and as a result, one can rub off on the other pretty easily. Definitely let your GYN know what your urinary system is up to.
  8. The Odd Ones
    Endo could be a US spy—it can slide and slink its way into almost every corner of the body. It has been reported in the lungs, the arm, the thigh, the diaphragm, and even surgical scars! So while it is unlikely to hide out in these spots, any atypical symptoms should be reported to your doctor, as it might break the code as to what’s going on in other parts of your body.

Put them all together, and what do you get? No, not bibidi bobidi boo, but rather a pretty bad case of the blues. The symptoms of endometriosis can take quite a toll on your quality of life. They can cause you to withdraw from friends, family, and all sorts of fun. Don’t suffer in silence. There are not only thousands of women who are in a similar situation but also several physicians who are well equipped to treat your pain. We just need to know what’s bothering you, how bad it is, and how best to fix it. Together, we can knock this out!

Oops, I Missed a Pill…Did I Mess Everything Up?

One of the most frequently Googled GYN questions is “What do I do when I miss my pill?” Pill oversights, although common, can cause a lot of panic and fear. Getting pregnant now is not an option! Staring at the pack and realizing you are up to Tuesday but it is Thursday can be horrifying. However, the reality is that, if you haven’t at some point in your pill-taking career missed a pill, you deserve a medal. Almost all of us have had an oops or an uh-oh over our one, five, ten, or fifteen years of taking the pill. You are most certainly not alone.

When you miss a pill, the first question to ask yourself is, how many did I miss? When you miss just one pill, it’s no big deal. Just take the missing pill as soon as soon as the light goes off in your head. If it is not until the next day, take the missed pill plus that day’s pill together.

If you miss two-plus pills, that is slightly more of an issue and requires some more effort. Again, once you have your “a-ha I missed my pills moment,” take both ASAP. Then resume your daily pill schedule.

However, forgetting to take a pill is like forgetting to brake when approaching a red light. The ignition will rev up, and you may roll right through an intersection. Without the daily suppressive effect of the pill, your brain may start to develop a follicle and get ready to release an egg. So to prevent pregnancy, the best thing to do is use an additional form of contraception (a.k.a. condoms) until you have taken seven days of active pills.

If the oops was in the last week of the active pills, don’t take the placebo week; restart a new pack a week early.

If the error was in the first week and you had unprotected sex, you should strongly consider emergency contraception (a.k.a. Plan B) as well as continue with your current pack for maximal protection. Call your doctor, and let him or her know what happened so that together you can design a plan that will prevent pregnancy.

When thinking about pill errors, think in terms of sevens:

  • It takes about seven days of continuous pill use to prevent ovulation.
  • Never take fewer than 21 consecutive active pills.
  • Never have more than seven pill-free days (any longer than this gives the body a chance to ovulate).

While seven may not be your lucky number, if you follow those rules you will make sure you stay lucky (and not pregnant)! One notable news flash: if you forgot to take the sugar pill (a.k.a. the placebo one), don’t sweat it. Those pills are not doing anything more than keeping you in the habit of taking a daily pill. However, if you miss any of the active pills, even if you followed the back-up schedule, take a pregnancy test. Although many women on the low dose or the low, low dose pills don’t get a period, it’s best to check and confirm a negative.

The majority of unintended pregnancies on the pill occur from missed pills. If you are one of those who seem to suffer from forgetfulness as it relates to the pill, then oral contraceptives are probably not right for you. There are several other forms of reliable hormonal and non-hormonal contraception that can do the same trick without requiring the daily light bulb to go off.

Remember, mistakes happen. Most of these momentary lapses are not a big deal. In an effort to minimize these hiccups, pair your pill pack with a daily activity that you never forget—brushing your teeth, washing your face, taking your contacts out. This will help minimize mistakes and maximize effectiveness. We want this to work for you until you are ready to work on becoming a mom!

Am I Ready to Be a Parent? Single Parenthood

Of all the questions we ask ourselves, “Am I ready to be a parent?” is probably the biggest one (followed by “What should I wear on that first date?” and “Should we go for dinner or drinks?”). But all kidding aside, knowing when the time is right to become a parent can be downright difficult. Even us non-lawyer types can convincingly argue both sides and sway even the toughest of juries (ourselves, our besties, and our family) to see it our way. Add to that deciding to go at this on your own, and the decision can be even more difficult. When embarking on single parenthood, you need to think about things like sperm source, fertility medications, inseminations, and ultrasounds. Sorting this stuff out can make even the most level-headed among us a little loopy.

But just like any legal battle, evidence is needed before a decision can be made. And to get to that decision, it takes time, research, and a whole lot of effort! Deciding if, when, and even how to have a baby without a partner is no different. It takes a lot of thought and evidence before you can reach your decision. And although it is unlikely that we will be sitting with you when your personal verdict is delivered, we can offer some advice on how to craft your argument about if single parenthood is right for you (#PROSandCONS).

PROS

  • You are ready to be a mother. You don’t want to freeze your eggs and think about becoming a parent in the future but are ready to become a parent (without a plus one) today.
  • You no longer want to wait for someone else to do this with—you are pretty sure that you can do this on your own.
  • You spoke with a fertility specialist, reviewed all options, and are cleared for pregnancy (a.k.a. you are in good health, your reproductive organs ready, and you have selected a sperm source).
  • You have thought about your decision for a while; it was not made in haste.

CONS

  • You are not physically your best you. While most of us can tolerate pregnancy (aside from the back pain, the constant urge to pee, and the swollen hands and feet), there are some medical conditions that preclude us from getting pregnant. Although most of them can be fixed (blood pressure can be controlled, diabetes can be regulated, and seizure medications, changed), it is super important that you deal with all of this before you get pregnant.
  • You are not financially stable. Kids cost money! And while you certainly don’t need to be a billionaire before you bring a baby into this world, you do want to make sure that your financials are in order before you start a family.
  • You are not emotionally ready. Children require A LOT of attention and time. They are pretty much all-consuming all of the time. Make sure you are ready to give of yourself to someone else before you go all in.
  • While you want to be a parent, you don’t want to be a single parent by choice.

Odds are that, although our list may not match your list, there is probably a good amount of overlap. Minus the few additions or subtractions, at the heart of it lies the big question: “Are you ready to do this on your own?” And while we as physicians can’t tell you which way your “jury” will go (a.k.a. are you ready to do this?) we can tell you if your uterus, your ovaries, and your body are ready do this.

Furthermore, no matter how long that list is, we can assure you that while you may be thinking of this as single parenthood or as “having a baby on your own,” you are really never alone. You have friends, you have family, you have your fertility team, and you have an entire community of individuals who have also become single parents (many who are eager to share their experiences and offer advice). Go and speak to your OB/GYN and/or a fertility doctor—they can not only provide you with the information about the process but also help you make this baby thing happen.

We will make this closing argument brief. If you want to be a parent, you can become a parent. The modern family has many different faces. Find out what you want yours to be, and shape it. In this courtroom, you write your own verdict. While the process of becoming a parent may take a slightly circuitous path, with a knowledgeable physician and a good support system, you can certainly do this—case closed!