Fibroid: What to Do When Fertility Is Not on Your Mind

If you have fibroids, you are probably saying a choice curse word every time you think of your little (and in some cases) big uterine friend(s). Like a bad house guest, they can be a big pain in the rear end. They can cause bleeding, pain, pressure, and infertility. Bottom line, they are not fun. And unfortunately, this un-fun party is very well attended; nearly a quarter of reproductive-age women have fibroids. Furthermore, fibroids are the cause for about 2% of infertility cases.

Simply stated, you are not the only person who RSVPed “yes” to the fibroid gala. While there are many ways to treat them, not everything works for everyone at every point in their life. Women at different stages of their lives (a.k.a. reproductive “stages”) and symptomology warrant different procedures. For those of you who are nowhere near ready for anything to do with the F word (FERTILITY) but want it in the future (be it near or distant), here’s what we recommend.

Fibroids can be treated medically and/or surgically. Medical treatments include oral contraceptive pills (a.k.a. OCPs or the pill), the intra-uterine device (a.k.a. the IUD), Lupron (a.k.a. “I feel like I am in menopause with these hot flashes and vaginal dryness”), progesterone receptor modulators (mifepristone or ulipristal acetate), SERMs (raloxifene), aromatase inhibitors (letrozole), and anti-fibrinolytics. While some of the medical options are better at improving some of the symptoms (for example, OCPs will improve heavy bleeding but not the pressure symptoms), they very rarely fix it all.

Just like when you’re selecting the OCP you want to marry, you may have to shop around for medical options before you land at your symptom-free spot. While Lupron (a GnRH agonist) will do it all, it will cost you in the side effect department. Hot flashes, sleep problems, vaginal dryness, muscle and bone pains, and even changes in mood/thinking often come along with the reduction in fibroid bleeding, pain, and pressure. It’s because of the side effect profile that we don’t go with Lupron as our first medical treatment.  

Surgically, the options are limited for women who have not yet had kids. It’s basically a myomectomy or bust. Fibroids have been nicknamed myomas; -ectomy means removal so myomectomy = fibroid removal. While a myomectomy is the only option for you ladies who are not yet ready to part with your uterus, what varies in the myomectomy part is how you “myomectomize.”

The procedure can be performed abdominally (through a bikini-cut incision), laparoscopically (through a camera), robotically (through a robot), or vaginally (no explanation needed!). The approach depends on the size of the fibroid(s), the location of the fibroid(s), and the number of fibroid (s). It also depends on your surgeon’s experience and preference. Make sure you are comfortable with all of the above before you commit to anything or anyone.

As with most things, there are pros and cons to both medical and surgical options. If you like lists (we love them!), here are the important points to note. For most young women who have not had kids but want them in the future, we like to go medical first. Most of the medical options are transient and provide birth control (killing two birds with one stone!). While they will not rid you of your “f”riends, they will decrease many of your symptoms:

Bleeding, check.

Pain, check.

Protecting your future fertility, check.

In many cases, with medical treatment, the fibroids will shrink. Fibroids feed off estrogen, so low estrogen equals famine for fibroids, and hopefully your symptoms will dissipate. If medical management doesn’t do much to alleviate your symptoms, you may have to amp up your treatment to surgery.

Surgery will almost definitely bring the bothersome bleeding, pain, and pressure to a halt. However, it can increase your chance for scar tissue (both within the uterus and the pelvis) and other surgical complications. Surgery, no matter who does it, is the real deal. For this reason, you want to avoid going under the knife unless it is absolutely necessary.

The only absolute cures for fibroids are menopause and/or a hysterectomy. For women who have baby making on their mind and in their future (be it near or distant), neither of the above is a good option: major con! It is for this reason that we need to find a way to temporize the symptoms until you get the pregnancy process started. We usually recommend starting low and going high, but only if you have to. Give the easy or simpler stuff a shot first before you shoot in out of the park.

Just a side note: while fibroids are pretty pesky for most of us, some women are completely unaware of their presence. They find out totally by accident during an ultrasound, a pelvic exam, or during pregnancy. And just like if it isn’t broken don’t fix it, fibroids that are causing no symptoms are really no big deal. They can hang with you for as long as you both shall live. No divorce in sight.

If they don’t bother you, don’t do anything with them until you have to. Prophylactic or preventative therapy to avoid future problems is not recommended—no pre-nup here! Fibroids need to be fixed only if you can’t take them anymore. Otherwise, do your best to forget they even exist!

Can We Call a Cease Fire to Cervical Cancer? The HPV Vaccine

Admission….despite endless years of schooling, training, and then more training, there is a lot that doctors don’t know. We wish we did, because inherently it is in our nature to heal and to fix, but unfortunately, there are many questions in medicine that remain unanswered. Despite our fancy tools (and trust us, there are a lot!), we still lack that crystal ball. And not only can we not diagnose everything, but we also don’t always know why somebody gets a disease. The latter is super frustrating.

How does the woman who eats only organic, exercises daily, and has never smoked get breast cancer? How does the man who has never eaten at McDonalds and spends two hours a day on his treadmill have a heart attack? It simply does not make sense. Therefore, what we do know and what we can stop we want to share or, rather, shout as loud as possible! We want to make sure you know what you can do to decrease your risk, to stay healthy, and to prevent a bad event.

While most cancers are not preventable, for the most part, cervical cancer is. The majority of cervical cancer is caused by a virus (the human papillomavirus, or HPV): not the same virus that causes the common cold or a stomach bug but a virus that can infect the cervix and, if not treated over several years, lead to cervical cancer. Now, just like there are many different types of viruses that can ultimately lead to the same end point (e.g., the common cold), there are different strains of the HPV virus (120 to be exact!). And again, in the same vein as the common cold, some strains are going to knock you on your behind more than others.

So while there are 120 different viruses, about 40 HPV types (medically called genotypes) are sexually transmitted, and 13 have been shown to cause cervical cancer. And to whittle it down even further, about 70% of all cases of cervical cancer are caused by two HPV genotypes, 16 and 18, and 90% of genital warts are caused by HPV genotypes 6 and 11. Therefore, if you can avoid ever being infected with HPV, you will nearly eliminate your chances of getting cervical cancer. Additionally, because regular Pap smears will almost always pick up abnormalities on their way to cervical cancer, if you do get or are infected with HPV and develop cervical abnormalities (a.k.a. abnormal Pap smears), good screening and frequent visits to your gynecologist can ensure a bad thing doesn’t get worse.

But pap smears and the further testing that is required (colposcopy, LEEP, and the cold knife cone) when one is abnormal can be really scary (these procedures can translate into taking off a piece of your cervix). Additionally, it can become a tedious chore (you have to be seen every six months, and who has time for that?). If cervical surgery is required, it can put you at risk for a preterm delivery in the future. By avoiding an infection with HPV, you could avoid a trip on this unhappy merry go round. Although abstinence would do the trick, while we are mothers, we are not ignorant! From teens on up, girls are going to have sex; we do our best to educate and advise, but it’s going to happen. Therefore, the next best thing to do is to prevent the transmission of HPV. This can be done by a vaccination—just as we prevent the measles, the mumps, and polio through a vaccine, we can now prevent the spread of HPV. By vaccinating girls (and boys!), ideally before their first sexual encounter, we can significantly reduce the incidence of cervical cancer, anogenital cancers, oropharyngeal cancer, and cervical warts (now, that’s one heck of a shopping list—not one thing on there we would like to acquire!).

So currently there are two vaccines that have been approved by the FDA to work in preventing HPV infection. One protects against the big four genotypes of HPV (6, 11, 16, 18), while the other only protects against two genotypes of HPV (16 and 18). The latter is only approved for administration in females while the former (four) is approved for administration in females and males. The good news is this: if either is given in the right way—three doses, six months apart in girls (and boys) between the ages of 9–26 years old before they have been sexually active—it works really well. Under these guidelines, it’s nearly 100% effective.

In order to hit all these points, you need to start vaccinating girls (and guys) at a young age. In fact, the target age to start is 11 or 12 years old. If you miss the window and sexual activity starts before you start vaccinating (or you don’t start vaccinating until a later age), it is still worth a shot! While you may have already been infected with HPV, it could be just one strain (let’s say 6). That means that, while the vaccine won’t protect you from 6 or the goodies that come along with it (hello, genital warts), it will protect you from other strains (those that cause cervical cancer). So roll up your sleeve, and start the series, because it is still worth it.

Points worth mentioning…the vaccine can be given to girls as young as 9 and as old as 26; the window is large enough that you shouldn’t miss it. If you are late for a shot (say, you forget to come in 1–2 months after the first dose and roll into your GYN at month three) you are still okay to proceed. Once you start the series, no matter how long it is paused, you can finish it.

The only exception is pregnancy. While there is no definitive data to show that the vaccine is harmful in pregnancy, OB/GYNs recommend waiting to finish the vaccine series until your nine months are up. Breastfeeding women have the all clear to take the vaccine, as the HPV vaccine is inactivated (no live virus).

It’s a small price or “prick” to pay to protect yourself against cervical cancer and genital warts. Neither is pleasant, and we can assure you won’t be missed by anyone. While you still need Pap smears and still need to visit your OB/GYN for checkups, you can check some pretty unpleasant gynecologic conditions off your list if you follow the schedule. Despite the negative hype, vaccines are sort of amazing; we don’t get polio, we don’t get the measles. Now (if done in the way it’s prescribed), we won’t get HPV. This is just another example of how preventative medicine can be effective. So take yourself or your daughter and/or son to the OB/GYN. You don’t want to miss your window, for many women won’t get another chance.

How Does Food Affect Your Vagina?

While your diet and vagina may seem unrelated, what you ingest can make a difference in your vagina’s health. Vaginal odor, vaginal secretions, and overall vaginal health can be impacted by what you eat and what you drink. Here’s why….

You were probably unaware that your vagina is home to lots of good bacteria. And while you may never see them or even feel them, these bacteria are far from lazy houseguests. They are working around the clock to keep the vagina healthy, balanced, and acidic. Believe it or not, your vagina (just like your Secret deodorant!) is pH balanced. A normal, healthy vagina, in large part due to good bacteria, is acidic. This acidic environment helps to keep infection and the resultant nagging symptoms at bay. Therefore, when this balance is interrupted, your vagina can go a bit haywire. Here are some tips on what you can eat to keep your vagina in “tip-top” shape!

  1. Sugar: Sugar in many ways is public enemy #1 when it comes to your vagina. It increases your vaginal pH (a.k.a. makes things more basic), making you more prone to yeast infections. And while yeast infections are known for that annoying itchy sensation, they are not only uncomfortable but can also change the vagina’s odor.
  1. Salt: Although we, too, love a bag of potato chips, popping one open before you hop into bed may not be the best idea. Salty foods can decrease blood flow to the vagina—decreased blood flow can lead to decreased sex drive and the decreased ability to orgasm.
  1. Probiotics: There may be no better friend of the vagina than yogurt and probiotics. These items are super important to maintaining the healthy vaginal flora (a.k.a. bacteria) and that acidic pH. Yogurt, kimchi, and probiotics are chockfull of good bacteria. They serve as reinforcements to your own fleet of good bacteria and are essential to maintaining vaginal health.
  1. Vitamin C: Hello, sunshine state! Foods high in vitamin C (think oranges, lemons, and grapefruits!) help reduce inflammation and infection throughout the body (your vagina included). By increasing your vitamin C intake, you will not only ward off that cold circulating around your office, but you will also help protect your vagina from unwelcome guests.
  1. Phytoestrogens: Phytoestrogens are structurally very similar to estrogens. Therefore, they can cause very similar effects throughout bodies. Take that one step further, and eating foods high in phytoestrogens (flax seeds, tofu) can increase vaginal lubrication.
  1. Omega 3 Fatty Acids: Start making your way over to the seafood shop because foods like salmon and tuna, which are teeming with omega-3 fatty acids, are super important for circulation. And increased blood flow is not only good for the heart and the brain but also the vagina. It can help improve sex drive. They also come with the bonus of decreased inflammation, which can translate into decreased menstrual cramps!
  1. Magnesium: And if fish isn’t your speed, make a sharp left for your veggie aisle. Foods high in magnesium, spinach, avocado, and leafy green vegetables also improve circulation and blood flow.  
  1. Oysters: Oysters are no strangers to the vaginal health list. The high zinc content in oysters has been demonstrated to increase sex drive.
  1. Green Tea: While we all know that cranberry juice can help fight urinary tract infections, it is also loaded with sugar (public enemy #1 for the vagina). So if you are looking to ward of those pesky UTIs but not overload on sugar, try green tea. Data shows that green tea may possess the properties needed to fight off UTIs.

   10. Water: Last, we all know that water does a body good, but it also can do your vagina good.        Staying well-hydrated improves vaginal lubrication and maintains proper vaginal pH balance. So keep on chugging that water. Your entire body will thank you!


Putting Out the Fire: Endometriosis Treatment

Living in New York City, we don’t usually see those forest fires some of you ladies see out West. While we watch it on TV and read about it on the Internet, those days and days of blazes are something of a foreign concept to us. However, what we have taken away from those images are the hoses upon hoses and the buckets upon buckets that those firefighters must use to quell those flames.

Endometriosis (a.k.a. endo) is to your pelvis as a big forest fire is to California. If it is not put out quickly, it can be devastating. The good news is that, just as the firefighters have many tools in their truck, we too have several potential treatment options.

For women who do not have babies on the brain, there are many “hoses” that can help put out your fire. You have both medical and surgical options. When fertility is not in the near future, shutting your own system off medically with hormonal therapy is no big deal. Most GYNs will recommend that you start basic (non-steroidal anti-inflammatory agents/NSAIDs plus hormonal contraceptives).

Go big only when the fire continues to rage. NSAIDs combined with continuous hormonal contraceptives (continuous birth control pills) are usually pretty good at putting out “smaller fires” (mild/moderate endometriosis). It doesn’t matter if you prefer the oral, vaginal, or skin (a.k.a. patch) route for hormonal treatment. They all work the same, and here, it is more a matter of preference than potency. If estrogen is out because of a medical contraindication (clots, smoking etc.), then progesterone can be given in isolation with NSAIDs.

If this concoction is not keeping your symptoms quiet, we start climbing the treatment ladder. Our next step is usually a GnRH agonist (cue Lupron) combo’d with add-back hormonal therapy (estrogen and progesterone). If this doesn’t bring things to a halt, we usually give aromatase inhibitors (think Femara) a try. The aromatase inhibitors work by decreasing circulating estrogens in the body.  Estrogen is like gasoline to the endo fire. It doesn’t take a firefighter to tell you that it’s probably not a good idea to throw gasoline on a fire!

One treatment is not necessarily better than another. Some just work better in certain people. What is different is how they are administered (oral, injection), how frequently they must be taken (daily, weekly, monthly), and how much they cost (a little vs. a lot!). You have to see what works best for you and your symptoms.

When medical treatment isn’t cutting it, surgery is an option—no pun intended. We try to reserve the bigger guns for the bigger flames; starting with surgery is usually not a good idea. In general, the basic tenant of endo is to max out on medical treatment and avoid repeat surgeries—repeat trips to the operating room do not earn you frequent flier miles. It just earns you a lot of scar tissue, a lot of risk, and a lot of anesthesia. It’s not something you want to do.

If you do find yourself needing to make that trip down the runway, make sure your pilot has been around the block several times—no first-timers here. Endo surgery is no walk in the park; you want your surgeon to be experienced.

Gynecology has gained a couple of new subdivisions in the past few years. There are now GYNs who spend years after their residency learning how to do endo surgery. Their second home is in the operating room. Let’s just say that, when you need a tour, they should be the ones to do it! There are a variety of surgical procedures that can relieve your symptoms. The specifics are above the scope of our conversation, but what you do need to know is the following. Know your surgeon, know why they are doing what they are doing, and know how many times they have done what they are suggesting you do. Trust us; it’s super important.

No two fires are exactly alike. Similarly, no two cases of endo are exactly alike. While for some, pain is the biggest problem, for others, it is GI symptoms. Because of the variability in symptoms, in severity, and in life plans (fertility vs. no fertility), the treatment plan that “puts out your fire” will likely vary. What gets you going or stops your endo from growing may be different than what helped your sister or what helps your BFF.

Although we probably won’t ever treat you, we can recommend that you treat yourself with the utmost respect. Be aware of your symptoms and what makes them better or worse. Have your GYN on speed dial—don’t tell them we told you that!—and tell them when things are not going so well. And while we don’t recommend you ringing them on weekends and in the nighttime unless urgent, you should feel comfortable calling them. If their answers are not cutting it, don’t be afraid to remove them from your contacts and find a different doctor.

Unfortunately, endo is a chronic condition. Once the treatment hoses are turned off, the fire will likely return. After your baby days are done, you may elect to undergo definitive surgical treatment (a.k.a. a hysterectomy and bilateral salpingo-oophrectomy: simply stated, ovaries, tubes, and uterus out) to ensure that you never face another forest fire. Until then, let us help you temporize the flames so that you can fight whatever fires, be it professionally or personally, that you choose to extinguish. There is nothing you can’t put out if you put your mind to it!

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!