Take a Bite Out of This: What Your Teeth Could Be Doing to the Rest of the Body

There may be no bigger hassle than a dental problem. A root canal, an implant, a denture, or a chipped tooth: it’s all a big pain and a big hit to your bank account. And unfortunately, as we age so do our teeth. Just like your ovaries, they have been present for all your bad decisions. The sweets, the “oops, I forget to brush and floss,” and the endless packs of gum have taken their toll. (Trust us, we know, we do it too!) And while it may come as a shock to you, what’s going on your mouth may be a barometer for what’s going on in the rest of your body.

Oral health disorders like periodontal disease (a medical way of saying “gum disease”) have been associated with problems like cardiovascular disease, diabetes, Alzheimer’s, respiratory infections, and even preterm labor. Inflammation in the gums can lead to inflammation in other parts of the body. Picture this—bacteria make their way into the body through the gums. The gums have lots of blood vessels. Blood vessels act like a shuttle transporting bacteria throughout the body. Wherever they land, they bring inflammation. Inflammation in the blood vessels can cause the blood vessels to narrow. Narrow blood vessels cause blood flow to slow down and clots to form. Such clots increase the risk for heart attack and stroke. Because women post-menopause are already at increased risk for heart disease due to age and other medical risk factors, you don’t want to add to it by introducing gum disease and inflammation.

But there is more to the teeth’s story than gum inflammation and bacteria. After menopause, estrogen levels drop. This drop not only causes hot flashes and vaginal dryness but also the loss of bone in the jaw. Bone loss can lead to loose teeth and tooth loss. And unfortunately, when you lose a tooth at 55, there is no tooth fairy—just a lot of dental bills and inconvenience!

On top of the age and decreased estrogen part, medications that are used for osteoporosis have been linked to osteonecrosis (a.k.a. bone decay). And while this is very rare and most often seen in women with cancer who are on high-dose bisphosphonates, it is important to give your dentist frequent updates on your medication list so that your dental work is scheduled appropriately.

To make matters a little more distasteful, menopause and its hormonal fluctuations can also bring oral discomfort. Post-menopausal women report changes in their taste perceptions and dry mouth. And your gums feel it, too. Receding gums and sensitive gums are not uncommon.

Age gets us all over. From your hair and skin to your bones and toes, time takes a toll. Your teeth didn’t want to be left out! To decrease damage, the American Dental Association recommends that you make a trip to see your dentist twice a year. And for your homework, they suggest daily brushing and flossing. Also, limiting sugary foods and things that stick is a sure-fire way to improve your dental health.

So, don’t follow the nearly 35% of US women who did not see a dentist last year. Make an appointment to get those pearly whites (or at this point, some shade of white) checked out. You will be doing your whole body good.

Tap It Back…Add It Back: Hormonal Add-Back Therapy

All you indoor cycle enthusiasts probably got the reference pretty quickly… Tap Backs are not only good for your core and your gluts but for your quads and your arms (and they are sort of fun at the same time). Dancing on a bike is liberating, to say the least, and lets you think, at least for 45 minutes, that you too could be Beyoncé’s next back-up dancer!

Tap backs are not just good for the body; they are good for the soul (no pun intended!). In the same way, add-back hormonal therapy is good for many different organs. With oral progesterone + estrogen, you are hitting many of those key areas and shaping your future.

Let’s take a seat in the saddle and review why you would need add-back therapy and how it does its job. Many GYN pathologies think fibroids, endometriosis, and adenomyosis run on hormones. No hormones usually = no pain/no symptoms. Therefore, our treatment choices for such problems frequently center on taking the hormones away. Our first line of attack usually includes oral contraceptive pills (OCPs). The synthetic estrogen and progesterone in OCPs feeds back on your brain and shuts off your natural production of estrogen and progesterone.  It’s a complicated pathway of events, but this one daily pill is usually very good at putting the brakes on the body’s own hormone production and keeping those pesky symptoms (pain, bleeding) at bay.

However, in certain cases, the OCPs are no match for the pathology pervading your pelvis—in these instances, we need to look into our bag of tricks and pull out something more powerful. Cue GnRH agonists (a.k.a. Lupron). These injectable (and in some forms nasal) medications shut off the brain’s production of the hormones that stimulate ovarian estrogen production. They don’t waste their time with feedback but rather go right to the source and turn off that switch. And while they are good at keeping things dark when this switch has been flipped to OFF by Lupron, it’s like a major blackout occurred in your body.

Everything hormonal goes dark. And while this darkness is good for stopping endometriosis, fibroids, and the like, it is not so good for those organs that desperately depend on estrogen (think bones). Therefore, in order to satisfy both parties (those that like the dark and those that need some light), we give what is called hormonal add-back therapy alongside the Lupron.

Think of the add-back therapy as a flashlight. It shines light on the areas that are really afraid of the dark (a.k.a. the bones). And like all good nightlights, it does its job well—it can keep the bones happy without reducing the efficacy of the Lupron. It also quells those crazy hot flashes that women can get while taking a GnRH agonist (Lupron). You may be making a funny face, thinking this doesn’t really make sense? If endo is fed by estrogen and then the doctor gives estrogen, won’t that make matters worse? You are sort of right and also sort of wrong. Here’s why.

The doses at which you are taking oral add-back therapy are right at the hormone sweet spot. They are just enough to protect your bones and stop the hot flashes but not enough to fuel your disease (endo, fibroids, etc.). As a result, add-back therapy has become all the rage for women taking GnRH agonists (Lupron). By supplying it, we can give Lupron without much stress over the possible negative side effects. Examples of add-back therapy include norethindrone acetate alone or norethindrone acetate + estrogen. Either combo has been shown to work; however, what works for you must be figured out with your doctor. Most of the time, we start add-back right when the agonist is started. While we used to wait a few months before initiating add-back, we now don’t really think there is any benefit to delaying its start.

Whether you are a SoulCycle or a Flywheel girl, an Equinox fan or a Crunch crazy, you know that, while on the bike, you will burn a serious number of calories. Add-back therapy is the lubricant that allows those wheels to keep turning. Without a little juice, over time, the bike will break down, and you will come to a screeching halt. We want to prevent that in your body by giving add-back hormonal therapy alongside a GnRH agonist. It will allow you to keep “cycling” without much pain. Not bad… Now, let’s see you Tap It Back!

SPF: Don’t Let Your Bones Get Burned

Whether you opt for 15, 30, or 50, it’s rare to find someone amongst us that doesn’t lather up before laying out (or even being out on a summer day!). The sun and its rays are no joke. They can leave their mark in the form of burns, peels, sunspots, and even wrinkles—ugh! And if that wasn’t enough to scare you into some good water-resistant SPF, think skin disease and skin cancer. But while sunscreen fills the shelves at nearly every drugstore, reminding you to lather up or pay the price, what lies under your skin is much quieter. Your bones don’t tell you when they are about to burn (a.k.a. break), and the reminders to protect them are much subtler. However, if they are ignored, the burn can be just as severe as the strongest rays.

In the same way that you would protect your skin during the summer, you should protect what lies under your skin #yourbones all year round. Adequate calcium and vitamin D intake, coupled with a healthy diet, weight-bearing exercises, and estrogen during the reproductive years are the SPF that your bones need. In fact, this is the formula that makes up the SPF 70 sunscreen for your bones!

But while most of us know that milk (a.k.a. calcium and vitamin D) is “what does a body good,” you might be surprised to know that estrogen is equally as important. News flash: estrogen is not just a hormone made by your ovaries to keep your eggs developing. It is also necessary for bone buildup and bone strength. In fact, how much you take in during your adolescent and young adult years can dictate what happens in your later years. No estrogen in your younger years can cause some major breakage in your later years (think osteoporosis and osteopenia).

Bones reach their peak mass by about age 30. However, to reach the “summit,” they need estrogen during your teens and twenties. Therefore, women who are not on hormonal contraception and don’t get regular periods (a lack of periods because of continuous pill usage does not count!), is sort of standing out in the sun without sunscreen. When your bones don’t reach peak bone mass, there is nowhere for them to go but down later.

And as most of us know, the estrogen story does not end at age 30. Your bones continue to rely on their fountain of youth for years and years to come. Estrogen production is essential deep into our 40s and even 50s. Therefore, for women whose periods bid them adieu early it’s important to make sure that you speak to your GYN about hormonal replacement therapy.

While postmenopausal hormone therapy has gotten more bad press than both Democrats and Republicans making a decision combined, it’s actually not bad for most women. In fact, estrogen supplementation, started at the right time in the right woman, can be the key to reducing your chances for heart disease, bone disease, memory loss, and serious vaginal dryness. So, don’t listen to everything you hear on TV; this is one decision for which you should hear what your doctor has to say.

It’s really no different than sun damage. Burns sustained in your younger years make your skin way more susceptible in the later years. And while freckles and sun spots may be cute at age 15, they’re not so much at age 55. Additionally, they pose a risk for skin cancer at age 50. The same goes for how you treat your bones then and now. So, don’t forget to lather them in milk, vitamin D, calcium, and exercise: this SPF will save you big-time breakage in the future.

Less Is More: When Can Pap Smears Come to an End?

There are very few areas of medicine that come to a halt or even slow down as we age. Doctors’ visits, medications, check-ups, and those oh-so-pleasant aches and pains just keep on piling up. You need a calendar just to keep track of it all!

That’s why, when your GYN recommends throwing in the towel on Pap smears, it will likely sound somewhat confusing. But the truth is, as we age the frequency with which Pap Smears are performed can be tailored tremendously. In fact, for most of us it can be totally tossed, assuming that your cervix has cooperated and been checked and free of cancer or CIN (the precursor to cervical cancer) for many years. Here’s why.

Pap smear guidelines have changed big time in the past several years. Taking a page out of our friendly Glamour, “yearly is so out,” and every three years or in some cases, never again is so in. The American Congress of Obstetricians and Gynecologists has re-written the Pap smear guideline’s ending, and this is how this story goes…

If chapters 1–5 (that is, ages 21–64 years old) have been pretty clean and clear, once you hit the big 6-5 you can call it quits with Pap smear screening. In the land of cervical cancer screening, clean and clear refer to three consecutive negative (normal) Pap smear results or two consecutive negative co-tests (Pap smears plus HPV testing) within the past 10 years.

To top it all off, the most recent Pap smear test must have been done in the past five years. And while words like co-testing may sound like Swahili, just knowing what to ask your GYN when it comes to Pap smears and when to ask these questions will make sure that they don’t play on and on and on… (#BrokenRecord)

If chapters 1–5 (a.k.a. 21–64 years old) were not totally clean and clear, then you might have to do some editing before you can close the Pap smear chapter. The exception to the “once you turn 65 years old break-up rule” are women who have a history of abnormal Pap smears/cervical screening in the past, specifically a history of CIN 2, CIN 3, or adenocarcinoma in situ. (Think of CIN as a staircase: the higher you get, the closer you are to cervical cancer.) If you fall into this group, you need 20 years of screening after the resolution or treatment of the CIN 2 and beyond, even if it takes you past the 65-year-old mark.

And while there are likely some terms in here that are making you do a double take (a.k.a. CIN and adenocarcinoma in situ), knowing the specifics is really secondary to simply having the knowledge to start the conversation with your doctor. For example, if you know for sure that you have never had any or all of the above (CIN 2, CIN 3, or adenocarcinoma) and your doctor is still performing Pap smears on you at 67…it’s time to start asking questions.

If you had a hysterectomy before reaching the magic 6-5, you might be able to bid Pap smears adieu at an even earlier age. In fact, women who had a hysterectomy with removal of the cervix and never had a history of CIN 2, CIN 3, adenocarcinoma in situ, or cancer can stop Pap smears immediately following the removal of the uterus. Those that had a hysterectomy with removal of the cervix and have had a history of CIN 2, CIN3, adenocarcinoma in situ, or cancer must continue with Pap smears. Again, you will need 20 years of screening after the resolution or treatment of the CIN 2+ before you can call it quits.

Last, if you had a hysterectomy and kept your cervix (a.k.a. a supracervical hysterectomy), you can’t bid your Pap smears a fond farewell until you hit 65 (or longer, depending on your history).
And while you might be breaking up for good with your Pap smear, let us be very clear that you are not saying goodbye to your GYN. There are many more topics and tests that are checked at your yearly visit (as well as a good old fashion chat!). Maintaining an ongoing relationship with your GYN is important—remember, you have many reproductive organs other than your cervix!

Should They Stay, or Should They Go? The “Ovary Debate”

The ovaries are many women’s unsung heroes. They not only make the estrogen that keeps your body and brain going, but they also house the eggs that form your baby’s “better half.” Month after month and year after year, they do their job without even a pat on the back or a nod of appreciation. Unless a problem arises (a cyst forms, they stop releasing an egg, or they prematurely run out of their supply), no one pays them much mind.

Therefore, when a woman is having her uterus removed (medically termed a hysterectomy) and the question “Do you want to take or keep your ovaries?” is posed, many of us are not sure what to do. Unlike the “milk and sugar?” question, this isn’t something you’re asked on a daily basis. If you do find yourself straddling the in or out line, here are some pointers to help you make the “ovary in” or “ovary out” decision when you are planning to undergo a hysterectomy.

Think of the ovaries as a professional athlete. They peak in their 20s. After that, things start to go downhill. However, most don’t really hit retirement age until their late 40s. The ovaries hang on for even a bit longer and are producing estrogen and eggs until menopause. After this, things start to change. The estrogen production drops significantly (#helloHOTflashes), and ovulation ends.

The ovaries enter retirement; they are ready to sit back with a good book and watch the sunset. They seemingly aren’t doing a whole lot. But what their presence perpetuates is the possibility of ovarian cancer. If they stay in, there you are, at risk. And while the risk of ovarian cancer in the general population is about 1 in 70, most ovarian cancers are pretty good at hide and seek. They are often not detected until they have reached an advanced stage. This makes them a formidable foe and nobody we women want to mess with.

While the ovaries occasionally play the bad guy role, most of the time they are doing a lot of good, particularly for women who are peri-menopausal. Therefore, taking them out (medically termed an oophorectomy) may cause problems before natural menopause occurs. Issues like heart disease, osteoporosis, and cognitive impairment occur more frequently in women who experience premature surgical menopause (a.k.a. the ovaries come out before they have stopped functioning).

Even after the ovaries have taken their last bow (no more eggs and no more estrogen), they continue to produce hormones (specifically, testosterone) that are important to the postmenopausal body. Therefore, while we used to lump an oophorectomy in with a hysterectomy (sort of like peanut butter and jelly), that’s no longer the case. While removing the ovaries can eliminate your risk of ovarian cancer, it can also add to your risk of other diseases.

Bottom line, before you sign on the dotted line, you should know what you’re taking out—and why. We love widely televised debates as much as the next gal, but the ovarian preservation conversation should be between you and your GYN surgeon. He or she knows your medical history, your family history, and your risk factors for developing cancer better than anyone else. Together, you can create a pretty comprehensive pros and cons list for keeping or taking the ovaries out. Make sure to hash this one out with your doctor before you take anything out. While your vote is important, this is one decision that shouldn’t be made alone.

The Seesaw of Hormonal Production: Why Your Periods Are Wilder Than the Old- School Wild, Wild West!

When the arrival of your period becomes more erratic than airplanes during the holiday travel season, you know something is up, especially if before they were like clockwork. Why this is happening and what this all means can be confusing. It can also make deciding if you should wear white jeans very difficult! Most fingers point towards the ovaries and their dwindling supply of eggs and specific hormones: think inhibin, estrogen, and AMH.

As the ovaries start to run on empty, they shoot mixed messages to the brain. The brain, which is used to orderly and steady hormone levels from the ovaries, is thrown into a tailspin. Without adequate ovarian hormone production, the brain overproduces certain hormones. Think FSH and LH. There goes the regularity of your menses. In medicine, we refer to this period of confusion and “crazy” period timing as perimenopause. And to put it bluntly, this period (no pun intended) can be a big pain.

In terms of the brain-ovary relationship, think of a seesaw. As the ovaries (egg production and select hormones) go down, the brain’s hormone production goes up—and in some cases, way up. FSH levels can reach the high double digits. Ovarian hormones and hormones in the brain, specifically the pituitary gland, work in a negative feedback loop—high ovarian hormones keep the brain’s reproductive hormones low. So when you are nearing menopause and the ovarian production lays low, lower, and then lowest, the seesaw will remain lopsided. And while on this seesaw, the person left high won’t get hurt, it will have a major impact on how frequently you see your periods—as well as other things like your internal temperature gauge.

For most of our reproductive lives, the ovaries and the brain work as a team to prepare an egg, ovulate an egg, and maintain the corpus luteum (a.k.a. the structure that makes progesterone and helps maintain a pregnancy). There are some conditions where this system doesn’t run so smoothly—cue PCOS, thyroid disease, or hypothalamic amenorrhea. But for most of us, it is pretty well-oiled machine, that is, until we hit our mid-40s or so. Then the pendulum starts to swing erratically. Periods come closer together (about 20 days) and then farther apart and then close together AND farther apart. Not a pleasant combo.

Consistency becomes a thing of the past. While your mind may view pregnancy as a thing of the past, your ovaries haven’t quite given up. They are still working to prepare and ovulate an egg each month. Because of the diminished supply, they start to prepare the egg in the second half of the menstrual cycle the month BEFORE that egg will be ovulated. Simply stated, they are letting the horse out of the gate (a.k.a. the egg) long before the race goes off (a.k.a. the next menstrual cycle starts). As a result, the menstrual cycles will get shorter and shorter.

Although irregular menstrual cycles are quite common when we hit our 40s and beyond, when bleeding becomes excessive or all of the time, you need to speak to your OB/GYN. While it likely means nothing more than the ovarian reserve fuel tank is running on empty, you want to make sure there is nothing structural (a polyp, a fibroid, or even a cancer) that needs to come out. Don’t brush it off as another joy of aging!

Just like any relationship, when one member of the team goes haywire, things can fall apart pretty quickly. If you are not in sync with your partner, the partnership falls apart. The brain and ovary alliance is no different. When one stops working, the other one tries to overwork or make up for the deficiencies, which leads to irregular and often frequent periods. Although there may be nothing you can do to mend or tame this wild relationship (once ovarian production goes down, it generally will remain down), just acknowledging it can bring you some peace.

And with that, you can go out and face the wild, wild west!

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

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

Flavor (Is my uterus coming out?)

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

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

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

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

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

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

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

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

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

Are the Tubes More Than a Tunnel? Their “Connection” to Ovarian Cancer

For decades, we thought of the fallopian tubes as no more than a plus one. Whether they were the sidekick to the ovaries or to the uterus, they were sort of like the accomplice that everyone overlooked. We did make some noise about damaged or blocked tubes in women who were trying to get pregnant because damaged tubes meant the sperm and egg would need to find another way to meet up. But for women who had let the fertility ship set sail, the tubes seemed like no more than an afterthought. However, times have changed: the tubes have taken center stage. Here’s why.

In order to understand the tube story, you must first hear the ovary story, specifically the part that addresses ovarian cancer and ovarian cancer screening. Unfortunately, when it comes to ovarian cancer screening tests, the ending is not a happy one. The tests either fail to detect ovarian cancers until they are advanced, or they over call benign processes (think simple cysts, dermoids, and endometriosis) as cancers. And while you certainly don’t want to miss an ovarian cancer, you also don’t want to put women through additional testing and surgery that they may not need. Hence, every GYN faces a conundrum when trying to screen for ovarian cancer. How do you avoid missing an ovarian cancer without miscalling something as ovarian cancer? Cue the tubes…

When the news broke that the tubes might play a big role in ovarian cancer (basically, that ovarian cancers might start in the tubes and the endometrium and then spread to the ovary) and that tubal removals (medically termed salpingectomies) could be the answer to early screening and detection, the OB/GYN community erupted in cheers. Could we have found a clue to cracking the ovarian cancer code? For decades, the theory had been that cancer spread from the ovary to the tube. Could it really be the opposite? Evidence suggested that for select types of ovarian cancer this could very well be the case. A breakthrough that could have big-time benefits: if you took out the tube, then you could take out or at least take down the chance of ovarian cancer later.

While the excitement in the OB/GYN community is palpable, neither the American Congress of Obstetricians and Gynecologists nor we are recommending salpingectomies for everyone. Rather, we are suggesting that you view the tubes as more than just an afterthought, that you treat them as more than a plus one. If you are planning to extract your uterus or you are planning a tubal sterilization procedure (a.k.a. tie your tubes), you should have a serious conversation about simply removing the tubes at the same time. Think of it this way: if you aren’t planning future fertility, those tubes will not be missed. And their departure might help you duck out of the way of ovarian cancer.

Ovarian cancer is like the enemy that lurks in the dark. You often can’t see it until it’s too late. And while many have attempted to find some good night-vision goggles (a.k.a. good screening tests), they have repeatedly come up short. Tubal awareness/removal may be the first light in the dark. And although there is still a lot of black and grey in the area of ovarian cancer prevention and early detection, the data on salpingectomies have certainly brightened the situation.

Maybe soon, we will be able to see it all.

Can I Break up with My Birth Control?

The 40s are often deemed the decade of freedom. Careers are stable, and relationships are solid (for the most part). You are done with babies or opted to not go this route (and for those still on the baby journey keep this advice for later!). You are a seasoned player on almost all fronts. But just because your brain thinks pregnancy is a thing of the past doesn’t mean that your ovaries are in agreement. Despite a decrease in egg quality and quantity, you can get pregnant in your 40s, so much to your chagrin, you can’t throw your birth control out when you hit 43, 45, or even 48. As long as you are still ovulating, you can get pregnant, no matter how old you are!

The reality is that, although your body is changing, your birth control options are not much different as you move throughout the decades. No matter what age you are, the name of the game for hormonal contraception is preventing ovulation, fertilization, and implantation. While certain options might work better at certain points in your life, they will all work in preventing pregnancy. For example, we are big fans of the hormonal IUDs (Mirena, Skyla, Liletta) for women in their 40s. They not only prevent pregnancies but also do so with little systemic exposure to hormones (a.k.a. the hormones stay in the uterus rather than in other areas of the body). This reduces the risk of negative side effects from hormones. It also reduces the risk of select cancers such as uterine cancer, a malignancy that affects women as they age.

On the flip side, while oral contraceptives may have been your go to in your 20s, they may not be right for you in your 40s. Women above the age of 35 are more likely to suffer the negative side effects from oral contraceptive pills. This is because age plus issues like high blood pressure, obesity, diabetes, and high cholesterol/triglyceride levels (disease processes that are more likely to be present as we age) equal a greater chance of bad things (stroke, blood clot, etc.) happening while on oral contraceptive pills. So while oral contraceptive pills are not totally out, a good history and physical exam are required before starting them.

The bottom line is that you can’t just assume that your baby-making days have passed you by, even if you used fertility treatments to conceive or if everyone around you is using fertility treatments to get pregnant. While age is a risk factor for infertility, not every woman in her 40s is infertile. Until your periods bid you adieu, you can’t break up with your birth control. This is one relationship you can’t seem to get rid of! While your ovaries may be running on empty, they still have some gas left in the tank. And although we all love surprises, this surprise may be one that will make you do a whole lot more than scream!

A Is for Adenomyosis

Of all the words, terms, and phrases you have heard us utter, adenomyosis may sound the most foreign—and if you think it’s hard to say, try spelling it! It’s likely that, unless you have it or know someone who has it, you will close the chapter (or computer) on this piece pretty quickly. But Bear with us for a minute; push past the A to C of what this Diagnosis is really all about and why it’s something worth learning about.

In many ways, adenomyosis is sort of an Enigma. If you don’t look for it, you won’t Find it. And Getting the diagnosis right can be Hard. Unless you have surgery or an Individual who is really skilled at his or her Job looking at your ultrasound or MRI, you may not Know that you are suffering from adenomyosis. It can often masquerade itself as a Leiomyoma (medical term for fibroids). Although adenomyosis also forms Masses in the uterus, they are no fibroids.

In many ways, adenomyosis is like the first cousin of endometriosis. Both pathologies arise from endometrial tissue that has gotten lost (a.k.a. made its way out of the uterus) and is Not sure how to get back—uh Oh. While in endometriosis this lost uterine tissue can go pretty far (think lungs and even skin), in the case of adenomyosis, the endometrial tissue Prefers to stay much closer to home. In adeno (the medical nickname for adenomyosis), the tissue inside the uterus has taken up residence within the muscle of the uterus. So although that trip may be small in distance, the impact of this unwanted visitor can be big.

And unlike those distant cousins that you never knew you had, adenomyosis is not so unknown or removed. In fact, nearly 10% of all women suffer from adenomyosis. The number is much higher in women with infertility. And while many might not know they have it, they will be aware of the heavy bleeding, the dysmenorrhea, the abdominal pressure/bloating, and the infertility that often accompanies adenomyosis. The symptoms can be pretty severe and often send women (usually in their 30s and 40s) to the GYN in a Quandary (a.k.a. not the best of physical and mental states…we needed a Q!).

Historically, the only way to diagnose adeno was in the operating Room with a piece of tissue that was sent off to our pathology friends. Oftentimes, women were incorrectly diagnosed with fibroids (for years), and until the uterus came out Surgically, they didn’t really know what was causing their unpleasant symptoms. Nowadays, due to huge improvements in our imaging Techniques (cue Ultrasound and MRI), we can see adeno before women walk into the operating room.

Although there is much crossover between the treatments for fibroids and adeno, surgery for the latter can be much less successful and much riskier. The division between normal healthy uterine muscle tissue and adenomyotic tissue can be harder to find. With fibroids, the distinction between the two is pretty clear. Thus, there can be a loss of healthy tissue and, in some cases, loss of the uterus.

The treatment for adenomyosis, like its cousins the fibroid and endometriosis, Varies based on the severity of a woman’s symptoms as well as where a woman is in her fertility plans. For Women who have said sayonara to their baby-making days, a hysterectomy is usually their best bet. Goodbye, uterus, means goodbye, symptoms. For women who are not ready to make their uterus their eX, hormonal treatments (oral contraceptive pills, IUDs, aromatase inhibitors, and Lupron are also pretty good at getting you back to a Zen state. Whatever path You choose, it’s super important to go hand in hand with a physician who can recite the ABCs of adeno as he or she catches some Zzzzs (that is, in his or her sleep). Trust us. This is a song that you don’t want to “sing” alone.