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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!

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!

When There Is More Than Your Plus One in Your Pelvis

Pregnancy can be a tight squeeze. By the end, not only are your clothes not fitting, but also your organs seem to have a limited place to hang out. It can be difficult to breathe, sit, stand, and walk. You name it, it’s hard to do it. And if you are carrying more than one (#twins, #triplets), it can be a doubly or triply painful situation. The pelvis and abdomen of a pregnant woman is like Manhattan real estate—it’s limited, to say the least. So, when other “things” have taken up home like ovarian cysts and fibroids, it can be an unpleasant situation. However, before you rush to “sell” them off, listen to what we have to say.

The most commonly encountered uninvited houseguests in pregnant women are ovarian cysts and uterine fibroids. They usually have taken up residence and despite the rent hikes are refusing to move. Sometimes, they can stay put, and sometimes they need to be evicted. Here’s the lowdown on what’s legit and what needs to leave when it comes to cysts and fibroids.

When it comes to cysts, most of the time they can stay. In fact, it’s not uncommon to detect cysts during pregnancy. For many women, it is the first time we have seen a “picture” of their ovaries (say cheese!). The ultrasound is the mainstay for fetal evaluation—most women have at least two if not more ultrasounds performed in their pregnancy. During these exams, the ovaries are not camera shy; we usually get a good look at them. Most flash us a smile and never bother you or us again. We might look for them later in pregnancy to ensure that, if a cyst was present it is stable in size, but we infrequently act to take them out. And the numbers tell us why: adnexal masses (cysts in the ovaries/tubes) are seen in about 0.05 to 3.2% of all live births. Cancer is diagnosed in ONLY about 4 to 8% of these cysts. The bottom line is, they are very, very rare, and therefore we usually need to do nothing more than watch them from the outside.

Most cysts encountered in pregnancy are BENIGN and include dermoids (mature teratomas), corpus luteum, and para (adjacent to the ovary) simple cysts. Because nearly 50 to 70% of ovarian cysts during pregnancy will vanish like the bunny in a magic show, we usually leave them alone (only about 2% will cause you any acute problems requiring surgery). Those that won’t step out of the spotlight and need to come out tend to be larger (>5cm) and more complex (a.k.a. scary looking). They are usually removed in the second trimester, as this is the safest time to perform surgery in pregnancy.

Let’s call an Uber and travel from the ovaries to the uterus (a short trip even with price surging!). Here in the uterus, fibroids are often the most common foe faced during pregnancy. While they are sometimes dealt with before pregnancy even occurs, in most cases they are not. As they are very rarely the sole cause of infertility, most women don’t even know they are there until they are plugging along in pregnancy. Again, that trusty ultrasound that we use to capture your baby’s first pics will often identify fibroids that you never even knew existed. For those with infertility or recurrent miscarriages, fibroids will likely have presented themselves long before pregnancy. However, unless they’re inside the uterine cavity or significantly distorting the uterine cavity, they can usually stay put. Preventative surgery is not so popular.

In those women who have fibroid symptoms (bleeding, pain, pressure, etc.) it’s a different situation. You must take care of yourself and your uterus! If the symptoms are mild, we recommend holding off on surgery until you are ready to start trying. Surgery done as close to the time of desired pregnancy will cut down on the risk of recurrence. Although you will need about 3 months’ respite to let your uterus recover, you can pretty much get back on the field in no time (keep this in mind as you attempt to plan out your life).

If your symptoms are major or are causing your infertility, there is no better time than now to act. Don’t wait, as it won’t make your life or your symptoms any better. It will just make you more frustrated and fed up!

Newsflash…if you had a big fibroid removed before pregnancy and your surgeon said they “went through and through the muscle,” you are most likely going to need a C-Section. A uterus that has been sliced and diced, poked, and prodded may not be as strong as one that has never been disturbed. By performing an elective C-Section before labor starts, we can reduce the risk of a uterine perforation (uterus opening at the incision). This makes things way safer for everyone involved!

The reality is that most women with fibroids do just fine during pregnancy. Despite the influx of estrogen and progesterone, most don’t grow, and those that do usually only do so in the first trimester. On occasion, this brief rapid growth can cut off blood flow to the fibroid causing “degeneration” and significant pain.  However, most women don’t even remember that their fibroids are there. In very few cases do fibroids cause serious problems; when they do, it’s the following that we are on the lookout for:

  • Increased risk of miscarriage.
  • Preterm delivery and labor.
  • Abnormal fetal position.
  • Fetal growth restriction.
  • Placental abruption.
  • Labor dysfunction (and the need for a C-Section).
  • Heavy post-partum bleeding.

Even with these potentials on the horizon, removing fibroids in pregnancy is almost NEVER an option. A pregnant uterus has lots of blood. Lots of blood makes surgery very scary, and very scary surgery is nothing that anyone is interested in doing. That means you should wait until pregnancy is over to deal with your fibroids!

Unfortunately for the potential buyers out there (ourselves included!), the market is not about to crash. In fact, most say there is nothing more stable than real estate in the long run. Therefore, don’t move or remove “things” just because you have a plus one or maybe a plus two on the way. Their additional presence may be pesky, but unless there is a major problem pre-pregnancy (bleeding, pain, infertility), let them stay in their rent-controlled apartments. If they start to make too much noise, we have ways to deal with them!

Fibroid: Is This Causing Your Infertility?

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. They work their magic (or rather interfere with the magic) usually by interfering with implantation, distorting the uterus, or blocking off one or both of the tubes. They can take up prime real estate, and this can lead to miscarriage and pre-term delivery.

Depending on the block they chose to call their home (a.k.a. their location in the uterus), their impact on fertility and pregnancy may be more pronounced. Fibroids that are located within or partly within the uterine cavity (medically termed submucosal) almost always need to be evicted before pregnancy. Additionally, these are the ones that are most likely to cause true infertility. Intramural fibroids (those located in the muscle) can go both ways; how they are going to lean is really anyone’s guess. As a general rule, the bigger, the bigger pain for you and everything fertility related. They can press on important things (like tubes or the cavity) and cause problems that need to be dealt with. Last, those hanging out outside the uterus (subserosal) have almost no effect on fertility or pregnancy. Don’t even give them a second thought.

While fibroids can be treated medically or surgically, when it comes to fertility, medical options are no bueno. Most, if not all, medical options will prevent ovulation and implantation, which will prevent pregnancy, so that’s not going to work. Surgical options are really the only ones on the table, and even these “dishes” are limited.

So here is what is on the menu—myomectomy (myoma means fibroid and ectomy means removal). Myomectomies can be performed through an open bikini-cut incision, a camera (laparoscope), a robot, or vaginally. 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.

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. It will also in many cases, particularly when there are many fibroids, require that you to have a C-Section. The uterus is a muscle, and after surgery, it will be forever changed, scarred, and sometimes weakened. You want to make sure that you treat your muscle with tons of TLC—labor, contractions, and hours of pushing is not anyone’s definition of TLC.

And while we are talking about surgery, we recommend that you always ask your surgeon for their notes from the surgery (a.k.a. the operative report). This is super helpful to anyone else—your OB/GYN or your fertility doctor—who decides to date your uterus in the future. Knowing who has been there and what they have done will help us guide your treatment.

Two big questions come to patients’ minds and ours when considering fibroids and fertility. Are they causing my infertility, and should I treat them before I do fertility treatment? First things first, fibroids are very rarely the sole cause of infertility. If you think of a pizza pie, they are even smaller than the smallest slice (think more of like a baby bite). Usually, fibroids plus something else are keeping you on the fertility sidelines. So even if your fertility doctor diagnoses you with fibroids, they are usually not alone in making this baby thing difficult. For this reason, we always recommend completing the entire fertility work-up before pointing the finger at the fibroid.

The second question is way more complicated. When do you treat a fibroid? This question about fibroids is more controversial than religion and politics at a family dinner! However, while getting us all to agree on when to treat is nearly impossible, we can almost all agree that fibroids, which are on the outermost layer of the uterus, are outside the realm of what we need to treat. They are not causing infertility and don’t need to be treated before a fertility treatment. Exceptions to this are if they are very large causing pain and pressure of the bladder.

On the flip side, fibroids that are in the uterus (submucosal) of women who are experiencing infertility or recurrent miscarriages need to come out before any fertility treatment is started. The fibroid is like a roadblock, blocking any and all traffic. They need to come out before any cars try to pass. The trickiest ones are the ones in the muscle (intramural). It’s like our Congress—no one can really agree on what is right. For most there is a split down the aisle for which to treat and when. The line in the sand usually comes down to how big it is, where it is, and if you had previous fibroid surgery. Fibroid surgery is not something you want to double down on!

Unfortunately, of all the partners you will have, your fibroid is the least likely to leave you. Only menopause and a hysterectomy will break you two up. However, there are ways to temporize them and to temporarily remove them so that you can “attempt to see other people.” Take our advice. Tell them, “It’s not you. It’s me. I just really want to have a baby and don’t want you hanging around.” While they may reappear one day, hopefully, they will leave you alone long enough for a pregnancy to take place.

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.

Secondary Infertility: When Getting Pregnant Isn’t like Riding a Bike

While the “It’s like riding a bike” saying always seems somewhat perplexing (You mean that, after 20 years, I am going to hop on that two-wheeled thing, balance, and ride?), it’s pretty spot on. Even the worst childhood bike riders amongst us are able to pull it together as adults for a ride to the beach. And while you may not enjoy any of it, you can certainly do it. The same can be said, or seemingly should be said, about having a second (a third or even a fourth baby). You did it before; how hard can it be to do it again? And while having a little one will mess with your sleep schedule (and sex schedule!), most couples can find at least a few minutes to give the baby-making thing a go. Unfortunately, unlike the infamous bike, sometimes the second time around isn’t so easy. Sometimes, it is way harder.

Medically speaking, fertility problems when you try for your second, third, or fourth child is called secondary infertility. And although you may have never heard of the words secondary and infertility in the same sentence, you have for sure heard your friends say, “It is so much harder to get pregnant the second time!” “Why?” you may ask. For most couples, the answer is, simply, “time.” No matter how long you put your baby-making efforts on the shelf, time can do some terrible things to our ovaries (decrease in egg quality and quantity). It can also allow GYN problems (fibroids, endometriosis, scar tissue, cysts) time to regroup and regrow. Furthermore, general medical issues occur more frequently as we age. Therefore, while things like high blood pressure and obesity may not cause our reproductive systems any problems per se, they can impact our overall health and your ability to carry a pregnancy.

Much to our dismay, secondary infertility is not uncommon. Nearly three million women in the US find getting back on that bike to be a challenge. All of the potential problems that caused primary infertility (infertility for a first child) are at play in secondary infertility (ovulatory dysfunction, poor egg quality, blocked tubes, low sperm count) and then some…. In fact, with secondary infertility, we are particularly interested in what went down during your first delivery (emergency C-Section, fever/infection, heavy bleeding, retained placental tissue). These factors can be the cause of some serious problems and prevent another pregnancy from progressing. While surgery can fix a lot of what has gone flat, oftentimes, fertility treatments are needed.

The good thing about secondary infertility is that we know that the system(s) worked at some point. Eggs were being released. Tube(s) were open. A sperm was able to fertilize an egg, and the uterus was willing and able. All good news. And while things may not be running so smoothly now, knowing that they did in the past and that you were able to carry a plus one is positive. Whether we can return the system to its previous functionality is debatable (often decided by a slew of fertility tests, including blood work, ultrasounds, a hysterosalpingogram, and a sperm test), but knowing that it was a go in the past is helpful.

While we don’t want you to get back on the bike until you are ready to ride (having more children just to prevent secondary infertility is certainly not wise), don’t wait too long. Although in many cases it will be like riding a bike, there are a good number of us who will run into some major roadblocks. Don’t be fooled by how simple stuff was the first time around—this ride may be totally different. Think of this advice as your helmet. While it may be in your head instead of on top of it, our recommendation may help save you from a pretty bad fall. And if you are going to hop back on that bike, safety is key, because in reality, it’s not always that easy.