Done and Done! Permanent Contraception

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Most mothers could probably recall the day they found out they were pregnant like it was yesterday: where you were standing (or sitting if it involved peeing on a stick), what you were doing, maybe even what you were wearing. There truly is no other feeling like that of becoming a parent. But when you decide that you are done, there may be no other fear like finding out you are going to be a parent again. How can we afford another child? Where will we live? Can I take those sleepless nights again? And while we definitely don’t have the answers to these questions (trust us, we live in New York City and get the space thing!), we do have suggestions on how to avoid having such things happen. Simply stated, we offer: permanent contraception.

It’s funny, women ask each other the question “Are you done?” all the time. And without more than those three little words, we know exactly what the question means. Are you having more kids? Cutting, tying, blocking, or clogging are common ways to permanently turn the system off. Both women and men can undergo procedures that will make getting pregnant without any fertility assistance nearly impossible (nothing is impossible because all methods, even the forms discussed below, have a failure rate).

The options available to women all center on blocking an egg from meeting a sperm, a.k.a. tying, cutting, or blocking the fallopian tubes. Tubal sterilizations can be done immediately after a woman has a baby, a few weeks after a baby, or years after a baby. When the former is done, a small incision is made below the belly button, and the tubes are found and subsequently cut/tied. When done weeks or years later, the procedure is most commonly performed through a camera (medically termed a laparoscope). The laparoscope is inserted through the belly button, and the surgery is performed through three tiny holes (one in the belly button and two above the hipbone). When done this way, the tubes are most frequently burned and cut (although a clip can also be placed).

Last, GYNs now have the ability to place a spring-like device (think a Slinky) into the fallopian tubes through the vagina. Again, a camera is inserted, but rather than placing it into the belly button, it travels through the vagina, past the cervix, and into the uterus. Under direct visualization, these springs are deployed into the tube; in the months following their insertion, the body forms scar tissue around them. Together, a serious roadblock is formed and it becomes nearly impossible for anything (including those swimmers) to get through. The caveat here is that you need to make sure all systems are a no go before having unprotected intercourse. Therefore, a hysterosalpingogram (a.k.a. HSG or dye test) must be performed approximately three months after the device is placed to confirm that the tubes have become a steel trap. Once the red light is seen, you get the green light for unprotected intercourse.

While women often find themselves in the driver’s seat for permanent contraception, the number of men electing to undergo a vasectomy is rising. Similar to what happens to a woman’s tube, a man’s vas deferens is “interrupted.” The vas deferens (like the fallopian tube) also serves as a tunnel, transporting sperm from the testes to the urethra. So while the path out may be closed after a vasectomy, men who have had a vasectomy are still producing sperm. The testicles go on as usual, producing both sperm and testosterone, ignorant that their hard work is for naught!

The procedure has no impact on a man’s ability to achieve an erection or to ejaculate. The prostate, the ejaculatory duct, the seminal vesicles, and the glands are all functioning as is, and while the ejaculate is devoid of sperm, it is chock full of other products. While post-operatively there is some pain, in most cases a little Advil and Tylenol should do the trick. It’s quick (usually no more than 15 minutes) and can be performed in the office. The biggest point to stress is that, similar to female sterilization, in which spring-like devices are placed into the tubes, a three-month wait period is required before it’s safe to use this as reliable contraception.

If you should have a major change of heart, there are ways to undo the undoable. Fertility treatment has found a way around tubes that have been tied or sperm that has been stopped. Although it requires in-vitro fertilization, IVF allows women a second (or third or fourth) chance if they should want it. In reality, both men and women who have undergone a tubal sterilization or a vasectomy are still producing both eggs and sperm. They are just no longer able to meet up with each other (think being grounded and stuck in your room).

Fertility doctors have the ability to go right to the source (ovary or testes) and get the goods (egg or sperm). So while we recommend you be certain about your decision before taking the leap, remember there is always a back-up plan should you change your mind.

 

Compounded Bioidentical Hormones…Are They Really the Best Fit?

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Thanks to Samantha on Sex and the City and Oprah, compounded bioidentical hormones have gotten a whole lot of press. They have been billed as the best thing since sliced bread. They have become the good guy, while the prescription drugs (a.k.a. conventional hormone replacement therapy, or HRT) have become the bad guy. Bioidentical hormones have been called “natural,” “organic,” and everything in between.

Unfortunately, most women are being sold snake oil, and what they are getting is far from natural. They are victims of false advertising and in most cases are unaware of what compounded bioidentical hormones actually are and how they differ from standard hormone therapy, if at all.

The public and medical opinion on hormone replacement therapy for post- and perimenopausal women has run quite the gamut. The pendulum has swung further on this issue than almost any other topic in gynecology. Before the results of the Women’s Health Initiative (a large study initiated in 1991 to examine estrogen and progesterone’s impact on postmenopausal women) were released in 2002, HRT was lauded as the fountain of youth.

Estrogen and progesterone in the postmenopausal woman were not only believed to improve the nagging symptoms of menopause (hot flashes, vagina dryness, etc.) but also to improve a woman’s overall health. The results of this large study showed almost exactly the opposite. This led GYNs to turn their HRT-writing prescription pads in ASAP and caused women to quickly trash their stash! However, a closer examination of the study and the study population over the past 10 to 15 years has called into question a lot of the initial findings and negative hype.

It now seems that HRT in the right woman (again, the right woman) is no longer the devil and actually can be pretty helpful. While it is no longer believed to improve overall health and prevent things like heart disease, stroke, and breast cancer, it can be useful for women with beyond-bothersome menopausal symptoms.

So if HRT was good, then bad, and now sort of good, what is all the hype about compounded bioidenticals? Did they, too, follow this trend? What are they, and what makes them so different? Bioidentical hormones are plant-derived hormones similar to those produced by our bodies. They include both products that are and are not approved by the FDA.

Think of the FDA as the FBI; they are there to keep you safe when it comes to anything drug- or medicine-related. They test products, procedures, and techniques and make sure things look kosher before you use them. However, the FDA does not oversee the production of compounded bioidentical hormones. They have not checked these drugs for safety, efficacy, potency, purity, or quality. Basically, the inmates are running the asylum. Overdosing and underdosing are both more than possible, and you can’t be sure that what you took on Monday is going to be the same thing you take on Tuesday.

You might now ask, what is compounding? Is it just a fancy way to say “mixing”? Basically, yes. Compounding is creating an individualized product based on the prescription written by the health care provider. Given that the product is custom made, there is no regulation over what is put into that “cocktail.” While you may think your vodka cranberry drink tastes better with a little more vodka, it might not be good for you. And unfortunately, given that it has deviated from the traditional vodka cranberry, no one will be checking to make sure it’s safe.

Now don’t get us wrong; compounding has its place in medicine. It has traditionally been used when specific products are not available or if different preservatives, routes, or ingredients are needed to deliver a medication. An example is the following…you need to take progesterone but it traditionally comes mixed in peanut oil—but you are allergic to peanut oil. Therefore you can’t take the medication UNLESS it is compounded with something else (aka sesame oil). Changes like this are what compounding was meant for!

But give me a little of this, mixed with some of that, and a splash of something else (a.k.a. blending) is not what compounding is or was intended to do. However, this blending concept is how it is often sold and marketed when used to describe hormone replacement therapy. When we were all down on HRT, compounded bioidenticals gained foot traffic because they appeared, and were billed to be, a safe alternative. They were marketed as the same good but no bad. The story was bought by many hook, line, and sinker and led many women to have a false sense of security about what they were putting into their bodies.

Many practitioners who prescribe bioidentical hormones tout them as personalized or tailored. They sell them as a perfect fit (sort of like those jeans that you are always trying to find!). But in reality, you don’t really know what you are buying, ingesting, or drinking. They are free from warning labels and any information on risks. But while ignorance can certainly be bliss, in many cases, this is not one of them! For example, if you are not taking enough progesterone in comparison to estrogen, you can put yourself at risk for uterine cancer—it’s just not a good situation.

And let’s take it one step further. Those that tout compounded bioidentical hormones will tell you they can check your levels through your saliva and can further tailor your treatment according to what they find. There is no evidence that hormone levels in saliva have any biological meaning; while we can pick up some things from your spit, we cannot pick up the level of your circulating hormones. So chew on this: don’t put yourself in danger because you want something natural. Compounded bioidentical hormones are not necessarily the answer.

The specific medications, the dosage, and the way the medications are delivered (oral, patch, vaginal) should be made to order for you. However, this should be done with FDA-approved medications where your doctor knows exactly what they are writing for you and you know exactly what you are ingesting. So while, yes, medicine should be tailored to you, the tailoring should not come in how the medication is mixed but rather how it is administered.

While we all agree that you need a good designer, some designs are not meant to be worn (think midriff shirts). So while you can look, please don’t buy. If the salesperson tells you it looks good, don’t believe it…just like bioidentical hormones, it’s not necessarily the best fit!

The 8 Facts Every Woman Should Know About Breast Cancer

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October is not a month of black and white. We definitely see lots of ghosts, goblins, witches, and skeletons, but reds, yellows, oranges, and pinks (#BreastCancerAwareness) own this time. These colors open our eyes and make us aware of our surroundings and ourselves. And while you can pretty much count on the leaves changing year after year, you want to make sure you don’t ignore any changes in your body, particularly your breasts. Here are the eight facts every woman should know about breast cancer.

  1. One in eight women will be diagnosed with breast cancer during their lifetime. And while this number as a ratio or a percentage may not seem all that impressive to you, think about it in everyday terms. Count the number of mats or bikes in your exercise class. If each row holds about 16 people and there are about three rows in the class, then about six people per class will be diagnosed with breast cancer over the course of their lifetime! And without even saying, “Boo,” those numbers are pretty scary.
  2. It’s pretty safe to say that we all know someone who has or had breast cancer. Breast cancer is the most common cancer in women and the second-leading cause of cancer death in women. Put it this way: every two minutes, a woman is diagnosed with breast cancer, and every 13 minutes, a woman will die of breast cancer.
  3. Once again, age matters. The older you are, the more likely you are to be diagnosed with breast cancer. In fact, the majority of women who are diagnosed with breast cancer are older than 50, and the median age of diagnosis in the United States is 61. However, while less than 5% of women are under the age of 40, young women get breast cancer as well. Bottom line; don’t ignore your breasts just because you haven’t reached the big 4-0.
  4. Screening saves lives. Period. Putting off your mammogram only puts you at increased risk for breast cancer. Don’t be foolish (now we sound like our mothers!). Get checked out. And for you younger ladies (less than 40), it is NEVER too early to give your breasts their own monthly exam, and make sure you see a health care provider who does so once a year. If you feel something, say something.
  5. What you eat, what you drink, and if you sweat matter. Obesity, high alcohol intake, and a sedentary lifestyle are all risk factors for breast cancer. So if you needed more motivation to move and make healthy food choices, here you go. Come on, ladies, let’s get moving!
  6. Your chromosomes dictate a whole lot more than whether you produce sperm or eggs. There are genes on those 46 chromosomes (23 from mom and 23 from dad) that increase your risk for cancer. Harboring one of these genetic mutations—think BRCA-1 and BRCA-2—does not mean you will get breast cancer, but it can significantly increase your risk. And while nearly 65% of breast cancers occur in women with no risk factors, if you know you or your family member carries the BRCA-1 or BRCA-2 mutation, you should be screened early and frequently for breast cancer. Make sure your GYN knows everything about your family history (trust us, your secrets are safe with us!).
  7. When your period first presents itself and parts ways with you (a.k.a. menarche and menopause) can alter your risk for breast cancer. Women who have an early period or a late menopause are at a slightly increased risk of breast cancer. While you shouldn’t panic if you see red early or late, it is something important to keep in mind. Additionally, women who don’t have children or who have their first child after age 30 have a slightly higher risk of breast cancer. While this statistic should not dictate when you decide to do the baby thing, it’s something we GYNs make a mental note of.
  8. Breast cancer does not equal infertility. While the diagnosis used to mark the end to one’s reproductive days, we now have ways to cryopreserve (a.k.a. freeze) eggs and embryos. This technology can safely be used prior to any chemotherapy or radiation that may harm the ovaries. With advances in diagnosis and treatment, breast cancer does not always mean the end to a woman’s reproductive road.

Breast cancer treatment is evolving every day. It is truly (#ourFAVORITEword) amazing. We take our hats off to our friends, the scientists and physicians, who have revolutionized how we diagnose, treat, and ultimately cure breast cancer. Because of their smarts and hard work, what we know now pales compared to what we knew five years ago. And while you may never meet these fantastic men and women who have dedicated their lives to making us all safer and healthier, we at Truly, MD, can make you aware of what they have found and how it can impact you.

So do us a favor and check out your breasts. While the presence of certain risk factors (particularly those listed above) increase one’s risk for breast cancer, nearly 75% of women who are diagnosed with breast cancer possess NO risk factors. Therefore take a moment to stop and feel your breasts on a monthly basis.  Although what they have won’t impress you (unlike that fall foliage that October is known for), if they do you will act quickly. Early detection of breast cancer can save your life. So think pink and make a point to do self-breast exams and get screened—it may just ensure that you see the leaves change for years and years to come.

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

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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

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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

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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?

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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”

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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!

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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

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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!