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Putting Out the Fire: Endometriosis Treatment

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

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

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

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

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

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

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

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

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

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

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

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

Let’s Play Pill! Controlling the timing of your cycle.

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For all of you blackjack and poker fans out there, you probably get the “Let’s play some cards” reference pretty quickly. And while you may have never put the words birth control pill and pack of cards together in the same sentence, there are some similarities. Think about it…both come in a pack, both have two colors, and both can be purchased at most local drugstores. And it doesn’t end there. In fact, the biggest similarity between these two “packs” is the way you can manipulate them to make things a little more interesting. If we lose, you don’t despair. We will lay all our cards on the table and talk you through this.

Although as GYNs we are pretty partial, in many ways, OCPs are science’s greatest gift to women. It gives us flexibility, it gives us choice, and it gives us control. It also takes away cramps, minimizes bleeding, and puts a stop to acne and unwanted hair growth. Not bad! And while it does require a daily thought (we recommend combining it with brushing your teeth!), most of us can handle that. On top of these pluses are some plus + pluses (a.k.a. contraception).

And if that wasn’t enough, the pill can now be used to adjust when and if you see red. By extending the active pill pack and skipping the placebo (sugar pills), you can avoid that un-fun time. The constant dose of estrogen and progesterone will keep the inside of the uterus (the lining) from shedding. And while it may sound like we have lost our minds, you can live in this steady state of estrogen and progesterone for many months, even years (truly, you can!). It won’t hurt your body or your future chances of having a baby.

Sometimes you just don’t like the hand you are dealt. Luckily, you are not in Vegas and can reshuffle your cards. In fact, counting cards is what we GYNs do best. By looking at your pill pack and your calendar, we can come up with a period schedule that not only works for your body but also for your life. Let’s face it,getting your period on your vacation, wedding day, or honeymoon is just not fun.

But don’t count your cards before the game is over. While altering the pill schedule usually works to avoid bleeding on big days, sometimes your body has a mind of its own. Breakthrough bleeding can occur despite continuous OCP use—and although it’s a big bummer, it’s not a big deal (medically speaking).

So if you play your cards right, you might just be able to avoid taking tampons on your next trip. It requires some planning, but with your ace up your sleeve (a.k.a. your OB/GYN), you can plot out your next move. While most card players are taught to keep their cards close to their chest, in this game, to win you have to let a couple of people in. Don’t worry; we won’t tell the dealer!

Can I Break up with My Birth Control?

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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!

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

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

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

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

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

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

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

Getting Your Timing Back: Preparing for Pregnancy

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Nowadays, many of us prepare for getting pregnant in the same way we would train for a race or prepare for a big meeting at work. We carefully map out when we will stop our contraception, how we will tackle the trying thing, and how long we will let things go “naturally” before seeking out fertility advice. Infertility has gotten a lot of press (one in six couples will experience infertility), and therefore, many couples are thinking about what could go wrong before the process has even begun. But let us mitigate some of the madness about becoming a momma with a few morsels of advice about the “pre” period.

Most women who are not trying to conceive have a better idea about when their Amazon Prime package will arrive rather than when to expect their period. Tracking often applies only to packages, not periods! And the situation is even more confusing for women who are on the pill, the patch, or the ring or have an IUD. These forms of contraception can turn the system off all together (which is not a bad thing, we promise!), which makes knowing what’s up with your periods pretty problematic.

And while we certainly don’t recommend that you stop your hormonal contraception to focus on Aunt Flo’s arrival, we do suggest that you say goodbye to hormonal contraception a couple of months before you are ready to give things a go. During this time, you can get a good idea about the regularity (or irregularity) of your cycle—this information will be helpful when you are trying to track your ovulation and time intercourse. To protect yourself from pregnancy while you are getting your timing back, we suggest using a non-hormonal form of contraception (a.k.a. condom)—barrier methods only block pregnancy in that moment. They won’t have any impact on your menstrual cycle/ovulation.

Second, while we don’t want to turn the process into a science project from the start, we do suggest that you visit your OB before you get the pregnancy party started. During this visit, they will not only offer you good advice about timing/trying but also will make sure you have a clean bill of health. Medical problems that predate pregnancy can get worse with a baby on board; therefore, it’s important to make sure your body is prepared for what’s to come. A thorough medical history and physical exam can reveal a lot.

Additionally, during the pre-conception visit, most OBs will perform a genetic screening panel—this blood test is basically taking a magnifying glass to your genes to see what’s normal and what’s abnormal. And although we don’t have the ability to look at all 25,000 protein coding genes, we can look at a good number of them. In cases where you come up as a carrier for a genetic disorder, we will want you to chat with a genetics counselor and test your partner. Couples who are both carriers for the same genetic condition may elect to do PGD to screen embryos.

For anyone who has ever played tennis, golf, baseball, or squash, you know how important timing is. It can take a good number of practice sessions before you are making good contact with the ball. The same can be said for your menstrual cycle. Taking a few swings before game day can help. But remember, not everyone needs so much time on the practice field. Although infertility will affect many couples, you may not be one of them. Don’t let fear force you to start trying before you are ready for a baby. You will get your timing back, and if it doesn’t happen on your own, we can coach you through it!

IUD: When Your Bumper Sticker Reads “Babies on Board and I Need a Break!”

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You know when you are out on one of those awkward first dates that are not going well? There are endless uncomfortable silences, those pregnant pauses that are just yearning for some interesting conversation. And then someone breaks the ice and says, “What animal would you be if you could be any animal?” And in that moment, you know: we are never going on a second date! But while the relationship may be over, you probably spit out something like a dolphin, maybe a horse, or even a dog. Those animals that sort of elicit a positive emotion in all of us. Come on, who doesn’t like dogs? We highly doubt that anyone has ever said a camel. I mean they have humps, they walk in the desert, and they can shut their nostrils in a sandstorm. But if you have or have ever considered using an IUD, you may be surprised to find out that the first IUDs were used in camels. Yup, camels. Story goes that many, many years ago traders put stones into their camels’ uteri to prevent pregnancy. It worked. And that, ladies, leads us to IUDs…

Fast-forward several hundred years, and IUDs (intrauterine devices) are one of the most popular forms of long-acting reversible contraception. Given that they take almost no thought (after placement), they do a pretty good job at preventing pregnancy. They allow a pause between pregnancies or a pregnancy pause that can go on between five and ten years, depending on which type you use!

IUDs come in two basic “flavors” (think your local soft-serve shop in the summer)—the Copper T or the Mirena. Recently two more IUDs have come on the market, the Skyla and the Liletta (they are very similar to the Mirena). While the three hormonal options (Mirena, Skyla, and Liletta) differ in a few minor ways—size, the amount of progesterone they release, and the length of the time they will be good at putting baby making on hold, when it comes to the major stuff, they are pretty much the same!

The Copper T is a T-shaped device wrapped in copper. It does its job (a.k.a. no pregnancy) in a couple of different ways. First, it holds the SLOW DOWN sign to both sperm and egg. By slowing down the swimming of sperm as well as changing the speed at which the egg moves through the tubes, fertilization is delayed. However, it not only acts pre-fertilization but also post-fertilization, that is, it can damage or destroy the fertilized egg. Pretty smart, huh? It is important to remember that everything that the IUD does (both the hormonal and non-hormonal types) happens before an embryo implants. The Copper T is your steady eddy or your tortoise in the tortoise and the hare race…it is good for 10 years. But while it lasts and lasts, symptoms are not uncommon. Women often complain of irregular or heavy bleeding and occasional pain. However, the majority of women are pretty pleased with their selection and don’t even know that it’s there.

The other options on the table are the hormonal IUDs, the Mirena, the Skyla, and the Liletta (the levonorgestrel IUD). They are also T-shaped, but rather than being wrapped in copper they are wrapped in hormone: progesterone (levonorgestrel). Despite these differences, the two work in a similar fashion. Both limit egg and sperm movement and, thereby, fertilization. While the Mirena has a shorter half (five years) and the Skyla and Liletta even shorter (three years) they come with fewer side effects—primarily, less bleeding. The progesterone in these IUDs thins out the uterine lining, something that is particularly good for women who have a tendency to develop thick linings from irregular periods.

A thin lining = not so much to shed = fewer annoying bleeding episodes!

News flash: most women who use IUDs still ovulate. Therefore, when the time comes, and you get ready to pull it, pregnancy can potentially happen pretty quickly because ovulation is not suppressed.

Nobody is perfect; everyone and everything has their flaws. Trust us, we have several! The same goes for seemingly flawless medical devices and treatment plans. The IUD is pretty picture-perfect…it prevents pregnancy, you don’t have to remember to take it, and when you are ready to have a baby, you just remove it and are off to the races. What could be bad?

While IUDs are pretty easy to place (most OB/GYNS learn in their first year of residency), there are occasions where a uterine perforation (hole in the top of the uterus) can occur. The perforation rate is about 1/1000. So basically, you have about the same chance of an asteroid hitting the Earth in 2182! Bottom line, it is likely not going to happen. Additionally, there is a small risk of expelling the IUD—this happens more frequently (between 2–10% can dislodge in the first year). Last, if pregnancy should occur while an IUD is in place, calling all of you super-fertile women, you are at a slightly higher risk for an ectopic pregnancy. When things (eggs, sperms, embryos) move slowly down the tubes, they may get sidetracked and start to sightsee. This delay in transit (hello, subway system!) can increase one’s risk for an ectopic pregnancy. So while IUDs don’t cause ectopic pregnancies, if you get pregnant while an IUD is in place, the chance of an ectopic pregnancy is slightly higher. This caveat is not meant to scare you, but it is meant to have you take a pregnancy with an IUD in place seriously.

Historically, IUDs got a bad rap. When you mention, “Mom I am going to get an IUD,” she may have a visceral reaction. In the 1970s, they were blamed for everything from infertility to infection and got the “I definitely don’t want to use that” verdict from many women. However, changes in the design, particularly the string that comes off of the IUD, made them much more attractive to potential users. Now even women who have never had a baby (medically termed nulliparous) as well as adolescents are cleared for boarding. There is no good data that IUDs cause infection or infertility and as a result are “in play” for almost anyone. And bonus— routine antibiotics are no longer needed when placing an IUD.

IUDs are a great go-to for women who want an extended baby-free break. Whether these are young women who are not ready, women who have a baby and want a big-time breather, or women who are done and done, it works. Placement can be performed at any time of the cycle, although right after the period is usually preferable. While we may not have inspired you to use an IUD, we probably gave you some good dinner-party conversation (#camels) or a fighting chance when watching Jeopardy. When having kids or more kids or more and more kids feels harder than trekking across the Sahara Desert without water, think about that camel. And ask your OB/GYN about the IUD.

It’s Not You, It’s Me: When Is It Time to Break Up with Your Pill?

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As much as it hurts to remember, we have all been the victims of a painful breakup at some point. Whether it was your high school sweetheart, your first kiss, or the guy whose professions of love sounded convincing after numerous tequila shots, we have all been there.

While some are more painful and memorable than others, breaking up with your pill (or thinking about breaking up with your pill) can be pretty frightening. For many of us, it keeps us pain free, it keeps us headache free, it keeps us acne free, and most importantly, it keeps us baby free. However, when you start to think about having a baby, you start to wonder: could all those years on the pill be doing something bad to me?

Although voices don’t carry over the Internet or through the written word, picture us shouting NOOOOOOO as loud as possible! The pill did not harm your fertility, and the pill is not causing your infertility. The pill did not harm your ovaries or your eggs or your uterus or your tubes. Whether you spent one, five, ten, or twenty years on the pill, it does not matter. Fertility issues arise totally irrespective of the length of time you were on the pill. In many ways, the pill protected you from some of the fertility monsters (think fibroids and endometriosis) as well as some of the other monsters in GYN (ovarian and endometrial cancer).

One of the most common complaints we hear is “I spent so much time on the pill I don’t know what my period is like.” And while this is true, it doesn’t matter so much. Yes, it might have tipped you off to menstrual irregularity before you started to try and led you to stop the pill a couple of months sooner, but in the grand scheme of things, it won’t make a huge difference in your fertility or your future pregnancies.

While you may not know you had something going on, the delay is unlikely to change the outcome. The only time it may have blinded you to important information is for women who undergo an early (a.k.a. premature) menopause. In these rare and select cases, had a woman not been on the pill, she might have seen her cycles becoming shorter and more irregular and therefore sought treatment earlier. However, premature menopause is very, very rare (affecting an infinitesimally small subset of the population). Bottom line, breaking up with your pill to rule this diagnosis out is completely unnecessary.

There have been many amazing developments along the way for women and women’s reproductive rights. Oral contraceptive pills are definitely at the top of this list. And while your friends, your mom, or any stranger willing to give you advice on anything and everything, we want you to stop worrying about how many years of your life you have devoted to this daily ritual; you did NOTHING wrong by engaging in chronic pill use. In fact, you did just the opposite—you were proactive in thinking about your reproductive health. This wise and thoughtful decision definitely gets a double thumbs up.

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

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

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

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

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

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

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

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

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

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

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

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