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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!

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!

The Low Down on the Low-Dose Oral Contraceptive Pills

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Loestrin, Mircette, Yasmin, Yaz, Ortho-Tricyclin, Ortho-Novum, and Alesse—the list goes on and on. Many of us have sampled more pills than flavors at our local ice cream shop (even when the sign says one per customer). And no, it is not all in your head; different pills make you feel differently! Who is the culprit, or the Oz, making your body and maybe even mind feel different on Ortho-Tricyclen vs. Yasmin? Drum roll, please: it’s the progesterone!

While almost all oral contraceptive pills share the same type of synthetic estrogen component (ethinyl estradiol, a.k.a. EE) the progesterone content can vary significantly. Some may make you feel good, even great, while others can make you feel down right crummy. In order to understand the difference in progestins, we want you to picture your family tree. Hone in on four consecutive branches, or generations: from great grandma right down to you. And as with most families, generational changes are huge—think landline to the iPhone, black and white TVs to flat-screen monstrosities, a quarter to ride the subway to a whopping $2.50 per ride.

Similar changes can be seen in the generational changes of synthetic progesterone. The first-generation crew was not so specific in whom they “mated and connected with.” Therefore, they would bind to both progesterone and androgen receptors alike. Their affinity for the androgen receptors resulted in some unwanted side effects: think hair, acne, and bloating. Oh, what a joy! Such side effects made them somewhat unattractive and unpopular.

However, over the next several years, scientists found ways to alter the synthetic progesterone component and reduce the androgenic properties; this translated into way less negative side effects and even some positive ones! Such alterations made pills way more appealing and widespread in their use. Bottom line, if one type of pill (a.k.a. progesterone) doesn’t agree with you, try another. There are many “branches” to climb!

Now, while the progestin component varies, the synthetic estrogen component is pretty much always the same—think of the menu at Applebee’s. It’s just not going to change! However, while the estrogen content is always the same, the dose will differ. And what makes the modern-day pills low dose or, even better, low, low dose is the very low dose of estrogen that each pill contains.

Today, most pills have between 20–35 mcg of EE. This is in contrast to traditional pills (circa 1960), which contained about 50 micrograms of estrogen in each pill. The past 50 years have shown us how low we can go on the estrogen—minimizing clots, strokes, and a slew of negative side effects—while maintaining the efficacy. So although lower dose EE = lower negative side effects, lower dose ≠an increased chance of pregnancy. Currently, we are, taking it back to the limbo reference, as low as you can go without giving up on efficacy.

While intuitively, it seems that the lowest would be the best, this is not the case for everyone. Sometimes the low-low versions cause lots-lots of breakthrough bleeding; this can often be fixed by raising the estrogen dose. So just because low-low seems to be the “in thing” to do, it may not be right for your uterus. A slight bump up in the estrogen dose won’t take you back to the doses seen in the 1960s, but it will give your body just enough estrogen to maintain the lining and maintain your sanity.

You might be wondering what is up with the Tri and even Bi part in the name of some pills (e.g., OrthoTri-Cyclen vs. Ortho-Cyclen). For all of you number fans who can’t wait to travel back in time to middle school math class, tri means three, bi means two, and mono means one. The number part of the name describes the number of phases or changes in hormones that will occur throughout the cycle (a.k.a. the pill pack). Monophasic pills (Loestrin, Ortho-Cyclen, Yaz, Yasmin, Seasonale) contain the same amount of estrogen and progestin in all of the active pills. Biphasic pills (two-phase pills; e.g., Mircette, Ortho-Novum) alter the level of estrogen and progestin twice during the active pack. Last, triphasic pills (three-phase pills; e.g., Ortho Tri-Cyclen, Enpresse) have three different doses of estrogen and progestin in the active pills; the dose changes every seven days during the first three weeks of the pack. These triphasics were the original pills. Scientists were doing their best to mimic the natural cycle. However, research soon showed us that we didn’t need to vary the dose each week. Slow and steady could also win the race! In fact, monophasic pills are equally as effective and in many ways more tolerable. The consistency of the dose translates into less side effects and less breakthrough bleeding.

We have covered doses, phases, and progestins. Last but certainly not least is the number of active pills contained within the pill pack. Traditionally, pill packs contained 21 active pills and seven inactive (a.k.a. placebo or sugar pills). This, like the triphasic pills, was designed to mimic the natural cycle. However, newer formulations have increased the number of active pills to 24 and reduced the number of inactive pills to four. By altering the balance and pushing the pendulum a bit further to the right, there are fewer days off the active pills. Fewer days off the active pills means fewer days of bleeding. In fact, some women skip the placebo pills all together every month and only take the active pills. This does no harm to them or their fertility. It merely removes the need to buy tampons or pads.

Believe it or not, the pill has benefits beyond contraception. It can reduce the risk of ovarian and endometrial cancer, improve acne and unwanted hair growth, regulate the menstrual cycle, decrease heavy menses, reduce the size of fibroids and painful periods, treat PMS symptoms and menstrual migraines, and offer symptomatic relief to women with endometriosis. The list is long, and the benefits variable. Simply stated, the pill can do a lot more than prevent pregnancy!

However, with every peak there is always a valley, and with every pro, there is also a con. Even with the best medications, you must read the fine print. Although the pill has a lot of benefits, there are some of us for whom the glass slipper just doesn’t fit. Certain medical problems preclude women from even trying to shove their foot in! Such conditions include women with a history of blood clots (or a family member who harbors an inherited clotting disorder), impaired liver function, smokers older than 35 years, elevated blood pressure, migraines with visual aura (think flashing lights), and markedly elevated cholesterol/triglycerides. Before starting you on the pill your doctor will likely take a thorough medical and family history to make sure you are a good candidate.

You will likely not marry the first person you date or say yes to the first dress you try on. Don’t quit after one bad month on OCPs; just because one didn’t agree with you it doesn’t mean the dozen others will too. OCPs are a great form of birth control and come with a lot of other benefits. As long as you can remember to take it daily (put it by your toothbrush or face wash!), it’s worth giving it a go. You’ll find something that fits!

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!