I’m so excited to share the second installment of the Wine & Gyn series that covers women’s health, fertility, egg freezing, and more. This post covers women’s health and wellness questions that were answered by Dr. Mary Rosser, Dr. Zev Williams, Dr. Brianna Ruddick, and Dr. Paula Brady from Sloane Hospital for Women at New York Presbyterian. Dr. Rosser’s specialty is Obstetrics and Gynecology and Dr. Williams specializes in Fertility, specifically recurrent loss. Dr. Ruddick is a Reproductive Endocrinologist within the area of third party reproduction and same-sex couples, and Dr. Brady specializes in egg-freezing. We were very lucky to have all four specialists in attendance to answer any and all of our questions to gain some clarity on sometimes confusing subject matter. To avoid a 30-page transcript of the conversation from the event, I divided the questions into three categories, like I did for the first installment of Wine & Gyn. Here is part 1 and you can find the first post covering similar questions here.
Dr. Rosser: To the question of birth control. We have gotten much better with our doses of birth control pills. Typically they contain two hormones that your ovaries make, estrogen and progesterone, and when they first came out in the late 1950s the doses were very high. Now the companies have been able to titrate, or lower, the hormone levels to just the right dose to prevent pregnancy, so they can be very safe to continue. It's also safer to be on the pill then actually get pregnant, have a pregnancy termination, or carry a pregnancy full term, and have a vaginal delivery or a C-section.
The other thing I'd like to tell women is that it's protective also against some cancers such as uterine cancer and ovarian cancer so there are many benefits for being on the pill. A lot of women go on it for cycle control when they're young, or it could be for endometriosis, or acne. When a woman comes in and says, “You know I just I'm really want to go off of this”, I individualize it. If this person is very anxious and really wants to see what her body is like off of it, I think we should have that conversation at the same time we have a conversation of what other options are out there that really work for birth control.
Dr. Rosser: There was an arbitrary number years ago where people were saying go off for three months to get your cycles back before you get pregnant, but if you go off and you get pregnant the next month, generally that is just fine. If you were on something like a progesterone containing IUD, the Depo Provera shot that has progesterone, or even an implant called Nexplanon that's placed in your arm, once those are removed it may take some time to get your cycles restored to normal. We usually say seven to nine months, so I don't think you have to stop two years in advance.
Dr. Williams: Actually for some conditions like endometriosis, birth control pills actually help suppress the disease and the disease gets back under control. This is a condition where the cells are normally on the inside of the uterus but are instead found outside the ovaries and the fallopian tubes. It's a chronic condition which can lead to scarring of the fallopian tubes and one of the ways to suppress it is to be on birth control pills, so that's one of the cases where being on birth control pills helps preserve fertility for later.
Dr. Rosser: We have seen that the progesterone containing IUDs are very helpful for the pain caused by endometriosis and they are the most popular methods of birth control. I constantly tell patients, and I'm not really a drug pusher and I give everybody their options, but it's the most desired birth control for female OBGYNs ourselves to use. The wonderful thing about IUDs, there are so many wonderful components, but you don't have to remember to take something every day so it is incredibly effective because it doesn't rely on us to remember. It only contains one hormone, progesterone, not both progesterone and estrogen, and they last anywhere from three to seven years. You can take it out whenever you want, but it is really a wonderful method of birth control.
Dr. Ruddick: Online is actually great. Lot of great options online. Fertility IQ is actually kind of an up and coming site with a lot of good resources for patients to learn about natural fertility. The ASRM, American Society for Reproductive Medicine has really great educational pamphlets, brochures, and little cheat sheets on the various aspects of fertility, like how to enhance natural fertility. So, there are a lot of good things online but just stay off the chat rooms. You want to keep something objective and data driven.
Dr. Rosser: For the general OBGYN questions, the American College of OBGYN has great information just on general women's health questions and I usually tell people to start there before they hop around to the rest of the interest just so you can get a base of information. You can be frightened a lot online so be very, very careful and if you do have a question, give your clinician a call, and that's what we are supposed to be there for.
Dr. Rosser: I have heard it and someone gave it to me, but I haven't really read it yet. I came out of medical school thinking Western medicine is just the best and after being in practice and hearing people's stories and treating different women, I understand that it really is an individual situation. I think that we should be blending Eastern and Western medicine, so yes you're right that there are not a lot of clinical studies to back this up, but I think as long as it's not harmful, you should try it if you want and try it. What it really does is it helps to make you more aware of your body and I think that's what your generation is doing- becoming very empowered and very aware of your body while asking more questions. I think it's really important in your overall health.
Dr. Williams: I think you're right that high school health classes do a terrible disservice. When you think about what's happening on a regular basis in your body, it's an amazing and intricate communication between the brain, the ovary, and the uterus. They are all communicating to each other in a very elegant manner. It's kind of amazing when people have gone through health ed and then learn the whole story and think like wait a minute this is actually really amazing and what my body is doing is pretty incredible. I think it's great to take that interest and to learn about what is happening on your own.
Dr. Rosser: And I can’t tell you how many times I'm drawing pictures of uteruses and the fallopian tubes to make sure people of all different backgrounds understand and when I ask, “Have you seen this before?”, it's almost nine times out of 10 that people never saw it. I agree that sex ed is not as optimal as it should be so finding out now and using online resources is great.
Dr. Rosser: If you don't have children it does increase your risk and the idea behind that is that when you are pregnant your ovaries are not working to turn out the hormones that they normally do. Your cycle is basically shut down for the 40 weeks that you're pregnant. The risk of getting pregnant when you're older, besides some genetic issues, is that women are older so they are more apt to have started developing chronic conditions and you might not even know if you have an underlying condition like high blood pressure, so it's usually unmasked when you are pregnant and under constant care from your doctor. We see more people with those chronic conditions, the older they get. This is what we talk to women about before they get pregnant; we ask you to please come and see us to do pre-conception counseling. We can talk about your individual case with you and your partner so that we can optimize your health before you actually get pregnant and make plans for consultations with other experts if needed. So that's really important.
Dr. Williams: So it is actually funny, about four hours ago I was meeting with the head of the NIH’s group that oversees contraceptive development. We were talking about the their top five priorities and one is male contraceptive development. It's not an easy thing to develop because, from a biological standpoint, there is a very effective method…a vasectomy, which is extremely effective, very well tolerated with very minimal side effects. The challenge with it is it's not reversible. So there is an effective male contraceptive, it is just not reversible. What they're trying to develop is a non-hormonal, reversible male contraceptive. The challenge is a single ejaculate can have hundreds of millions of sperm in it. Trying to knock those numbers all the way down without suppressing the male hormones so that he doesn’t have extreme side effects is the problem. Most women say, “Oh wow, so he has to go through some side effects from contraceptives, welcome to what we've been going through for decades”, which is a fair point. There is certainly an interest in trying to develop that for a number of reasons, but it’s not an easy target for drugs.
Dr. Williams: It’s interesting, if we went back in time, I'm not sure if female birth control pills could have been developed today. It was developed in a time where the tolerance for risk was much higher. Those sorts of hormone levels they had decided to profile wouldn’t have went through today.
*I thought this was such an interesting point and made me think about other drugs that are never brought to market today due to their risk factor, even if they present promising cures for people with different health issues.
Dr. Ruddick: That's a great question. Frequently when I'm doing a pregnancy ultrasound for a patient, I often ask them how they're feeling and then I will turn to the partner in the room and say, “and how are you feeling?”, because sometimes we just don't pay them enough attention. There is a role of just being nurturing and supportive but this is a very difficult role to fulfill because many times the partner is not undergoing treatment, but they still have feelings about the process that frequently get overlooked. This is why having such good ties with an amazing university with a psychiatric department that ties in very nicely with women's mental health can be very beneficial. We have excellent psychiatrists who focus on really every aspect of women's health at every stage in her reproductive life cycle, whether it's puberty, infertility, whether it's having a baby, or postpartum, or going through menopause. The changes in your hormones that happen over the course of your life really do affect your emotions. Sometimes it's very easy to overlook what the partner is going through, but especially in a fertility clinic, we see all the time that we are treating couples and not just a single person. When we lose sight of that, the couples start to lose sight of that. Addressing those feelings, talking about them, and offering resources for support is a very important part of all this.
Dr. Williams: It's also a very common concern in same sex or heterosexual couples, if they are using a donor egg donor sperm, to ask themselves, “Am I going to feel connected to the baby?” I would say, without even a single exception, everyone feels like it is their child. They feel that connection and it's really beautiful to see how that bond develops early.
Dr. Ruddick: People talk a lot about nature versus nurture and I think at this point, we're really coming to realize that it's really both and it's not just one or the other.
Dr. Rosser: It's is true that doulas are becoming more and more popular. And I think that is a wonderful way for a woman to have a support person in the room with them. Many times with the mother and the mother in law in the room, it can be a little bit of a tense situation. I tell people to make that decision with your partner in advance so that you're not struggling with it on the day that you're in labor. A lot of times people have substituted that for a doula. I trained with midwives and I love midwives. They are fabulous, but having that support person in the room, like a doula, that is there for you is really important. To the point of the couple, you just make sure that you keep open communication with your partner throughout the whole process because then you will get what each other needs and support each other through the process.
Dr. Ruddick: I have a fair number of same sex couples who ask me about being pregnant at the same time and that kind of goes back to that point. There is usually the person who is carrying in need of a lot of support and it is a particularly hormonal time so that's not something I typically recommend.