Expiration Dates

Hi Dr. Kate,

If birth control pills are expired, or about to expire, but they are still in the original sealed, unopened package without punctures and have been stored in a cool, dry area away from heat and humidity, are they still safe to use and still effective at preventing pregnancy if taken correctly? Is an expired but unopened/sealed condom package stored in a cool, dry area away from heat and humidity still safe, usable and effective at preventing pregnancy when used correctly? These types of expiration dates on BC and condom packages confuse me, for example: the expiration info on a package of birth control pills/sealed condom shows the following: Exp. 12/10 (Meaning it expires December 2010). Exactly WHEN does it expire? Does it expire on December 1st, 2010, or on December 31st, 2010?

Thank you so much!
J

Dear J,

The good news is that you have the entire month of the expiration date to use the product (pills or condoms). In your example, the pills/condoms expire on December 31st.

The bad news is that these products really shouldn't be used after this date. Even if you've treated them with TLC (they haven't been baked in high heat or had their packaging damaged), the manufacturer can't guarantee effectiveness after this date. Now, if you're about to have sex, and the only thing you have on hand is an expired condom, I would still use it - an expired condom is better than no condom at all. There's no way to estimate how much less effective the pills or condoms would be after the use-by date, though. So it's best to keep track of your birth control stash, and make sure you're prepared for sex with the freshest contraception you can.

Best of health,
Dr. Kate

Photo credit: Chazz Layne

The Logic Behind Sunday Start

Dear Dr. Kate,

I recently began taking Ortho-Tri Cyclen again for a variety of reasons and I've always been a Sunday starter, so I wanted to stick with that routine. I began my period on a Friday and, like clockwork, started taking my pills on Sunday morning bright and early. I know I am suppose to use a back up method for the first seven days if I am a Sunday starter. Here's my question...why is this? I understand if I woman starts on Monday and is a Sunday starter that she has the potential to ovulate during the first week of the pills, especially if her follicular phase is short, but if I start on Friday and begin my pill pack on Sunday, what are my odds of ovulating in the first seven days?

Sincerely,

Sunday Starter

Dear Sunday Starter,

The advice about when to start the pill and for how long to use back-up has more to do with simplicity than science. There's no magic to beginning the pill on Sunday - it's been long thought by doctors that it's easier to start the pill pack with the start of the week. It's fine if Sunday works for you - it gives you the whole weekend to get your pills refilled, and you may be more likely to be home on a Sunday night to take them. But in general, you can begin your pill any day you want - even if you're not on your period ("Quick Start").

The issue of back-up birth control has two parts. If you begin your pills within 5 days (some say a week, I'm more cautious) of the start of your period, you're protected. So if your period begins on a Friday, you're right that if you begin your new pill pack on Sunday, you don't need back-up that cycle. But if you begin your pills later than 5 days after bleeding begins...or in the middle of the month...you'll need condoms for a full 7 days after. Because this rule can get complicated, many doctors simplify it to "always use condoms for the first week of the pack." In theory, if it's not really a period when you start your pack (you just think it is), then you'd be at risk of ovulating, and would need the condom back-up. But if your bleeding looks and acts like a period, your chances of ovulating that week are very low.

Best of health,
Dr. Kate

Photo credit: Vincent Caplier

When A UTI...Isn't

Dear Dr. Kate,

I've been having this recurring problem that my OB/GYN and primary doctor can't seem to figure out. I started feeling like I have early symptoms of a UTI two months ago (I've had a few so I'm familiar with the symptoms). I have an urge to urinate but I don't have pain and sometimes it even goes away if I force myself to go less often, or avoid caffeine. Eventually it stops but then it seems to start again. When my symptoms started I went to my OB/GYN for a UTI test, which showed only an elevation in white blood cells, I took antibiotics and felt better for a while. I know that I don't have an STD, and it doesn't feel like a typical UTI. This has been not only a problem because I am uncomfortable but it also can make sex uncomfortable and even painful. My doctor doesn't seem to have an answer. Any ideas?

Thanks so much,
Sara

Sara,

It sounds like you may have interstitial cystitis, a diagnosis many doctors don't initially think about. IC is basically inflammation of the bladder that gives you all the signs of a UTI but there's no infection present. Bladder pressure, pain, and burning, along with the constant urge to pee, are the most common symptoms. It's a fairly common cause of chronic pelvic pain as well, affecting almost one million women.

You may want to see a urologist - they're the best equipped to do bladder testing and give you a definite diagnosis. Testing may include a potassium sensitivity test (through a slim catheter placed into your bladder) or cystoscopy (where the doctor can actually look inside your bladder through a skinny camera). Treatments vary from oral medications to actual treatment of your bladder, and depends on how severe your symptoms are. But once IC starts to intefere with your quality of life - which sounds like where you are - it's time to get help.

Best of health,
Dr. Kate

Pregnant On My Period?

Dear Dr. Kate,

Can I get pregnant if I have unprotected sex during my period? I've heard that you can, but what are the odds? Especially if I'm really regular...?

Messing Around During Menses

Dear Messing Around,

Short answer: yes, with low odds.

Long answer: If you're really regular, you likely ovulate around day 14 of your cycle (or 14 days after you start bleeding). This means that you can get pregnant from roughly day 10 to day 15. But you never know when your ovaries decide to go into overdrive and pop out an extra egg one month, that might be around during your period. So the chances aren't high, but it's far from impossible. Add on the fact that bleeding isn't always from a true period (but from an infection, stress, a polyp or fibroid), and you'll see why the chance is there.

Final answer: if you have a uterus, functioning ovaries, and an orgasming penis near your vagina, you CAN get pregnant. Even with birth control, even during your period, even right after a baby/miscarriage/abortion, even the first time you have sex. The odds may not be high, but it's still possible.

One Tube + One Ovary = One Real Chance of Pregnancy

I’ve come to the conclusion that there’s no reproductive justice. I have patients who are trying anything and everything to have a baby. I have patients who seem to get pregnant when they wink at their guy. Then there’s R. She came to me in disbelief after a home pregnancy test was positive. I confirmed her pregnancy with my own test and an ultrasound, then sat and listened to her story.

R. was convinced that she would never get pregnant again (she has two little ones at home) because of her medical history. She had her left fallopian tube removed for an ectopic pregnancy, and her right ovary removed due to a large cyst. “How in the world did the egg make it all the way across?” she asked. It is pretty amazing, to think that a single cell egg could float across the pelvis, dodging small intestines, and get captured by the other fallopian tube, in time to be fertilized. That’s the body’s imperative to reproduce, I told R. Where there’s any chance of pregnancy, the body takes it.

I’ve never seen a person too sick to get pregnant, despite what their doctors may say about their illnesses. And I’ve seen other patients beside R. where against all anatomical odds, they get pregnant. These cases, of course, happen most to women who weren’t planning pregnancy at all. Like I said, no justice. Yay for the tenacity of our ovaries…but you’d best be using birth control if you don’t want that stick to turn blue. Have any of you known someone who’s gotten pregnant against all odds?

No Name Not the Same?

Dear Dr. Kate,

A few months ago, I read (on a reputable website) that generic birth control pills can sometimes not be as effective as their name brand counterparts because they do not always contain the same amount or combination of hormones. I am a poor college student, so $5 for pills each month sounds way better than $30, but not if I'm not getting the same amount of protection. I'd gladly pay the extra $25 if it meant significantly higher protection from pregnancy. Is it true that generic pills are less effective? And if they are, are there any certain generics that are better than others?

Scared of Generics

Dear Scared,

That's a great question. The FDA mandates that brand-name drugs and their generic versions need to be chemically the same drug. Generic pills have to have the same active ingredients, the same dosing, and the same kind of absorption. What’s different? Colors, shapes, imprints and preservatives…but the medication is the same.

So why do some women claim to see huge differences when they switch to the generic form of their favorite pill? It may be a reaction to the inactive ingredients in the new pill; these ingredients don’t affect how the pill works to prevent pregnancy, but intolerance of them may cause side effects. The other reason is a bit more high-school-chemistry, and is related to the bioavailability of the drug. Bioavailability is the amount of time it takes the drug to be metabolized by the body. The makers of generic pills must show that the bioavailability of their generic is not significantly different (plus or minus 20%) from that of the name brand. So generics have the same amount of hormones, but it may take a different amount of time for your body to absorb it. This difference shouldn’t change the efficacy of the pill, either, but it may cause side effects in women who are sensitive to small changes in hormone levels.

All pill manufacturers have to guarantee that the hormone doses in each pill are what they claim they are, plus or minus this 20%. So that gets a little scary with ANY pills, especially the ultra-low-dose ones (with 20mcg of estrogen), because what if you get a batch that has a bunch of pills that err on the low side? That's one of the reasons I'm not a fan of the ultra low dose pills...but the same concerns apply to generics AND brands.

My advice is that if the cheaper generic pills don't cause any crazy bleeding or other side effects, stick with them. And if one generic pill makes you feel bad, you can always try another - I'd hate for anyone to stop using the pill simply because of cost.

Photo credit: spentpenny

The 40-Year Old Virgins

Okay, so she was really 35 years old. But when L., a new patient, revealed to me that she hadn’t yet had sex, she really meant no sex—not the Clinton version of sexual relations, but no penetration or orgasms of any kind with a partner. L. had decided that she was finally ready, but was anxious about what it would be like. Her friends, upon hearing that L. finds tampons uncomfortable, told her, “You’re screwed. You’d better see a doctor for advice.” The irony of “screwed” aside, this was a less than considerate response to L’s concerns.

The average age of first intercourse is around 17 years in the U.S., and roughly 90 percent of us have done the deed by age 24. But that leaves a good number of our sisters who are delaying the first time until their late 20s or beyond. It may be for religious reasons, or cultural, or the mess factor…or one (or more) of a thousand reasons. And given that we’re living in a time when nearly everything is now okay—anal sex, threesomes, vibrators that sing, etc etc—we should be really support all the choices that women make on the subject. Which, of course, includes choosing not to do any of those things, or waiting until the perfect guy, the perfect moment. If a virgin friend asks you for any advice, tamp down your incredulity, be supportive and tell her the following:

* First-time sex may hurt. It may not. For certain, though, nervousness increases tension, which increases the odds that it will hurt. A glass of wine, a massage, Barry White on the Bose—whatever decreases her anxiety is a good thing.

* A test run may help. She can get used to the idea of something in her vagina ahead of time. Her own finger, a dildo or vibrator, two fingers—accompanied with a lot of lubricant.

* Lube, lube, lube. I can’t stress lubricant enough. No matter how wet she thinks she gets, she’ll find lube makes it easier. It’s not just for sex toys and porn stars anymore.

* Set the stage. This is not the time for a quickie; the more time they can spend together, the better she’ll be able to relax, get wet, and enjoy sex.

* Consider being on top. It’s the position she can best control how fast and at what angle he enters her.

* It’s okay to ask a gyno about it. If she’s really concerned, any good doctor should be happy to talk about these issues; many women may not think about a meeting with their doc before they really get down to business.

* Don’t forget the birth control. We can always get pregnant the first time we have sex, whether we’re 14 or 40.

There are some good resources online, but a lot of baloney as well—it’s all another reason an understanding friend can be indispensable. What would you tell the L. in your life?

I Don't Want Him - But Who DO I Want?

Dr. Kate,

I have only been with one partner, and I've never been abused. My partner is attentive and committed, equally inexperienced but enthusiastically willing to try anything I'm interested in.
Here's the problem: although I started out with very normal desires and expectations, things have really gone south over the course of our three-year relationship, and not in a good way. As far as I can tell, I'm the problem. I hate kissing, especially tongue kissing. I do not enjoy foreplay, although we've read countless books and articles and tried so many different things. I hate cunnilingus; it makes me feel nauseated. I think lingerie is dumb-looking and I feel stupid wearing it, although the idea of him dressing up for me is somewhat appealing. I can climax very easily on my own, but my partner hasn't been able to get me there once. I also don't enjoy cuddling after we have sex. It's the weirdest thing - here is he wanting to linger in the afterglow and share intimate secrets, and I'm the one wanting to roll over and go to sleep. I have a good sex drive and I'm not insecure about my appearance, but for some reason none of the activities we've tried did a thing for me. I always come away frustrated. I'm starting to worry that maybe I'm not straight...I'm from a very religious background and never had the chance to experiment with anything. I don't want to end this relationship because we work together so well on other levels...but I am getting so fed up with our sex life. Any thoughts?

Frustrated

Dear Frustrated,

You're not the problem. Likely neither is he - it may be in the pairing of the two of you. A question: do you ever feel aroused when you're with him? Does a look or a touch from him ever make you tingle or feel turned on or make you want to grab him? If not, it doesn't sound like you're attracted to him. Attraction is different for everyone, but generally leads to some physical feeling in you...if you don't want to kiss him, you simply don't want him.

You say that your sex drive is good - what gets you in gear? Do you get that physical rush from any man? One you know, or one you look at from afar (or even a celebrity)? Is there any fella that you would want to kiss? If not, it's very possible that you're not straight. Have you ever let yourself even think about being with a woman? How do you feel, just thinking about kissing a woman? Give yourself some time to explore thoughts like these. There are many resources out there for you - many are geared towards teens (and you haven't told me your age), but are still really good.

You might want to consider a psychologist or therapist to be able to confidentially talk out how you're feeling. I hope you can at least find a friend to talk to - it's not going to be easy, these next steps. But you're brave to take them - we all deserve to feel physically good with our partner. Your boyfriend sounds wonderful, but he doesn't sound like what you want.

Best of health,
Dr. Kate

The Ultimate User's Guide for the Nuva Ring

When it comes to hormonal birth control, I get more questions about the NuvaRing than any other method (see for yourself here). It just doesn't seem to be as intuitive as the once-a-day-every-day tyranny of the birth control pill. Most women's questions focus on the timing of the ring, and what happens if their schedule gets thrown off. So this is everything you need to know about using the NuvaRing.

1. When to start it. You can start the ring any time you want:

• If you're starting it with your period, put in the ring during the first 5 days of bleeding.
• If you're starting it later than that, or totally off your period, take a pregnancy test first. If negative, begin the ring that day.
• If you're switching to the ring from the pill or patch, you can place the ring on the day you would have started your new pack of pills or box of patches.
  

2. How soon you're protected. It dependes on when you started the ring:

• If you place the ring on the first day of your period, you're protected immediately.
• If you directly switched from the pill or patch to the ring, you're protected immediately.
• If you started the ring at any other time, you need to use condoms for 7 days for maximum contraception protection.

3. How long to leave it in. The ring needs to be in your body for 3 straight weeks. Don't take it out early if you start bleeding early than you expect - the ring needs its three weeks to work. If you remove the ring before the three weeks are up, you're at risk of pregnancy that cycle.

4. How long it can stay in. The ring has enough hormones so that it may be left inside for up to 5 weeks and still be effective. So you've got lots of flexibility in how long the ring is in. And you don't need to use the ring for the same amount of time each cycle - some months you may leave it in 3 weeks, some up to 5 weeks - your body will adjust. But if it's left in longer than five weeks, you're now at risk of pregnancy.

5. How long you can leave it out. The ring cannot be out of your body for more than 7 days - in other words, you need to put a new ring back in by the same day of the week that you removed the old one. This rule holds even if you're still bleeding - the new ring must be reinserted within a week.

6. When it's out, you're protected. If you've used the ring following these guidelines, you're still protected against pregnancy during the ring-free week. The ring has suppressed ovulation for that cycle, so you don't need a back-up method of birth control during the ring-free week (though condoms are always a good idea for infection prevention...).

7. Ring holiday. The exception to rule #3: you can remove the ring for up to 3 hours at a time for sex (or any other reason...) and still be protected against pregnancy. There are no studies that tell us how often you can take a ring holiday; I counsel my patients that they can remove the ring once a day for 3 hours and are likely still safe.

8. If the holiday runs long... If the ring is out of your body for more than 3 hours, it's possible that your ovaries will respond with a quickie ovulation. So put the ring back in and use condoms for a week.

9. If you're late putting a new ring in. If the old ring has been out for more than 7 days, put the new ring in anyway. Don't wait for your period to start (so many women become pregnant while they're waiting!). Then use condoms for 7 days.

10. Back-to-back. You can use a new ring directly after taking out the old one - you don't need to leave a ring out for any length of time, you don't need a back-up method, and you can do this indefinitely (no need to ever bleed).

11. Bleeding patterns. It's normal to have irregular spotting or bleeding during your first few months on a new birth control method. Don't pull the ring out if you begin to bleed early - it doesn't mean the ring is "finished," it's just breakthrough bleeding while your body is adjusting.

12. Other things in your vagina. All okay. Including semen.

13. You can't lose it in your body. As long as the ring is all the way in the vagina, and it feels comfortable, you’re good to go. It doesn’t need to be in a particular place to work, and it won't go in too far.

And one final thought - this should go without saying: If you have sex without using the ring correctly, you are at risk of pregnancy. Take a pregnancy test if your period doesn't come when you expect.

The Birth Control Pill Is So Much More

My new patient J. came into my office with her mother last week, to discuss her awful periods. She's 13, and has been to the emergency room several times (and missed over a week of school this year) because of heavy bleeding and disabling pain. I was excited about offering J. the birth control pill--I don't often have the chance to greatly improve someone's life with a simple prescription. But her mother resisted, because when she was young, "only bad girls went on the Pill that young." Forty-five minutes of conversation later, J.'s mother promised to think about it.
This encounter was a reminder that the birth control pill has a bad name. Sure, it's contraceptive power is fantastic (97% effective when used perfectly). But it's so much more than that:

• The anti-anemia pill. You bleed less heavily and for fewer days each month.
• The anti-cramp pill. You need less ibuprofen...and maybe none at all.
• The pro-clear-skin pill. Dermatologists recommend the pill to help control acne.
• The anti-hair-in-the-wrong-places pill. Meaning less hair growth on your face.
• The cyst-reduction pill. You reduce the chances of benign ovarian and breast cysts.
• The cancer prevention pill. Reduce your risk of ovarian cancer by 50% and your risk of endometrial cancer by 80%.
• The mood stabilizer pill. The pill can work wonders in some women with premenstrual dysphoric disorder (PMDD).
• The bone strengthening pill. Studies indicate that use of the pill can help ward off osteoporosis.
• The pro-fertility pill. The pill provides some protection against pelvic inflammatory disease (PID), a major cause of infertility.

All of these reasons can give you incentive to stay on your pill, even if you don't need the contraceptive benefits any longer.

How Will Her Ring Affect Me?

Dr. Kate,

I'm in a relationship with another woman who because of health issues has been put on a contraceptive device (Nuva Ring - a low estrogen ring thing that she inserts once a month). She has just started this but obviously none of the common questions included in the package address whether or not this will have any effect on a female partner. Any ideas? Thanks!

F

Dear F,

You're right, the package inserts of vaginal products are woefully short of advice for their user's partners, male or female. The Nuva Ring releases a small amount of hormone every day that will be absorbed through your partner's vaginal walls. The ring should have no affect on you during sex - your fingers or tongue are not going to absorb any significant amount of hormone. If you're both uncomfortable with the idea of the ring still inside her when you're intimate, she can take the ring out for up to three hours. She can then put it back in, and shouldn't see any change in her bleeding patterns or other happy-ring effects.

Best of health,
Dr. Kate

Your Body IS A Wonderland

The months after giving birth should be magical, relatively speaking—bonding with your new baby, a little time away from work, reveling in the wonders of your body (look at what I just made!). But C., the wife of a dear friend, is now four months postpartum and hating her body. She’s managed to lose her baby weight, but she’s amazed that her pre-pregnancy pants no longer fit. “My hips just aren’t the same,” she says.

Of course they’re not—they’ve just widened enough to allow her darling son to come into this world with the greatest possible amount of ease. But staring at the tabloids at how celebrities magically return to pre-pregnancy form in what seems like a weekend is a taunt to postpartum women everywhere. Many of us are probably conflicted about celebrity-watching in general—“why should we care about these people?!?” vs. “what will she wear/date/look like next?!?” And watching famous bodies around pregnancy—from the first bump to the postpartum runway strut—is even more fascinating. It’s a reminder that these women are mortal, and are “just like us” reproductively-speaking.

You CAN get your body back closer to what it was in healthy ways (and cheaper ones than hiring a chef, a trainer, and a nanny). But the bottom line is that some changes to your bottom half may be there to stay. Even if you lose all of your pregnancy weight—good for you!—pregnancy leaves a mark, in the form of changes to your boobs, belly and hips. I tell my postpartum patients (and friends...and even myself) to wear them proudly, as a badge of honor. You're a goddess for being able to grow and give birth to a complete little person.

Do you know any women saddened by their body's changes after pregnancy?

Photo credit: Shaun Johnston

Jiffy Lube

One of the best ways to improve your sex life is to add a lubricant. Lube may help prevent condom breakage, and may increase both your comfort and his sensitivity (a good answer if he’s whining about using a condom). Lubes are especially important for back-door play, when you’re more at risk of tears in your tissue. You want to find a lube that’s effective for your needs and non-irritating. Fortunately, there’s a multitude of options in the stores or even in your kitchen. In general, you’ll need to try out a few with your guy to see what’s most comfortable. To help find the one that’s best for you, use the handy guide below.

Water-based: Overall the safest types, non-irritating, but can dry more quickly. Ones with glycerin (Replens) or sugar (many flavored ones— for external use only) may increase risk of yeast infection, so steer clear if you’re prone. AstroGlide has the preservative propylene glycol, which may be irritating if you’re sensitive. Trying to get pregnant? KY Liquid contains chlorhexidine, which is toxic to sperm—but don’t count on it if you’re trying to avoid pregnancy!

Oil-based: Vaseline, mineral oil, baby oil. Not water soluble, harder to rinse off, may stain your sheets. Deadly to latex condoms, diaphragms and dental dams, but fine with polyurethane condoms. May coat the vagina or rectum and increase infection risk, so reconsider if you’re plagued with frequent bouts of vaginitis.

Silicone-based: Safe with all condoms and latex products. Longer lasting but harder to wash off—this makes it excellent in the shower. May cause damage to silicone sex toys (too much of a good thing).

And if you find lube messy, here’s a fantastic tip: buy an oil pump mister that’s usually used for nonstick cooking; fill it with the lube of your choice, then spray away where it’s needed. Presto, no sticky hands. Have you found any fun ways of using lube?

Photo credit: The Truth About...

All That Itches Isn't Yeast

A patient came into my office last week with the common complaint of itching down below. K told me that she has had multiple yeast infections in the past, but her self-treatment with an over-the-counter remedy wasn’t working this time. I examined K and found not yeast but bacterial vaginosis, or as it’s more whimsically known, BV.

For those of you lucky enough to not ever (yet) had BV, it is a vaginal infection but not an STD. Our vaginas normally have a number of bacteria that merrily reside there and keep us healthy, just like on our skin and in our intestines. Sometimes, and we don’t know all the reasons why, one particular bacterium oversteps its bounds and grows out of balance with the rest. We do know that women who are sexually active are much more likely to get BV, but they don’t get infected directly from their partner—it’s a homegrown bug, as it were. I know it sounds confusing—an infection that you get from having sex, but not one that you catch from your partner.

BV has a classic set of symptoms:

• The vaginal discharge is thin, white to grayish, and a bit sticky.
• There may be an unpleasant odor, unfortunately fishy in nature.
• Some women experience vulvar pain or burning, or like K, itching.

Fortunately, BV is easily treated, but you do need to see a doc for treatment—there’s no over-the-counter remedy. Your doc will likely give you metronidazole, in either the oral (Flagyl 500mg twice daily for a week) or vaginal gel (MetroGel, 0.75% nightly before bed for five nights) form. You won’t hurt yourself using a treatment for yeast if you have BV…but you won’t feel any better either. So if you notice a funky discharge, with or without itching or an odor, head to the gyno.