Friday, February 27, 2009

Does Pill Timing Need To Be Perfect?

Hi Dr. Kate,

I am hoping you can settle a debate between me and my friend. We are both on combination, triphasic birth control - specifically Tri-Sprintec. My friend's gynecologist told her to take her pill at the exact same time, on the hour, every day for it to be effective. My gynecologist told me to make sure I take one pill per day, but that time of day has little to no bearing on the effectiveness of my birth control. My friend sets an alarm to take her pill while I just take mine before I go to bed each night, whenever that may be. How important is it to take the pill at the same time every day? Thank you!

Contraception Clock-watcher

Dear Clock-watcher,

You win the debate. Before doctors knew better--about how long each pill stayed in our system, and how long the pill's effects lasted--they always advised patients to take the pill at the same time each day. But now we know that as long as a pill gets in your body each day, you're safe. In fact, even if you miss one day (and double up the following day), the pill's efficacy is the same.

So why do some doctors still recommend this perfectionist timing? It's a matter more of habit than biology. Women who have been on the pill know how difficult it is to take a pill every day for months or years on end--it's the rare woman who never misses one. Many docs think that patients should make their pill-taking as much a routine as showering or brushing their teeth. There's something to this for many people--but women should know that it's okay if they take it at different times each day (like your floating bedtime).

The only birth control pill that MUST be taken at the same time every day is the progestin-only pill, Micronor. This pill works differently than the typical "combination" pill (that contains estrogen as well), and has a very narrow margin of error. Women using this pill must take their next pill within three hours of the previous dose, or they're at risk of pregnancy. But for everyone else, figure out what pill taking habit works best for you.

How do you take your pill each day? What tricks or habits have you used to not forget to take it?

Wednesday, February 25, 2009

How You Know If You're Fertile

In the wake of the octomom, patients have been asking me more questions than ever about fertility--they all want some, but not too much. So I'm often asked to check to see if they're able to have children, whether it's more kids or any at all. In order to be fertile, you need three working parts: your ovaries to regularly ovulate, your fallopian tubes to be clear to allow fertilization, and your uterus to be clear to allow implantation. Gynos can evaluate each of the three, based on your medical history, physical exam and sometimes testing.
  • Ovaries. The best sign of regular ovulation is regular menstruation. If your periods are coming regularly--21 to 35 days apart--you are most likely ovulating. Longer or shorter periods could signify thyroid or pituitary dysfunction, which can be diagnosed through blood testing. Gynos can also evaluate the general state of your eggs, or "ovarian reserve," through specialized blood testing on day three of your period.
  • Fallopian tubes. Scarring of the tubes sometimes occurs with pelvic inflammatory disease, endometriosis, or pelvic surgery. Your doc can order a special X-ray of your tubes called a hysterosalpingogram (HSG) if she suspects tubal blockage. If a blockage is found, there are multiple procedures that can be performed to clear the path.
  • Uterus. Uterine anomalies like a septum, polyp or fibroids can impede a pregnancy's implantation. Often these anomalies don't cause any trouble, but if you have a history of super-heavy periods or several miscarriages, your gyno may order an HSG to check out the inner contours of your uterus. If something there is making mischief, it can be surgically removed.

If you have regular periods and you've never had any gyno woes, your reproductive tract is likely in order. The hardest question I hear is "Can I put off trying to get pregnant for a year or two?" While I can determine how your gyno health is today, there's no test that can predict what will happen in the future. In other words, I can't tell you when you'll run out of eggs, or if another problem will develop. The best things you can do? Stay STD-free, in the best health you can...and when the time is right, go for it.

Do any of you worry about your fertility?

Tuesday, February 24, 2009

The Wrong Kind of OHHH

Dear Dr. Kate,

The other day my guy & I were having sex and just when I was about to orgasm I felt a sudden sharp pain in the lower left of my abdomen. It was such a strong terrible pain that there was no way for my guy to not notice. He instantly thought that he had hurt me. The problem is that I honestly don't think that it was anything he did. At first I thought it was such a cramp and would go away but even after a we stopped it still hurt, and it's even still tender now.

Now I'm worried it will happen again & I tense up at even the thought of us hooking up again. I feel terrible that it's scared him too.

Cramped Sex Life

Dear Cramped,

Ouch - there's nothing worse during sex than pain replacing pleasure. There are a lot of reasons for pain during intercourse, if what you meant by "sex" was intercourse. But pain that persists after sex is over has fewer possibilities. It sounds to me like you may have ruptured a cyst on your ovary - that can really feel like someone's suddenly stabbing you. Fluid from the cyst can then irritate the tissues in your pelvis for hours or even days after, until it's all absorbed by your body. You can try anti-inflammatories like ibuprofen (Motrin, Advil) or naproxen (Aleve), along with a heating pad or hot water bottle (oldies but goodies) to help with the pain.

Every woman gets an ovarian cyst that's large enough to pop, now and again. Generally, you just need to ride out the pain. But if the pain seems to be getting worse, it's best to see your gyno for an exam and a sonogram. There's not much that you can do to prevent the occasional cyst. Women who are prone to recurrent cysts, though, may find relief by going on the birth control pill or ring.

The other possibility is that you pulled a muscle in your pelvis - think of it as a sex stitch. This is more likely if you're exerting effort to maintain a certain position, but it could happen at any time when your muscles are getting tense. You can treat it the same way, with heat and painkillers. And either way, you--and your guy--did nothing wrong. So when you're feeling up to it, get right back on that horse, so to speak.

Dr. Kate

Thursday, February 19, 2009

A Taste of Things to Come?

Hello Dr. Kate,

My question is about the taste of my vagina. Both from what my boyfriend has said/his reactions and my own taste-tests, I know that sometimes I taste of nothing and sometimes almost bitter
(even after showering). Is this change due to hormones, or is it like with men where the foods you eat affect your taste?

Thank you so much,

(would rather be) Tasteless

Dear Tasteless,

Every woman has a unique taste, that changes based on many things. At different times in your cycle, your taste can change from sweet to salty to sour. When you're aroused, or if you're sweating (or both), the flavor can also be different. And certainly having an infection (yeast or vaginosis) can cause your taste to change.

It's unclear if diet can really change the taste of vaginal secretions - unsurprisingly, it's hard to get funding to do such research. But anecdotally, different foods in your diet can change how you taste. The foods I hear about most: raw garlic, citrus fruits (particularly pineapple), strawberries, coffee, and asparagus. Even alcohol, nicotine and vitamins have the potential to change your taste. Violet Blue goes into further details that she learned while researching her book on cunnilingus.

I'd love to hear about this from you all...Have any of you (or your partners) noticed a change in your vaginal taste? What do you think it's due to?

Wednesday, February 18, 2009

Committment and Condoms

As much as I laud the benefits of dual protection - using condoms in addition to a more effective form of birth control - I know that many women don't want to use condoms forever. For many of us, sex does really feel nicer without the latex barrier. And when you're in a mutually monogamous relationship, you don't need the condoms theory. Of course, the cynical side of me says that just because my patient says they’re both monogamous, doesn’t mean that he is saying the same thing to his doctor, or friends, or the woman in the bar. I joke with my patients that it's my job to always believe what they tell me...and never trust their partners, as the best way to keep them safe and healthy.

So how do you balance trust and health? This is what I tell my patients who are going steady and want to deep-six the Trojans:

• Use condoms EVERY TIME you have sex for the first six months.
• After six months, both of you should be tested for STDs—HIV, Chlamydia, hepatitis, the works. If you both test negative, you may decide to forgo the condoms.
• If you don’t want to get pregnant, you’ll need to use a very effective method of birth control, very consistently.
• You have to trust that your partner is truly monogamous—if you have any doubts, back on with the latex.

Nothing is foolproof, but this seems to be the best compromise. What do you think? When do you stop using condoms in a monogamous relationship?

Sunday, February 15, 2009

It's National Condom Week

In honor of National Condom Week, I'm revisiting some of my favorite latex-related posts this week.

Hi Dr. Kate,

My boyfriend is a virgin, and I'm...not. I've always used protection with previous sexual partners, and I got tested for STD's after my last encounter. Last weekend he wanted to have sex, but didn't have condoms. I'm on the Nuva-Ring, but I made up an excuse and told him I didn't trust my birth control. My real reason was I was afraid to pass on STD's to him that I wasn't aware of carrying (even though I'm clean). I know that it's possible to transfer STD's to your partner when you show no symptoms (like herpes and warts). My question is if I theoretically didn't use condoms (I think I still will use protection with him, I already bought us a box) with him how likely am I to pass on something to him?

The (possibly) dirty devirginizer

Dear DD,

How considerate of you! First thing is to assess your chances of actually having an STD to pass. Gynos can test you for the following infections:
--chlamydia and gonorrhea (during your pelvic exam or with a urine sample)
--trichomonas (also with a pelvic)
--HIV (generally a blood test, though sometimes a finger stick or a cheek swab)
--syphilis and hepatitis (blood tests)
--HPV (during your pap smear)--we can't directly test you for warts

Herpes testing is tricky, and the only way to know for sure if you have genital herpes is to swab a bump during an outbreak. If you were tested for all of the other infections after your last encounter (and to be safest, six months after, to allow time for any tests to become positive), that gives you great peace of mind.

If you've never had an outbreak of warts or herpes, your chances are low of not having either one. Not zero chances, but lower. These two infections, unfortunately, are also the ones most likely spread even when using a condom...or by "outercourse" (which may mean that your boyfriend has been at risk as well, depending on what you mean by "virgin"). So what is the chance of passing an infection that you don't know you have? It's not high, but I can't say how low. While most infections with warts or herpes lead to an outbreak in the first several weeks of exposure, we don't know how common it is to not have your first outbreak for months or even years after infection (it's a hard thing to study).

Using condoms certainly lowers these risks, and gives you the best peace of mind.

Tuesday, February 10, 2009

Dating A Male Gynecologist?

Dear Dr. Kate,

My cousin wants to set me up with her husband's longtime friend, who happens to be a OB/GYN. Both she and her husband talk glowingly of the guy: He's a great doctor whom his patients adore; smart with a great bedside manner; comes from a good family. At age 40 he's ready to settle down after years of focusing on his career.

My question for you is how do male gyno's separate the clinical from the sexy? Mystery seems to be one element that makes the naked female body sexy for men: Most don't get to see many bare breasts or exposed nether regions so when they do they're thrilled regardless of their perfection. Does a male gynecologist get the same rush from those erogenous body parts when they're with their partner or is it just "more of the same"?

This guy sounds like a gem; however, I have this nagging feeling that his years of training and practice have wiped out his natural male instinct to see women sexually.

What do your male colleagues tell you?

Go For The Gyno?

Dear Go,

I can totally understand why you may doubt how a gyno can separate work from pleasure. But it's all about the context in which he gets to see someone's lady parts. The first part of this is why he's seeing someone naked. All of us gynos desensitize to a certain degree when examining a patient, whether we're male or female. It's better for me, when I'm with a patient, to not think about it as Susan's breasts or Lily's vulva, but simply as tissue that I want to examine and make sure is healthy. I don't want to be distracted by the person to whom the parts belong (because I never want to find something wrong with someone I like and care for). Male gynos do the same thing. So when they're with their lover, they know her parts but look at them in an entirely different way - not for pathology but for pleasure. Think about how you kiss your dad and how you kiss your boyfriend - both are men, and both are kissed, but the context is entirely different (I hope).

The other part of context is how the exam proceeds. You know what an exam room is like - bright lights, cold air, colder speculum. You also know from your own experience that the pelvic exam itself is no fun. Gynos try to make the exam go as gently and as quickly as possible, but we're well aware that we're making you feel uncomfortable - and sometimes outright causing you pain. And when you're making someone hurt, there's absolutely nothing sexy about it.

It's not just mystery that makes you attractive to a male gyno - it's the fact that after spending an evening with you, it's your body he gets to see and touch - not just not any body. And a gyno has the advantage that because of what he does every day, he won't be so overwhelmed by the mere sight of your bare breasts or bottom that he doesn't know what to do with them.

And anecdotally, all of the male gynos that I'm friends with are married - and if the number of kids they all have is any indication, they're not too bored with the female body at all!

Go for it,
Dr. Kate

Thursday, February 05, 2009

NuvaRing Ins and Outs

The NuvaRing is one of my favorite forms of hormonal contraception - all of the benefits of the pill, without the daily hassle of remembering to use it. But since the ring hasn't been around as long as the pill, many women have a lot of questions about using it. So I thought I'd address the most common ring issues that come up in my office. When using the ring....

What's okay to put in your vagina:
  • A penis. Intercourse will not push the ring up into your pelvis, or to any place where you can't retrieve it. And semen/sperm will not diminish the ring's effectiveness.
  • A vibrator or other toys. Same as above.
  • Tampons. Ditto.
  • Medication. It's fine to treat a yeast infection with over-the-counter creams like Monistat, or to treat vaginosis with prescription MetroGel. You don't need to rinse the ring off afterward, either - the medication will all absorb eventually.
What's okay to come out of your vagina:
  • The ring before sex. If sex is uncomfortable with the ring in place, just take it out. It sounds counterintuitive, to take out your birth control before having sex. But the ring works its magic by turning off your ovaries - and the hormones will remain in your system after the ring comes out. You can remove the ring for up to three hours without losing effectiveness (and if anyone is having sex longer than three hours, please share your good fortune with the rest of us!). Just be sure to put it back in before you roll over and go to sleep.
  • Increased discharge. It doesn't mean you have an infection - it's just your vagina's way of reducing friction with the ring in place. Think of it as more lubrication for sex.
Do any of you have questions about using the NuvaRing?

Sunday, February 01, 2009

Stinging Spermicide

Hi Dr. Kate,

My boyfriend and I always use condoms, don't worry! But I had a question about spermicide. I wanted a back up BC option. I don't have health insurance, so I can't afford the pill, an IUD, etc. I did save some money and ordered the FemCap, through which I know you're supposed to use with a spermicide, which I do in fact have.

But I used a spermicide ovule once, after a condom slipped off when my boyfriend pulled out, and it, the spermicide, really seemed to cause an irritation that lasted a few days. Can spermicide cause a yeast infection with prolonged use or is that just an irritation from the harsh chemicals? Is there more than one kind of spermicide and if so, what kind if best/least irritating? If I'm using a cervical cap, and the condom breaks or slips off again, how effective would the cap be if I didn't use a spermicide? The irritation wasn't like, unbearable, but it just made me feel not quite right in the vaginal area.

First, yay for the condoms! And yay for wanting backup! But spermicide is best used in conjunction with the cap - not as an afterthought if the condom fails. No one knows how effective caps and diaphragms are when used alone - all of the research is done in women who have used both methods at the same time. And it's unlikely the spermicide caused a yeast infection - it's more likely an irritation reaction from the nonoxynol-9 spermicide. Unfortunately, it's the only spermicide available on the US market...but it does come in different forms - film, foam, gel - in addition to the ovule. So it's possible that another form may not give you such irritation.

In the future, there's always planB if a condom slips off again. That's a better back-up than spermicide after the fact - so it's a great plan to stash a dose in your medicine cabinet, just in case.

Best of luck,
Dr. Kate