Committment Issues

One of my biggest challenges as a gyno is to match up each of my patients with a birth control that works for her. Something that seems simple...unless you've tried to be true to your birth control through every relationship, move, job change, and side effect. Which is, basically, all of us.

A 2008 report (PDF) from the Guttmacher Institute shows that almost half of women who are at risk of an unintended pregnancy--meaning they're having sex and don't want a baby--don't use birth control consistently and correctly. Some women have gaps in their use, some don't use their methods well, and others don't use birth control at all.

Why is staying on birth control so hard? Life changes make it really difficult to keep up with your pill. Who can remember--every month--to get a pill refill when you're moving/changing jobs/changing guys? Method problems are a huge factor--access, even for women with insurance, can be a problem. Some of the newer pills can have copays of $30, $40, even $50 a month...or aren't covered at all. Many plans have excluded IUDs for years, and now I'm even hearing about insurances that won't cover the NuvaRing. And hardest of all is ambivalence--not being sure that you don't want to be pregnant after all.

I often think that the most important feature of a contraceptive method is the timing of its use--more important than even side effects or effectiveness--since you have to use the method correctly for it to work at all. So if a patient is having trouble choosing birth control, I ask her:

• Can you really take a pill every day? Seriously, it's not human nature to do this--to take medication, every day, when you're feeling well. It's one thing if you have strep throat or a UTI (and you'll take anything to feel better)--it's another when you don't feel sick.
• Would you rather change your method every week or every month? On the surface, the patch and the ring are more convenient, since you avoid the "every day" problem of the pill. But trying to remember once a week or month may be even harder (unless you can count on your planner or Outlook to give you a reminder).
• How about coming into see me 4 times a year? Depo-Provera has the advantage of not having to remember anything at home, beyond scheduling your next appointment. But how many women really want to visit their gyno that much?
• So how about an IUD? I think that IUDs are ideal options for many women, because once they're placed, you can forget about it, until you're ready to have it removed. And birth control that's amazingly effective, that you don't have to pay attention to, may be the most effective method of all.
  

What challenges have you faced with finding the perfect birth control method?

Photo credit: ton3vita

What Happens During: Colposcopy

I've had to call a few patients this week to tell them that their last pap smear was abnormal, and that they need to go for colposcopy. Since they inevitably Google "colposcopy" and call me back with a ton of questions, I wanted to put together a primer on what to expect at the appointment.

What is colposcopy, anyway?
Colpo (the gyno's affectionate nickname for the procedure) is a way of assessing if your pap smear was right, in saying that there's abnormal cells on your cervix. Not everyone with an abnormal pap really has a problem, and colpo tells the difference.

What happens when I go?
Your gyno will use a usual size-and-shape speculum (most often metal) to expose your cervix. She may open it a bit wider than usual to really get a good view. She may then test you for STDs if you haven't recently been tested, with a cotton swab in your cervix. Next, she'll apply a clear solution (acetic acid--which is actually vinegar) to your cervix with large cotton swabs or sponges. She's looking for any areas on your pink cervix that turn white--abnormal cells absorb the vinegar and turn white.

What happens if she sees something abnormal?
Your gyno will take a biopsy of any area that looks suspicious. A biopsy is removal of a small (a few millimeters) area of your cervix. TIP: ask her if you can cough as she takes the biopsy--believe it or not, it will hurt less. After the biopsies, she'll likely do a scraping of the cervical canal, to sample cells that she can't see. This will also cause cramping, but only for 5-10 seconds.

What happens after the colposcopy?
Your gyno will make sure that all the biopsy sites have stopped bleeding before she lets you go home, though some light bleeding at home is normal. It usually takes about 2 weeks for results. Your follow-up is dependent on what the results show:

• All biopsies negative. You'll likely have pap smears every 6-12 months for 2 years, to be sure that nothing was missed on colpo.
• Biopsy shows a low-grade abnormality. Likely pap smears every 6 months, with a repeat colpo if things don't resolve on their own.
• Biopsy shows a high-grade abnormality. Then it's time for a larger biopsy procedure, called a LEEP or a cone biopsy.
  

Have you had an abnormal pap smear? Do you have any questions or worries about colposcopy?

Photo Credit: The Doctr

Bad Vibrations

A patient in my office last week confessed to me that she's worried she's hurt herself from too much vibrator use. She asked me how common vibrator-induced injuries were...and I had no idea. Searching throughout my usual (and not-so-usual) references didn't yield much information, either. Apparently, sex-toy-hazards are not a common area of research or publication (go figure). So the advice I could give her (and everyone else) is based mostly on common sense:

• Baby yourself. The skin covering your clitoris (the hood) and the surrounding tissue (your labia) is even more sensitive than elsewhere...it doesn't get a lot of sun or exposure. So if the tough soles of your feet can get sore from too much pressure, just imagine how your clit feels. While blisters, cuts or other injuries in this area are uncommon from masturbation alone, it's not impossible. If you're starting to feel sore during or after vibrator use, give the vibe a little rest.
  
• Choose wisely. Vibrators, like other sex toys, are not exactly regulated by the FDA. Just because something is for sale, doesn't mean it's necessarily safe. A vibrator might be too powerful for your clitoris, or too big for your vagina...
  
• Stay topical. In fact, most vibrators are meant for external use only. So definitely exercise caution when penetrating your vagina or anus with a vibrator that might not be designed for that purpose.
• Don't push through pain. We use vibrators to create pleasure, not cause pain (that's an entirely different post). So if you're feeling uncomfortable with your vibe, stop. You may be giving your clit too much direct stimulation, or are causing too much friction on the hood or surrounding tissues. Try a different speed, or a different position of the vibrator.
• When in doubt... See your gyno. Pain in the area of your clitoris might be from vibrator overuse...or it might be something else (like a yeast infection or even herpes).
  

Have you ever experienced "bad vibrations"?

What Does An STD Look Like?

Vaginal discharge is one of the most common complaints I hear in my office. Women are not only bothered by discharge, but almost always think it's an STD. So I want to give an overview of the most common ways that STDs present - to maybe save you some stress while you're waiting to get to your gyno's office for testing.

Signs that are common among STDs:

• Grey or green discharge. Trichomonas infection - a common but not well-known STD - often causes this kind of discharge, which may be frothy as well.

• Red bumps. Herpes can look like genital acne--but much more painful. When looked at closely, the bumps are actually clear, with a red "base" that shines through.

• Flesh-colored bumps. Genital warts (aka condyloma or low-risk HPV) look something like skin tags when alone, but may cluster together (like a small cauliflower). Like herpes, they can be on your labia, in your groin, at the entrance to your vagina, or near your anus.

• Skin ulcers. Severe herpes outbreaks (especially a first, or primary, outbreak) can progress from bumps to ulcers--craters or fissures in the skin that are extraordinarily painful. And a primary syphilis infection generally presents with a single, painless ulcer.
  

• Dark urine, yellow skin and muscle pain. Hepatitis infections are often sexually transmitted (hep B and C), but their symptoms come from the effects of the virus on the liver.
  

Symptoms that are most often NOT STDs:

• Vulvar itching. The hallmark of a yeast infection. Rarely can signify a mild herpes infection (but even more rarely if there's no bumps within a few days).
  

• White discharge. Possibly bacterial vaginosis (BV), but may be normal discharge as well. If it's clumpy and cottage cheesy, it may be yeast.
  

• Clear discharge. Most often is normal discharge (and often indicates impending ovulation).
  

• Fishy odor. Classic BV.
  

Symptoms that may or may not be an STD:

• Painful urination. While most often a garden-variety UTI, this may be the first sign of chlamydia or gonorrhea.

• Painful intercourse. There are many causes of pain during sex, but one of them may be an STD.

• Flu-like symptoms. Fever, headache, swollen lymph nodes and fatigue are most often influenza or a cold - but this is also how HIV infection presents for many people.
  

The scariest symptom of all:

• Feeling normal. Unfortunately, many STD infections don't have any symptoms at all. All the more reason to make sure you're getting tested (for HIV and other STDs) at least once a year or after a new partner.

I Had An Abortion, Can I Still Have A Baby?

Dear Dr. Kate,

When I was 15 I had an abortion. I am now 23 and I am considering having a baby. I am worried, however--I have heard that when you have an abortion it risks future pregnancies. I have always wanted a baby, and I couldn't imagine life without having my own children...but when I was so young I was in no way ready at that point to have one. My questions are: Is there a chance that I won't be able to get pregnant in the future because of my abortion? And how can I tell if I will be able to have a child? I mean, is there a way for me to assure myself that I will be able to reproduce?

The Worrier

Dear Worrier,

You're not alone, in either having had an abortion or being worried about future pregnancies. Abortion is incredibly common in the U.S.--more than 1 in 3 women will have one. So let me reassure you--having an uncomplicated abortion does not impact your fertility. You will be able to get pregnant, carry a pregnancy, and have a baby, in the same way as if you had never been pregnant. Fertility is affected by many things, of course--an untreated STD can lead to pelvic inflammatory disease and scarring of your fallopian tubes. And it gets harder to get pregnant as you get older, especially over the age of 35. But the abortion itself doesn't affect your chances. (What do I mean by "uncomplicated"? If you didn't have a massive infection that required hospitalization and/or additional surgery afterwards.)

Going on-line for information about abortion is quite tricky--many sites are set up to look educational, but are full of misinformation. Planned Parenthood is an excellent resource for information. So keep yourself healthy and continue to use birth control until you're ready to become a parent--that day will come, and your body will be ready.

Have any of you heard that abortion can lead to infertility?

All Wet

One of the most common concerns I hear from patients is about their vaginal discharge. "I have an infection…I’m too wet…I’m too dry…I’m dripping all the time…" Some women come into my office multiple times a year because they’ve noticed a change in their secretions. But vaginal discharge is a good thing--it's actually a sign of a healthy, working vagina.

What vaginal discharge means:

• Your vagina is keeping herself clean, just like when your skin sheds cells all day long
• Your vagina is keeping herself lubricated, so she doesn't stick to herself (ouch)
• Your vagina is actually protecting herself from infection, by forming a slippery barrier between you and the outside world
  

What vaginal discharge doesn't (necessarily) mean:

• You have an infection. I promise, most vaginal discharge is normal, especially when it changes throughout your cycle: from white and thick, to clear and stretchy, to downright watery.
  
• You're not keeping yourself clean. Discharge has NOTHING to do with how often you wash or shower.
  

Okay, what discharge MIGHT mean:

• You've developed a non-STD infection, like bacterial vaginosis or a yeast infection.
• You've caught an STD, like chlamydia, gonorrhea, or trichomonas.
• You're pregnant.
• You're on the birth control pill.
• You're sexually aroused.
  

So what should you worry about? Changes such as color, consistency, amount, and/or smell of your vaginal secretions that are not like your normal monthly changes. Abnormal vaginal discharge may also come with itching, soreness, rash, a burning sensation when peeing, or pain. If you have any of these symptoms, see your gyno for an exam.

Do any of you have discharge worries?

Pregnant from Anal Sex?

Dr. Kate,

I used to be a swimmer, so my periods were never exactly regular, but currently I have not had my period since mid December. I have never had intercourse, but I did try anal sex once with my guy right after my last period and we did not use a condom. During the past few weeks I've been itchy in and around my vagina and had more discharge than usual (white)... my thinking is that I have some kind of infection (and I plan on setting up a gyno apt) but I'm too embarrassed to ask... could I possibly be pregnant? I don't see how it would be possible, but missing periods just makes me nervous... and could an infection possibly cause you to miss periods?

-unsure

Unsure,

It's really unlikely that you're pregnant. It's theoretically possible to become pregnant if sperm on your perineum (the area between your vagina and your anus) swim into your vagina (especially if you're aroused and lubricated)...but the chances are slim. It sounds to me like you've got a garden-variety yeast infection (hallmarks: itching and thick white discharge). You could try self-treating with over-the-counter Monistat, and if you don't get relief, then see a gyno.

Infections don't cause you to miss a period. Many other things can--stress, illness, randomness. Frequent missed periods, though, could be a sign of a hormone imbalance--if you often skip two or more months in a row, it's best to visit the gyno to find out why.

But I do want to take a moment to caution you about anal sex without a condom. The anus isn't built like the vagina - it can't take so much roughhousing, and you're more likely to tear (ouch) or get an infection (double ouch) with anal. The best things you can do for your body with regards to anal:
--ALWAYS use a condom
--ALWAYS use a ton of lubricant, which reduces the risk of tears
--Make sure your boyfriend doesn't thrust quickly or deeply, but has more of a rocking motion with less in and out.

Best of luck,
Dr. Kate

Pregnancy With the Pill PLUS Condoms??

Dear Dr. Kate,

After I started having sex with my boyfriend, my first period afterward was incredibly light, just one day of spotting. The next month, however, my period was much heavier, 4 days worth of tampons (light ones) accompanied by body aches, cramps and nausea the likes of which I've never experienced. My usual period requires 1 day of light tampons, then pantyliners for the final 3 days. I assumed it was from stress, but someone mentioned the possibility of a miscarriage, which scares me because I'm on the pill plus we used a condom every time. The condoms never broke, slid off or did anything unusual. I was wondering, in your professional opinion, what you think is going on.

Thanks!
Contraception Cautious

Dear Cautious,

I understand why you're worried--regular birth control pill users get so used to light periods that a "normal" bleed (normal for those gals not on the pill, that is) can be a shock. While the pill gives most of us the benefit of predictable, light periods with fewer cramps and less nausea, it's normal to occasionally have a "breakthrough" in this control. It may be a heavy period, or may even be a missed one--which can be even more terrifying. Your miserable period may have, in fact, been from stress--one of the most common causes of a heavy bleed. A stressful month--job worries, family angst, even a new relationship--can overpower the pill's hormones and lead to an irregular cycle. If it's more than just one month, however, and you're experiencing nasty periods for months on end, it may be time for a pill switch.

I'm a big fan of dual method use to protect yourself against both pregnancy and STDs. The chances of pregnancy with regular use of both the pill and condoms are extremely low. While miscarriage isn't an impossibility, I don't think it's what happened to you this time. Miscarriages tend to bleed for a week or two, and not resolve as quickly as your period did. So I'd keep up the fantastic safer-sex practices, and chalk that period up to a bad month.

Best,
Dr. Kate

Post-Coital Bleeding, Not Bliss

Dr. Kate,

I am 20 years old, and I have been on birth control for about a year and a half now. I first got on birth control because I had painful and very heavy periods (went through the highest absorbency tampon in 2 or 3 hours!). My boyfriend and I have been sexually active together for maybe five months. He has been with others but I have not. I have been bleeding (just a little) after we have sex. It may or may not have been ever since the beginning, but it definitely has been going on for months now. I went to the Student Health Clinic at my university, where I was tested for STDs and pregnancy. All the tests came back negative. The nurse put me on a Z-pack anyway, just in case it was a kind of bacteria we couldn't test for. She said that if it didn't work, she would have to refer me to a gynecologist. I can't afford a gynecologist: I'm a poor college student!

I finally looked "down there" to check it out after a bleeding episode and I found that the pain came from a flap of skin at the bottom of the entrance to my vagina (the bleeding had stopped at that time, but I can only assume that's where the bleeding came from...). Is that my hymen? Could it be my hymen won't break completely but tears a little each time? What else could it be?

Thanks,
Hanging On Hymen

Dear Hanging,

Nothing kills a post-sex high like bleeding in bed. I don't worry when a patient has one episode of post-coital bleeding, but when it lasts for months, there's generally an explanation. There are multiple reasons why we may bleed after the deed--the most common 3 reasons are:

• Infection. Your clinic was right to test you for both "normal" vaginal infections and STDs. Chlamydia, gonorrhea, trichomonas, even a wicked yeast infection can cause enough inflammation in your cervix or vagina to cause bleeding.
  

• Trauma. Your hymen doesn't really "break" (what an awful mental image)--the membrane does open up, though, generally from physical activity in girlhood. If you've been seeing menstrual bleeding for years, you're "open" enough. But small scratches or lacerations around your vaginal opening can be caused by toys, fingernails, or not enough lubricant. If you can see a bleeding spot yourself, try using a generous amount of lube to make things easier on your vagina. And make sure you get enough foreplay to be really aroused before intercourse.
  

• Period jump-start. If you're seeing bleeding in the days before your period starts, it may be the first signs of menses (sex can "shake loose" the first drops). Similarly, if it's in the day or so after your period ends, it may be the leftover blood that you see.
  

After these three, there are some less-likely causes of bleeding after sex:

• Polyps and fibroids. Polyps are fleshy overgrowths in your cervix or uterus--think skin tags the size of a golf pencil--and fibroids are benign muscle tumors that can both cause irregular bleeding. A gyno can often pick these up on an ultrasound, but they would be unusual causes in someone your age (they're more common for women in their 30s).

• Hormonal imbalance. Abnormalities of your thyroid or prolactin hormone can cause irregular bleeding, and can be checked by a blood test. But if your periods are otherwise normal, and you're feeling otherwise healthy, these are unlikely causes.

• Cervical dysplasia. Post-coital bleeding can point to pap smear abnormalities. But you don't need a pap till you're 21 years old, if you've only been having sex for a few months.
  

• Endometriosis. This usually presents with other symptoms, too, like chronic pelvic pain, ovarian cysts or wicked pain with your periods--it's unlikely that post-coital bleeding is the only sign.
  

If you're worried, the gynos at Planned Parenthood can do a further work-up on a sliding scale (only charging you what you can afford). If the gyno rules all of these out, your bleeding may remain a mystery for now...but try not to worry. If none of these causes show up, your gyn health is clearly excellent, and something to celebrate.

Have any of you had bleeding after sex?

Is Breast Self-Exam Best?

Many of my patients have come in lately for their yearly check-ups, and as I do their breast exam, they confess that they haven't been checking themselves as regularly as they ought to. But there isn't really a clear answer as to whether or not women "should" perform breast self-exam (or BSE) on a regular basis. There are doctors on both sides of the debate, and if you search the web you'll find a plethora of opinions. I tell my patients that there are two arguments to be made:

Reasons to perform routine BSE:

• Most lumps that turn out to be cancer are found by the woman herself
• Knowing your own breasts--how they normally feel, what they normally look like--is essential for knowing when something doesn't seem right
• Many doctors, unfortunately, don't perform a thorough breast exam at your annual exam (how long did your doctor spend on your girls the last time you were there?)
  

Reasons NOT to perform BSE:

• Many young women have "lumpy" breasts, and have a hard time distinguishing a "bad" lump from normal breast tissue
• There's no study that shows that routine self-exam is any better at detecting breast cancer than occasional exams (by you or your partner) or preventing breast cancer deaths
• Routine exams, in fact, may increase the number of unnecessary biopsies that are performed for benign lumps
  
• It may make you more afraid, to be thinking about cancer so regularly, and not actually be helping you feel better about your body
  
• It's one more thing to feel guilty about not doing (and you already feel guilty about not flossing, right?)
  

In the end, I support what each of my patients wants to do. If she doesn't want to do BSE, no problem--I make sure she gets an annual exam from me. And if she does want to check herself regularly, I make sure she knows how to perform BSE and what to look for. There are many different resources available about how to properly perform a breast self-exam. Either way, you should know your body--but not approach it with worry.

Do you perform regular self-exams?

Is My Mound Too Round?

Hello Dr. Kate,

I'm a 15 year old girl. I am a bit overweight but other than that I am healthy. I'm really self-conscious about the bulge where the "mound" is supposed to be. I'm too embarrassed to wear certain clothes, bikinis, and I feel bad when I look at myself naked or in my underwear. Is a pronounced bulge normal? How can I get rid of it, through surgery or other means (such as weight loss)? And one last question, will my future male partner be grossed out or turned off if I do still have it?

Curvy In The Wrong Place

Dear Curvy,

I'm glad you wrote me. EVERYONE's mound under their pubic hair "bulges" a bit after puberty. It's actually your body's way of planning for the time that you start having sex: the fat pad under your hair will protect your pubic bone during intercourse. If you're really overweight (not just "not a size 6"), losing weight may help a bit. But my guess is that you're normal. And even if you could (and I bet there are skeevy surgeons who would offer you liposuction if you asked) you really wouldn't want to lose this fat--that could make sex awfully painful.

And believe me, your future boyfriends will be so happy to be naked with you, they won't be turned off at all. We women worry a lot about what our guys will think about our bodies when we're naked...and if you ask the guys, they're just so happy to be there in bed with you, that these "imperfections" don't matter.

So try to be the healthiest weight you can...and love that your body does things to keep you sexually healthy.

Best,
Dr. Kate