As obstetricians and gynecologists, we see newborn girls at birth, and then we kind of pass them off. Our next exposure is usually in their late teens, adolescence and into their mid-20s. What I would consider preconception times.
We take mothers through their reproductive years, which nowadays is from 25 to early to mid-40s; from their mid-40s to 50 — which is the time leading up to menopause — and then from 50 and on or after menopause.
As OB-GYNs, we start to get involved in those late teens and early 20 years for a number of reasons. Most importantly, it's to give education on safe sex, birth control and vaccination for HPV, which is the most common STD or sexually transmitted disease.
There are quite a few out there. The women who tend to come to see us tend to be certainly more proactive and want something convenient. We initially have conversations and look at risk factors. But in general, the majority of these younger women are going to be healthy and appropriate for any form of birth control.
We usually divide birth control into hormonal birth controls versus non-hormonal. The non-hormonal is fairly limited. Usually it's some combination of natural family planning, trying to predict when a woman's fertile and maybe using barriers like condoms. For women who maybe use no birth control, there is the morning after pill.
For hormone contraceptives, we have quite a bit of options now. We tend to ask questions about how long do they need birth control? Do they need something reversible? How convenient do they want to have it? What side-effect profile are they looking at?
Everyone knows about birth control pills, which have been around a long time. So, that's usually a good starting point. They're a lot safer now. The dosages have come down significantly. They're very safe for the general population.
In addition to birth control pills, now we have things like the birth control patch, which is worn on the skin and changed weekly. There's the vaginal ring, which is placed in vaginally by the woman once a month. The birth control shot [depo shot]} is an injection in the arm every three months. We now have a new implantable device. It's a little rod that goes in like an IV under the skin of the arm and it lasts for up to three years.
IUDs [intrauterine device] have become much more popular again, especially, among our Gen-Z and Millennial generations.
In high-risk pregnancies, hopefully some of the factors can be determined prior to conception. We do advise women that if they're planning to get pregnant that it would be a good idea to see an obstetrician in advance of conception, look at risk factors and discuss a plan of management, especially in the early pregnancy.
One thing we like to talk about before conception now too is to make sure they institute prenatal vitamins or a folic acid supplement that reduces certain birth defect risk, and also to see if they're interested in doing what's called carrier screening.
Women can now be screened through blood testing to see if they might carry some of the more common autosomal or recessive disorders, things such as cystic fibrosis, fragile X and spinal muscle atrophy. We look at a panel that might affect children, and offer this to women prior to pregnancy if possible.
We recommend cervical cancer screening, or Pap smears, begin at age 21. The current recommendations are they should be done at least every three years from 21 to 30. We recommend continuing screening from age 30 to 65, and that screening interval should be three to five years. That is now a combination of both the Pap smear plus screening for HPV, or human papillomavirus.
As far as other screening tools, breast cancer screening has become a little more controversial for women in their 40s. But as OB-GYNs, we tend to be a little more conservative. So I'm still recommending a baseline mammogram around age 40. I would recommend one at least every two years from 40 to 50. From 50 to 75, I would recommend yearly screening.
At Scripps Health, in our radiology department, for the most part, we do 100 percent digital readings on mammograms now. A digital tomosynthesis is a standard mammogram, but involves taking many more pieces or pictures through the breasts. For women with dense breast disease who are maybe at higher risk for breast disease, this would be a good option for them.
In general, women with just dense breasts and otherwise no risk factors, they're a harder group to know what to do with currently. My recommendation is those women might consider bilateral breast ultrasound in conjunction with mammography once a year, and maybe a breast specialist to be part of their care.
Pelvic organ prolapse is more common in women who have had vaginal births. Typically the more births they have, the greater the risk. The more difficult the births have been, the bigger the baby, the greater the risk.
We also have some genetic predisposition. You'll see thinner, fair-skinned women who tend to have smaller supporting ligaments to begin with be at higher risk than a heavier set dark-skinned person.
When it comes to pelvic organ prolapse, we're talking about basically the vaginal canal dropping or coming down, or even sometimes coming out.
Symptoms can vary quite a bit. Sometimes we just pick it up during a pelvic examination. But patients that come in symptomatic, the most common complaint is that they just feel a heaviness, a fullness. They might literally feel something coming out. It can sometimes interfere with comfort during intercourse.
For women in post-menopause, many of the issues a gynecologist might deal with might have started to occur already in their 50s. This includes menopausal symptoms, such as hot flashes, mood changes and vaginal dryness. These are all things that typically come up from the early 50s into the early 60s, and probably the most common reason why they come to the gynecologist for care.
A Pap smear is still recommended to be done into the mid-60s and older, depending on sexual activity. We also do a good job of screening for cervical or pelvic or gynecologic cancers. So pelvic examination is still important.
Most of our patients, by the time they get to their mid 50s into their early 60s should also have an internal medicine specialist seeing them as part of their annual physical exam. Many women will start to transition to an internist versus an OB-GYN at that age as well.
We remind women in their early 50s to consider colonoscopies. Bone density studies have also become a little more controversial, but I recommend them now when a woman has either been in menopause for 10 years or longer, or by her early 60s. Other than that, it would be women with risk factors. If there is a strong family history of osteoporosis, if a woman has to be on chronic steroid use, that might increase the risk of osteoporosis.
I treat people based on their age group. I'm certainly going to treat my 20-year-old a little bit different than my 40-year-old. So if a 20 year-old comes in without risk factors, most of us recommend that they continue trying for up to a year even before any intervention is done. If I have a 40-year-old who's getting toward the end of the reproductive age group, I might take that down to three months or four months.
Basic testing typically involves semen analysis from the spouse. Basic fertility testing includes lab function to look at ovarian function, ultrasound to look at the pelvic anatomy, consideration of injecting dye into the uterus to make sure that the fallopian tubes are open. That entails a good part of the basic workup.
I'd say probably 80 percent of the time, just through that simple testing, we can identify something. About half the time it's a male factor and half the time it's on the woman's side. And there are things, we can do at that point.
For those 20 percent that we can't figure it out, these are the people who are usually referred to a reproductive endocrinologist or a fertility subspecialist. Their main focus these days is to consider things like direct intra-uterine semination or in-vitro fertilization, where they harvest eggs and they create embryos in the lab and put them back into the uterus.
The younger the woman, the healthier the woman, the higher the chance of success for in-vitro fertilization. Once you get into the mid-40s or later, success rates have gone down very significantly. There are a couple of simple tests that are usually done early in the cycle to assess ovarian function. We do a test called follicle stimulating hormone, and something called anti-mullerian hormone testing. It's usually done around day two, three or four of a cycle. If those labs are normal, it predicts a very good chance of success with egg stimulation harvesting. If those numbers are not good, it's a much lower rate of success. So that's why we use our fertility subspecialists to determine what's best for that individual patient or couple.
With all the methods of birth control available now, sterilization is becoming less common. But when you look at those couples that know they've completed childbearing, and are absolutely sure they don't ever want to be pregnant again, sterilization is certainly worth discussing.
In the general population, about half the time males will do it and half the time females will do it. For the men, it's a vasectomy. For women, it's some type of tubal blockage. The most common is still tubal ligation, which is also done through a laparoscopic-type surgery.
I tell my patients it can range from being the lucky person for whom the only thing that changes is their period stops to the worst, where a woman is just miserable with these hot flashes and other symptoms. The majority of patients are going to be within those two extremes.
There's a familial predisposition. You'll see that if the patient's mother had a lot of trouble, they're more likely to also. For these patients who start to have symptoms in those years leading up to menopause, they're typically going to have a little bit more severe symptoms.
Most women take after their moms to some extent certainly. And there's obviously genetics there. So if your mom is thinner, fair-skinned and developed osteoporosis, certainly, if you have that same body type, you have a little more likelihood.
Pre-emptive things you can do include leading a healthy lifestyle. So, no smoking, alcohol in moderation, regular exercise, especially weight-bearing, calcium supplementation with vitamin D. A lot of it can be prevented by doing that.
Hormone replacement therapy is a hormone therapy for the average woman who has a uterus in place. The combination is usually estrogen and progesterone. These are the same types of hormones that are usually in birth control pills, but different in that they're more estrogen dominant. They're meant to replace what is starting to decline in production naturally in the body.
My recommendation is that this should be very individualized, and something that you should talk with your doctor about. For women who are symptomatic — women who are really having trouble with hot flushes, as a result of insomnia, they're fatigued the next day and having difficulty getting through their daily work — those are people that are usually very good candidates for hormone therapy. In a typical woman who's going to be in her late 40s, early 50s and is otherwise in good health, it's a great option for them.
What we try to do is find a program that has the lowest dose that's effective, and then we'll continue it for as long as necessary, and for the average woman, that will be several years. But by the time they get into their late 50s or 60s, often they'll find they no longer have symptoms and can discontinue therapy.
It's a symptom reliever for the most part. The down side is that there's a slight increased risk of breast cancer as a result. For older women, who might have a pre-existing cardiovascular disease, it might precipitate a blood clot. It can cause a heart attack and a stroke. But for younger women, it's still a pretty safe option.
I would highly recommend the HPV vaccination in the early teenage years for both boys and girls. It's important to get the boys vaccinated as well. The younger women, under age 14, can actually get away with just two vaccines, two injections. The standard is three. So, the younger women can save one extra sore arm. But I highly recommend it for any women at any age who's sexually active. Most insurers will cover it up until age 27, so you should try to get it done before that age.
HPV stands for human papillomavirus. It's the most common STD out there. HPV can cause cervical disease, including cervical cancer. It can also cause warts of the genital tract.
A colonoscopy for average risk people is still 50 to 55, and good for 10 years. For African-American women, there's some data saying they might want to take that down to age 45 now.