The full transcript is available below:
Mackenna: Welcome to Ask Away, the Broadview podcast where we ask students’ anonymous questions to experts of all fields.
Darcy: My name is Darcy Jubb, and I’m the City Life Editor for The Broadview, and my co-host is Editor-in-Chief Mackenna Moslander.
Mackenna: The podcast highlights female voices as it finds answers to anonymous questions from reliable sources. In our first episode of “Ask Away”, we interviewed a gynecologist — Dr. Mindy Goldman, with questions submitted by the community.
Darcy: Dr. Goldman is a physician and clinical professor at UCSF and is the Director of the Gynecology Center for Cancer Survivors and At-Risk Women. She received her medical degree from the University of Vermont and completed her residency at UCSF in obstetrics and gynecology. We speak to her now over the phone about sexual and reproductive health for women.
Darcy: What are the symptoms of Toxic Shock Syndrome?
Dr. Goldman: First of all, Toxic Shock Syndrome is pretty uncommon, and it can occur if someone leaves a tampon in place for too long, and oftentimes before you see Toxic Shock Syndrome, people would see sort of a foul smelling discharge, just from having a foreign body that’s inside the vagina. But if someone really got Toxic Shock Syndrome, they would actually get a fever, and be pretty sick. Their blood pressure could even drop. When you go into shock your blood pressure drops and your pulse can speed up, and people can get pretty sick and actually be hospitalized. But it’s pretty rare to see that degree of Toxic Shock Syndrome, because most people, a lot of people will forget to remove a tampon, but at some point they start noticing kind of a foul smelling discharge, and that usually gets people to realize that there’s something inside, and they tend to remove that before they actually develop Toxic Shock Syndrome.
Darcy: Can you get Toxic Shock Syndrome from pads or diva cups, or is it just tampons?
That’s a really good question. We typically think of it occurring from pads or tampons, but probably any foreign body that’s in the vagina for a long time, could lead to an infection. So, although I haven’t heard it reported with those, I would imagine it could happen with that.
Mackenna: What is a pap smear, and when do I need to get my first pap smear?
Dr. Goldman: Great question. So, a pap smears screen for cervical cancer, and what is done during a pap smear is a speculum is placed in the vagina. And when a speculum is placed in the vagina and opened, that allows the gynecologist to see the cervix. So the cervix is the lower aspect of the uterus, the opening up into the uterus. And what we see on the exam, is, essentially, something that’s circular, that has like a little hole in the middle, kinda looks like a miniature donut. And when you do a pap smear you take a spatula, and you put the spatula along the outside of the cervix, and you take a little brush, and the brush goes in the inner part, and rotates around to get cells. And that is screening for cervical cancer. And we know that cervical cancer is related 95% of the time to HPV, which is Human Papilloma Virus. So it’s actually, the way to think about it, cervical cancer, is essentially a Sexually Transmitted Disease. Because HPV is related to sexual activity, and anyone who has ever had sex is exposed to HPV. But what happens is, for women, um, most people will clear the virus — because HPV is a virus. But if we didn’t clear the virus the way we would express it, is by an abnormal pap smear. And there are different degrees of abnormality and, in fact, most people have now gotten the HPV vaccine, and that vaccine targets high risk HPV, with the hope that it prevents high grade abnormal pap smears, and cervical cancer. Now, it turns out when people are first sexually active, there’s a very high likelihood of exposure to HPV and actually expressing it by an abnormal pap smear. But we know that about two third of those abnormal pap smears go away on their own. So if you do pap smears on girls as soon as they’re sexually active, you’re more likely to pick up something that’s abnormal, and then the treatments that we do for abnoraml pap smears involve sometimes removing a part of the cervix, and that can have future implications for a pregnancy. So the old guidelines used to be, you begin doing pap smears at age 18, or whenever girls are sexually active — whichever comes first. But given that we know most people become sexually active 17, 18, 19, somewhere in that range, we don’t want to pick up an abnormal pap smear, when we know there’s a two thirds chance that it could go away on its own, and that the treatments that we do could have implications for a future pregnancy. So the new guidelines, I know this is a long answer, but the new guidelines are — you don’t begin doing pap smears until age 21 because by then most people have already become sexually active, they’ve been exposed to HPV, and they’ve cleared the virus, and that allows us to not over-treat people. So we do pap smears between the ages of 21 to 65, and they’re done every three years, or you can do HPV testing every five years, and then if they’ve been normal someone’s entire life, or for 20 years, they stop after 65 because it means someone’s immune system has been able to work on the HPV virus, and it doesn’t make sense that all of the sudden it would show up with an abnormal pap.
Darcy: What is endometriosis? How do I know if I have it? If I think I do, is there anything I need to do about it?
Dr. Goldman: Okay, so, endometriosis is a condition where the cells that line the lining of the uterus rather than flushing out through the uterus and through the vagina, when someone has their period, we think what happens is some of those cells along the lining of the uterus backflow through the tubes and implant in the pelvis. And they can implant anywhere in the pelvis, they can implant in the ovary, they can actually migrate from the lining of the uterus into the muscle of the uterus. And just like the lining of the uterus can sort of get inflamed and cause some pain when people have their period, those other areas that are outside the uterus can also get inflamed and cause pain. So the symptoms of endometriosis are painful periods, and then sometimes endometriosis implants in certain areas on these ligaments of support to the uterus. And, the, if it does, the symptom that, that would be associated with is deep pain with intercourse. So really deep, deep up inside. And then the other symptom of endometriosis is infertility. Now the problem with all of those things is there are many girls and many women who have pain with their periods — and that doesn’t necessarily mean they have endometriosis. And there are also many women who end up having pain with intercourse — and that doesn’t mean they necessarily have endometriosis. And there are also many women who end up having fertility problems — and that doesn’t mean that they have endometriosis. So, endometriosis is actually a surgical diagnosis. The only way that someone knows they would have it, would be, let’s say they have really bad pain with their periods. Usually we have certain things we do in that situation. We will have people use medicines like ibuprofen or advil. Um, we will sometimes put people on birth control pills, which uh, take over the hormonal cycling, and most times when people are on the pill they’ll tell you they have less bleeding and less cramping. And if those things don’t work, sometimes people end up having a surgery called a diagnostic laparoscopy — where a gynecologist puts a scope inside, it has to be done under general anesthesia, and looks inside, and if they see what looks like endometriosis they take a biopsy, and the biopsies go off to pathology. So it’s a surgical diagnosis. Um, and, the unfortunate thing is, a lot of times, um, someone could go see a doctor who does a pelvic exam, and they will tell them, ‘oh I have a lot of pain with my periods’ and people will throw around the term, ‘maybe you have endometriosis’ and then people really worry. And so, I try to tell people, look it really is a surgical diagnosis, there’s symptoms of it, but people can have those symptoms and not have endometriosis. And then there actually are sometimes findings on exam that can be suggestive of endometriosis. So, when we do a pelvic exam, um, you, uh, put, uh, one or two fingers in the vagina and you elevate the cervix, and uh, with your hand, and then you palpate from the outside on the abdomen, the uterus, and the tubes and ovaries. Also sometimes as a part of the pelvic exam, we actually do a rectal exam, and you feel the tissue between the vagina and the rectum. And when someone has endometriosis, sometimes they get these implants in what’s called the rectovaginal septum and so when people do an exam like that, it will cause really a lot of pain so you will feel these kind of hard modules. That can be suggestive of it, but for a true diagnosis is based on surgery.
Mackenna: What are the symptoms of Sexually Transmitted Diseases, and what should people do if they have an STD?
Dr. Goldman: So, first of all, the best way to protect against an STD is barrier methods. So, condoms are very effective at protecting against STDs. The common ones that we think about are gonorrhea and chlamydia, HPV is a sexually transmitted disease, and there’s another one called trichomoniasis. Rarely you can see other ones like syphilis, but that’s much much less common. When people go to the gynecologist, um, we will typically ask if people have multiple partners. We know that multiple sexual partners is a risk factor for an STD, and if they do we will ask, ‘would you like us to do STD testing?’ And what we do in that situation is we take a swab around the cervix, and that is then sent to the lab to look for evidence of gonorrhea or chlamydia. Um, uh, the pap smear will test for HPV, again which is also sexually transmitted. There’s another one called herpes, and herpes appears as little vesicles along the vagina or along the outside tissue which is called the vulva, and that would cause pain and bring someone in, uh, to the office. Um, sometimes Sexually Transmitted Diseases, um, can be silent. The one that classically may be silent is chlamydia, sometimes people may not know that they have that, but most times, Sexually Transmitted Diseases will cause a discharge, uh it may be yellowish, sometimes it may be green. Um, they may, um, because Seuxally Transmitted Diseases, spread up into the uterus, people may have pain. Um, there’s something called Pelvic Inflammatory Disease, which is if a Sexually Transmitted Disease spreads up into the uterus, and into the tubes, and potentially the ovaries, it can cause an infection throughout the uterus and the tubes. And that uh, causes, um uh, pretty mark pain, sometimes fevers, it will usually bring someone into the gynecologist — rarely into the Emergency Room. If they’re sick enough we actually have to admit people to the hospital and give them IV antibiotics. But if we see them in the office, we’ll treat it with oral antibiotics. So the way I counsel people is, if you have an unusual discharge, um, if it’s green if it’s yellow, if you’re having a discharge and you have pain, and certainly if you have a discharge pain and a fever, that’s something that’s really really important to be seen right away. And part of the problem, reason that’s important is, if, um, one of the complications of Pelvic Inflammatory Disease is that it can cause a lot of scarring, um, in the pelvis, around the tubes and ovaries. And that scarring could potentially affect someone’s fertility. Um, because when someone gets pregnant, pregnancy takes place in the outer third of the tube, so the fertilized egg and sperm, um, uh, meet in the outer third of the tube and travel down the tube. And then plant in the uterus. And if you have a lot of scarring, that fertilized egg and sperm can’t make it down the tube and get stuck in the tube, and that’s an ectopic pregnancy, which can be life-threatening, um, because a pregnancy cannot grow in the tubes, it has to be in the uterus. And so, the, we try to make sure that people recognize if they do have a STD, because we don’t want them to develop something like PIV, and develop complications like scarring that could increase the risk of ectopic pregnancies, pain and infertility.
Darcy: If I fall asleep with a tampon in, should I be worried?
Dr. Goldman: Um, no, that’s a good question. Again, the likelihood of something bad like Toxic Shock Syndrome is incredibly rare. Um, we recommend that, um, you know everyone, um, bleeding pattern with their period is different. So you know some people have to change their tampons every two hours, other people it can be four to six. In general you want to try to change your tampons about every six to eight hours. If you fall asleep, the worst thing I tell people that could happen is if your period is really heavy, you might bleed through onto your sheets. Um, but in terms of it causing any, uh, danger to you, it’s not, uh, it’s not a big deal.
Mackenna: Why am I not getting my period, and what should I do if I stop getting my period?
Dr. Goldman: Yeah, no, that’s a really good question. So, the average age that people get their periods is around 12, and, um, we know that it takes a while for the brain and the ovary and the uterus to kind of work in sync for people to have regular periods. So it’s called the hypothalamus, then the brain talks to the pituitary in the brain, talks to the ovary in the uterus. And we know that the hypothalamic pituitary ovarian axis takes a while to develop. So, it is very uncommon for girls when they first get their periods to have regular periods. So, oftentimes people get their periods and then they may only get a few periods a year, and sometimes that, while for most girls, it regulates within a year or two, there are some people that it can take, um, longer for it to regulate, like a number of years. There are some people, even though the average age of getting a period is around 12, uh, it’s actually dropping — we can see it as early as 10. Uh, and there are some people that don’t get their periods ‘til 15 or 16. And if they don’t get their periods ‘til 15 or 16, it may take a while before they regulate, and so they may get one and then they may not get another one until, uh, you know, much closer to like 17, or even, uh, 18. In general, if someone doesn’t have their period by, uh, 15 to 16 at the latest, we recommend that they be seen, so that we can do some, uh, evaluation. And the tests that we do, we check someone’s thyroid, because thyroid problems are really common in girls and women, and that can affect people’s cycle. And then we tend to check their hormone levels to see, um, if they’re in the normal range. And then sometimes we’ll do, uh, what’s called a hormone challenge — where we give them a specific hormone called progesterone, and we, uh, after they take it if everything’s working okay, they’ll typically bleed. So we want to know, do they bleed or do they not bleed. Now, uh, there can be a number of things that contribute to people not getting their period. As I mentioned thyroid disease is one, um, people can have problems with the pituitary in the brain. Uh, there can sometimes be, uh even pituitary tumors, not cancer, but they’re benign pituitary tumors and that can affect people’s periods. Um, we know that if someone is extremely athletic they may not get their periods. It’s called Athletic Amenorrhea. Amenorrhea means not having their periods. Um, we also sometimes see it if people don’t have enough body weight. So, in those situations with Athletic Amenorrhea, someone not having enough body weight, sometimes with eating disorders, um, the signals within the hypothalamus of the brain aren’t getting to the pituitary of the brain and the pituitary isn’t sending out the right signals to the ovary. So, we see that commonly in teenage girls, particularly if people are doing lots of sports. There are certain things – we see it in commonly in ballerinas, that’s one that, um, a common condition we’ll see when people have Amenorrhea when they do, um, uh, when they’re, um, do a lot of ballet, or extreme sports. So those are the situations, but if someone had their, end in eating disorders, which we unfortunately know is really common in girls, in teens and in women, um, what I tell someone is, if you’ve had your period and then it stopped and you haven’t had your period for six months or longer, that’s important to go, uh, to the doctor, uh to get that, uh, checked out, so that they can run some blood tests and see what’s going on.
Darcy: What is Polycystic Ovarian Syndrome?
Dr. Goldman: So, in the normal period what happens is the pituitary in the brain sends a hormone to the ovary, called, uh, Follicle-Stimulating Hormone or FSH. And FSH makes the follicles in the ovary grow. And in a normal period what happens is one of those follicles becomes super sensitive to the FSH that the pituitary is putting out. And that becomes what is called the dominant follicle. And that dominant follicle, all of the follicles put out estrogen, but that dominant follicle puts out more and more and more estrogen. And when that estrogen level reaches a critical threshold value, that sends signals back up to the pituitary in the brain, and the pituitary then sends out a second hormonal signal to the ovary called LH – a luteinizing hormone. And once luteinizing hormone is,um, uh, produced, that causes that dominant follicle to be released as an egg. After the egg is produced, the ovary produces the second hormone called progesterone, and the way that estrogen and progesterone work on the lining of the uterus is, estrogen causes it to build up, and progesterone stabilizes it. So progesterone is only produced after the egg is released, or after ovulation. And if someone doesn’t get pregnant, progesterone is around for approximately two weeks. And after that two weeks, the lining of the uterus is no longer stabilized, and someone sheds the lining, and that’s what happens on a period. So that’s how a normal cycle happens. When someone has Polycystic Ovarian Syndrome, they don’t get development of a dominant follicle. So they get a whole bunch of little follicles that, um, are being produced, that produce estrogen, but then not getting that dominant follicle that produces more and more and more estrogen, such that they get the critical threshold value that can feed back to the pituitary to cause the LH surge which stimulates ovulation. So people who have Polycystic Ovarian Syndrome don’t ovulate on a regular basis. Usually that process will happen and maybe every three, four months they will have a period, but they don’t have a period every month like people should. Now, the, um, the big thing is with Polycystic Ovarian Syndrome, we used to think of it as just a problem of the ovaries, but we now think of it as possibly being an autoimmune disease, and it may go along with other autoimmune diseases like thyroid disease, and like diabetes. So if someone is diagnosed with uh, um, uh, with Polycystic Ovarian Syndrome, we always check them to make sure they don’t have other types of autoimmune diseases. Now, um, within the ovary, male hormones — or androgens — are also produced. And when someone has Polycystic Ovarian Syndrome, because they don’t have the, sort of appropriate production of estrogen and progesterone on a regular basis, there tends to be an excess of androgens. So some people who have Polycystic Ovarian Syndrome present with acne, and they can get hair growth, or what is called hirsutism along their face. Sometimes they’re more often overweight, there can be what’s called insulin insensitivity, um, which can lead to diabetes, um, and, um there’s, so there’s sort of a triad what you can see with someone with Polycystic Ovarian Syndrome which is sometimes benign overweight, uh, sometimes having acne, sometimes having even hair growth along their face, like along the mustache area, the chin, even along the nipples. Uh, we also, and then you see irregular periods. Um, and, uh, for women who want to get pregnant we can see infertility. Um, Polycystic Ovarian Syndrome, it can be very, um, and uh, I’m sorry, on, uh, when someone presents and we evaluate them in the office, if we do an ultrasound, we see a lot of little follicles in the ovary. Polycystic Ovarian Syndrome can be treated. If someone doesn’t want to get pregnant, we usually put them on the birth control pill, and that regulates their period, and that makes the lining of the uterus, um, so it doesn’t get so thick. So in Polycystic Ovarian Syndrome, because someone isn’t ovulating regularly, the lining of the uterus has continual low level of estrogen exposure, and it can get too thick, and that isn’t good because if it did that for years and years and years and years, a lining that’s too thick can undergo atypical change, and that is a risk factor for, um, endometrial cancer, or cancer of the lining of the uterus. And when we put people on birth control pills, that regulates the cycle, and that thins the lining of the uterus, and that’s actually protective for uterine cancer, or endometrial cancer. So we can very easily treat Polycystic Ovarian Syndrome, it’s important for us to make sure someone doesn’t have associated thyroid disease, or diabetes, and then it’s also something that’s treatable if someone wants to get pregnant, they often times end up needing fertility drugs, but those fertility drugs can regulate their cycle that allows them to ovulate normally, and then, uh, be able to get pregnant.
Mackenna: Is it safe to use products that “improve smell?”
Dr. Goldman: Um, as long as someone doesn’t have allergies. So there are some people that have skin sensitivities, and uh, like some people who end up having other skin conditions like eczema or psoriasis. I always tell people, if they are someone who has a lot of skin sensitivities, they probably want to be cautious using, uh, tampons or products that have lots of smells, because they might get an allergic reaction that can cause redness and pain and itching or burning. But, unless someone does, typically those things aren’t going to cause, uh, problems. There’s a lot of kind of concern nowadays whether some of those things have chemicals in them, and whether that might be dangerous to our health, um, but there’s a lot less research I would say, that, that really has confirmed that, uh, you know, tampons that have a perfume smell will have negative health effects in someone’s life. The big thing people are wondering about is, could some of those chemicals increase the risk of a future cancer, and I would say there’s a lot of research going on looking at that, um, I know there’s a lot of research going on looking at that in like chemicals in makeup. Um, but I’m not as familiar with, um, uh, research looking at perfumed products that, that girls and women use for like sanitary napkins and tampons and whether those have dangerous effects. I’m not aware that they have been proven to have dangerous effects.
Darcy: What are the different types of birth control, and which type is the most effective?
Dr. Goldman: So there are hormonal options and non-hormonal options. Um, so for the hormonal options, the easiest one for people to use is birth control pills. And, or combined contraceptives. Those can come in a ring form. Uh, I don’t know if the patch is still available. Um, and most often in pills. And there’s 20, 30 different pills on the market. When I say those are the easiest, the reason why they are the easiest is they are easily reversible. Meaning you don’t like how you feel on it, or you have a side effect you just stop it, and it gets out of your system. Um, they are 99+ percent effective, so they are very effective at preventing against, um, pregnancy, um, they also have a lot of non-contraceptive benefits, combined contraceptives decrease the risk of uterine cancer, like I talked about before, they actually decrease the risk of, uh, ovarian cancer. Um, people tend to have less cramps, and less bleeding. So, a lot of people like that. The big thing about it is you have to remember to take a pill everyday. And there are some people who just aren’t good pill takers, and they forget to take them. Um, other types of contraceptives are, uh, barrier methods like condoms. Uh, they are lower down on success rate — they’re more in the range of about 92, 93% effective. Um, and part of that is condoms can break. Um, and so, that’s why they’re not as successful as things like, uh, pills, and, uh, you have to remember, uh, to use them. So some people like in a heated moment of sex will like forget to use the, the guy will say, ‘oh I’m not gonna put on a condom.’ Um, condoms are really helpful though, when preventing against diseases, so any sort of barrier method can prevent against an STD. Another effective form of contraception is what’s called Intrauterine contraception, or long acting reversible contraception. Um, the most, um, and these are hormonal and non-hormonal. The hormonal one is, there is one called the Mirena, um, and there’s two others that are hormonal called, uh, Skyla and Kyleena. They all contain the same hormone — it’s a progesterone. And progesterone thins the lining of the uterus. So when people have that type of contraceptive, um, in the first six months they have a little bit of irregular bleeding — which bums people out cause they can’t predict it. But after six months, particularly with the Mirena, people don’t bleed at all, most women don’t bleed at all. So they really like not having their period. They don’t have to worry about like bleeding through their clothes and things like that. Um, it’s most, you’re most likely to not get your period with the Mirena. The Mirena is likely to stay in place for seven years. Skyla and Kyleena are shorter, um, — five years, I believe they’re both five years. Uh, one may be shorter, maybe two, uh Skyla. And I’m actually, I, I always have to look it up because I don’t place those that often. Uh, but those are all hormonal forms of intrauterine contraception, and those are in the range of 91% effective. There’s another type of, uh, uh, and that’s called an IUD. Um, and there’s another type of IUD that isn’t hormonal that’s called the ParaGard. It’s the copper IUD. And that, um, creates kind of an inhospitable environment for a pregnancy to implant. And that, uh, type of IUD can stay in place for 10 years. So if we have someone who need contraception and they have really heavy periods, we’re more apt to say, either, something like a birth control pill or something like a Mirena IUD because that will make their periods lighter. Um, with a copper IUD, it won’t affect, um, kinda how heavy the periods are. But if someone’s got normal periods and they don’t want anything hormonal, the ParaGard IUD is really, a very good choice, and that is also close to 99%, uh, effective. Um, there used to be something called a Diaphragm, which essentially is like a little cup. It’s kind of like the menstrual cup that people use. Um, and it fits over the cervix, um, but these aren’t, people um, it’s used with a contraceptive foam or jelly, and it is, provides a barrier, uh for pregnancy. These are really harder to come by. Most places don’t fit women for Diaphragms anymore. Um, and so, uh, we don’t do it in our offices, and so, they’re really much much harder to come by. Um, but they provide a barrier method and are more kind of in the range of 95, uh, percent, uh, effective. Um, there is a new, uh, contraceptive gel, uh, called Phexxi, that just hit the market in the past year I think, or year and a half. And this is a, uh, gel, that people, uh, apply prior to, uh, sexual activity. And it creates, um, also an inhospitable environment for pregnancy, uh, for a pregnancy to implant. Um, I’m not 100% sure of the effectiveness, I think it’s in the range of around, uh, 92%, uh, effective. Um, then there is also something called Nexplanon. Nexplanon are these hormonal implants that are placed in the arm, so it’s a little surgical procedure where, like, these little tubes are placed underneath the skin in the arm, and it releases low levels of progesterone and that also provides long acting, uh uh, contraceptive. I sort of put that in the same category as like the Mirena IUD. And there’s one other type of progestin, uh type of contraceptive, which is called Depo-Provera which is a shot that people get every three, uh, every three months. What I don’t like about that one is, is if someone has side effects, you can’t take away the shot. And so they have to deal with those side effects for about three months. But any of these types of contraceptives that are progestin only, the Depo-Provera shot, the Nexplanon implants in the skin, the Mirena IUD, the Kyleena IUD, the Skyla IUD, all, um, decrease the amount of bleeding people will have with their periods, and some people don’t have periods at all. And so, a lot of women really like that. So, what I always tell people is, um, you know, A: If someone has a male partner, you definitely want to make sure you have, uh, some form of effective contraception. Most successful are things like the long acting, uh um, intrauterin, uh formulations and the hormonal formulations. Barrier methods and the new gels are less, uh, successful. Any other barrier methods, Diaphragms, caps, all of that less successful, um, don’t, they don’t, barrier methods like condoms, however, do protect against diseases, so sometimes I’ll tell someone until they’re sure that they have a monogamous partner, or if they have more than one partner, they should use barrier methods for disease prevention. And then, uh, a hormonal method for more success at preventing it against pregnancy. But I also think it’s really important to go in and talk to your doctor about like what’s going on with your periods, because if you have, you know, really really heavy periods, I’m gonna be more, and someone needs contraception, I’m gonna be more apt to suggest something that’s like a combined oral contraceptive pill, or something like the Mirena IUD. So, um, I think it’s important when people do need contraception that they also talk about like what’s going on with their period so that their gynecologist or their, you know, healthcare provider can help them figure out, like in the context of you, what’s the most appropriate, uh, form, uh form of contraception.
Mackenna: Can birth control affect fertility?
Dr. Goldman: Um, birth control, people worry that like if you’re on the pill, it’s going to decrease your fertility, and we do not have good data that says it does that. Uh, the big thing and part of the reason why people may get confused, is, we see patients, we see women who will go on birth control pills and they’re be on it for 20 or 30 years. And we know that fertility rates decline with age. And we can see fertility rates declining by even age 35, even though there are some people who get pregnant later. And so if you have someone who starts pills at like 15, and they stay on them, you know, ‘til they’re 35, and then they try and get pregnant, it may be that their own, we’re all born with only so many eggs, and it may be that their own natural bodies like biological clock was declining, but it’s not a function of the pill that caused them to have infertility. So, the hormonal forms of contraception, um, none of those affect people’s long term fertility. There used to be, years ago, there was a, uh, IUD on the market, it was way before my time, it was like, I don’t even know when it was, in like the 60s, 70s, something like that. And it was called the Lippes loop and it was a bad IUD that caused scarring in the uterus that spread to the tubes, and it did increase the risk of people having infertility. But they pulled that off the market, and none of the formulations that are currently on the market do we have, there isn’t data that suggests that they, uh, can increase, uh, infertility. Now, the one thing I do say, uh, with cation, is, if someone has something like an IUD in place, and they get an STD — like gonorrhea or chlamydia — when you have a foreign body in place and you get an STD, that IUD can sort of allow that STD to get up inside in the uterus, and spread to the tubes, that can then increase the risk potentially of scarring, which can increase the risk of infertility. So it’s not the IUD itself, it’s more, having something like the IUD in place, and getting an STD that causes infertility. But the, the, the contraceptives themselves don’t cause infertility.
Darcy: Do you need parental permission to go on birth control?
Dr. Goldman: Uh, that is a good, uh question. I do not think that you do. I think that, um, uh, that’s a really really good question. You need parental permission for procedures, but, um, uh, ya I guess the reason would be unless you’re paying for your, I know like Planned Parenthood would see people and provide birth control pills. But if you’re going to be getting birth control pills, it’s usually run through your insurance, and your insurance is typically going to be a part of your parents’, uh, insurance plans. So from that perspective you probably need your, uh, parent’s, um, permission to get, uh, birth control pill, um, birth control pills, uh from the cost perspective. But from a legal perspective, I don’t, I don’t do a lot of teenage, um, uh gynecology, but I do not believe that we have to legally get consent from a parent to give someone birth control pills.
Mackenna: What happens if you miss a birth control pill?
Dr. Goldman: Yeah good question. If you miss one pill, the recommendation is take two the next day, and it is still effective for contraception. If you miss more than two pills, we tell people you should use backup methods that month, like condoms.
Darcy: Does Plan B affect fertility?
Dr. Goldman: Plan B will give you high dose birth control pills, to help prevent implantation of a pregnancy. So it’s used more as an emergency for emergency contraception. And I have not seen any good data that says that Plan B in any way affects people’s fertility.
Mackenna: Often in Sexual Education classes we only talk about safe sex in heterosexual relationships, are there safety measures that should be taken between two women?
Dr. Goldman: Yeah it’s a good question, so there are, um, types of condoms that are designed for lesbian sex. Um, they’re not, the uptake on them — meaning the not, has not been that great meaning, uh, people don’t use them that often. Um, more often with lesbian sex you’re more often, uh, seeing a lot more oral genital sex, and people need to realize that, things like HPV that you can get cervical dysplasia, abnormal pap smears, and that’s a risk for cervial cancer, is actually much much rarer, but there’s reports of HPV in the esophogus and people getting, um uh, cancers related to HPV, uh in the esophogus. What I tell patients um, my patients who have female sex partners, uh is, same thing. Until you’re sure that you’re in a monogamous relationship, um, as safe as you can be in terms of some sort of barrier methods, there’s these, uh, like I said there are female condoms, there are like these mouthguards. Most people, I would say, don’t use it. So I will tell people look if you’re not using any sort of protection between you, you just need to be aware of any symptoms. So if you, either of you, get a foul smelling discharge, an unusual discharge, pelvic pain, something like that, you need to, uh, you need to go in. You certainly can see Sexually Transmitted Diseases in, uh, female to female sex, um, probably a little less common, although I have to look up the statistics on it. Um, but I think we don’t have as great barrier method, you know, types of protection for women, uh uh, who are having, um, who have female sexual partners. I don’t know, because the newer, uh things like Phexxi, which is really designed to prevent sperm from being able to get up inside in the uterus, I don’t know if things like that prevent disease transmission, between woman to woman. Again, it’s a newer formulation of contraception, and so um, uh, I have very little experience with it to know if it’s also helpful for disease prevention.
Darcy: Is there anything else you want teenagers to know?
Dr. Goldman: Um, let’s see, I think, if your period is, as I mentioned before, if your periods are, um, off for at least, uh, six months, make sure you go in and get it evaluated. I know that whenever someone who is a teen comes in to, uh see me, even if they come in with their parent, uh, there are things that are confidential between the provider and the teen. Meaning, uh, and that is, uh, between patient and doctor and does not have to be shared with your, uh, parent or guardian. So if there’s things that you have questions or concerns but you don’t want your parent to know, but you feel like I really want to ask my doctor, your doctor is, we have to abide by patient confidentiality to, uh, not share that unless it is something that is threatening your life. Um, so for example if someone is suicidal, um, we have to take action in that situation. But if you share medical information, or questions about sex, or things like that, that is something that is confidential between you and your provider. Um, the other things that I really talk to people about is, please try to do everything you can to prevent against a Sexually Transmitted Disease, because if those are untreated, it can lead to things that could affect your future fertility. So, um, try to use barrier methods unless you’re in a long-term monogamous relationship. If you have a male partner, use condoms, um if you have symptoms like a discharge, pain, fever, go in right away, don’t ignore it. I think there are places, you know hopefully you have a good relationship, whether you see still a pediatrician, or an adolescent gynecologist, there are providers that specialize in taking care of teens, and make sure you’re seeing someone that you feel comfortable, that you can talk to. Um, if you have questions about your periods — I find that so many people have questions about their periods and what’s normal or what’s not normal, or, um, and don’t be afraid to ask I think the biggest thing is, um, don’t get all your information just reading, uh, the internet and asking your friends. Make sure you’re asking a trained person, so that you make sure that you get evidence based, uh, information that kind of guides you in your health care.
Darcy: Thank you so much to Dr. Goldman, and thank you everyone for listening!
Mackenna: Our future episodes will feature a mental health expert and a financial expert. Submit any possible questions on financial literacy and mental health by emailing email@example.com, or direct messaging @thebroadview on Instagram.