As a gynecologist, I discuss birth control options with women a dozen times a day. And I start someone on the pill at least once a week. As a matter of fact, most patients who come to me are interested in oral contraceptives pills. This past month, however, brought several women who specifically were looking for non-pill options. It was in counseling these patients that I realized that a lot of women have only a vague idea of what non-pill options exist out there. So here is the skinny on birth control that is not The Pill:
NuvaRing: NuvaRing is a small plastic ring that is placed inside of the vagina monthly. It works the same way as the pill, but the hormones are released from the ring slowly over the course of the month. It stays in place for 3 weeks and is removed for the last week, which is when a period occurs.
When I first describe NuvaRing to patients, they almost always make a face. For some women there is an "ick" factor involved with putting the ring into their vagina. But as I remind folks, tampons are inserted into the vagina too, and no one thinks twice about that!
NuvaRing is great for people who can't remember to take a pill daily. It stays in place during intercourse and isn't felt by either partner. Most women who try NuvaRing are pleasantly surprised by how simple and easy it is to use. Like the pill, it can be manipulated to skip cycles (just bypass the ring free week and go straight to another ring).
Intrauterine device (IUD): IUDs are my favorite. Why? They are essentially foolproof. Almost all forms of birth control work really well...if used properly. Condoms, as a matter of fact, are 98% effective at preventing pregnancy if used consistently and correctly. The average person, however, does not use birth control consistently and correctly. People forget to take pills, put in rings, show up for injections or use condoms. They just don't.
That is the beauty of the IUD. It is a small device that is placed inside of the uterus by a physician in what amounts to a 5 minute office procedure. One type of IUD is hormonal and lasts for 5 years. The other is completely non-hormonal (made of copper) and is good for 10 years. Viola! You're covered. No trips to the pharmacy, no refills on the pill pack, no hassle. And should you decide to get pregnant, the IUD can be pulled out at any time and fertility returns.
IUDs are safe to use in any woman, and are seeing a renewed popularity these days. They are long lasting reversible forms of contraception, which is what most people are looking for. Among my ob/gyn colleagues, IUDs rank highest in personal use!
Implanon: Implanon is the new contraceptive implant that is placed just under the skin of a woman's upper arm. It is reversible and lasts for up to three years. The procedure to insert it is quick, and a local anesthetic is given to the skin of the arm to minimize discomfort with the insertion. I don't use Implanon as much as IUDs, because it tends to cause irregular and unpredictable bleeding.
DepoProvera: aka "the shot". This injection is given every 3 months. It works well, but has the hassle factor of having to come in to the clinic every 3 months, as well as a prolonged return to fertility once the injections are stopped. A few years ago, there was concern raised that it causes bone loss which may or may not be reversible. And it causes weight gain in a majority of patients. Enough said.
Condoms: The good old condom may be the easiest form of non hormonal contraception out there. It is relatively inexpensive, does not require a doctor's visit or a prescription, and has a high efficacy rate when used correctly. It also offers what no other method can: protection against sexually transmitted infections! Alas, the condom is often misused (or not used), which leads into a common joke among doctors.
Q: What do you call people who use condoms?
A: Parents.
There are a handful of other options that I have not reviewed: patches, diaphragms, cervical caps, sponges, spermicides and the rhythm method (to name a few). And then there are the surgical options: tubal ligations and vasectomy. The bottom line is that birth control has to be matched to the individual and the lifestyle, and each person's situation and needs are different. Talk to your doctor about what will work best for you. And know that there are lots of great options out there that are not The Pill.
-Dr. Jahedi
Small practice...exceptional care.
Monday, April 30, 2012
Sunday, April 1, 2012
HPV 101: Why you have a Pap smear and what it means
I have had the HPV conversation with a lot of women in my office this month- as pap smear after pap smear has come back abnormal and we move to the necessary steps of follow up. My patients are mostly young women, and my discussion of HPV (human papillomavirus) is usually the first time that they are really learning about this little virus. I am always surprised at how little women know about why we do Paps and how abnormal results can affect them. So here is a primer for Pap smears and HPV- with a little history thrown in!
The cervix is the opening to the uterus, and is found at the very top of the vagina. Back in the day, cervical cancer was the leading cause of death in women, and no one knew why, or how to test for it. Enter Dr. Georgios Papanicolau, who in 1923 was doing research on female guinea pigs and studying vaginal fluid to try to better understand the menstrual cycle. As chance would have it, one of his guinea pigs had uterine cancer and he realized that he could plainly see the abnormal cells under the microscope. It was an "a-ha!" moment for Dr. Papanicolau and a breakthrough in what ultimately became known as the Pap smear. Cells are obtained from a woman's cervix with a brush and studied under the microscope. Abnormal cells signal precancerous changes that can then be treated, thus preventing cervical cancer!
So what happened? Women starting seeing their doctors for annual pap smears, and cervical cancer rates dropped drastically- it was a public health success of tremendous proportions. But the cause of these cellular abnormalities was still a mystery. Then in 1976, German virologist Harald zur Hausen proposed that HPV was the cause of cervical cancer. As is often the case with important scientific discoveries, no one believed him, and he went on to prove his theory in 1983 with the discovery of HPV DNA in cervical cancer tumors. For this important work, he received the Nobel Prize in 2008.
Now we know: HPV is the cause of abnormal pap smears.
When you have a pap that comes back abnormal, it is because of HPV. So how does someone get HPV anyway? It is sexually transmitted. As a matter of fact, HPV is the number one sexually transmitted infection out there. The prevalence is high- it is estimated that between 75-80% of Americans have been exposed to HPV at some point in their lifetime. That means 8 out of 10 people walking around have (or have had) HPV!
Patients ask me all of the time what they can do to prevent getting it, and the answer gets tricky. HPV is small enough that even condoms don’t protect you entirely. The key would be not to have intercourse with anyone who has already been exposed- but how can you tell if someone has been exposed? While men certainly carry this virus, most never know that they have it, because it does not cause any symptoms at all. And it is not something that they are ever tested for, so when someone tells you that they have "been tested for everything", it usually does not include HPV. In most men (except for the HPV strains that cause genital warts), it does nothing. In women, it can cause cervical cancer. It is an inherently unfair setup!
I tell my patients not to stress about an abnormal pap smear, even if it means that they have been exposed to HPV. So have 8 out of 10 people out there! It is so common that I hate to give it the stigma of an std. It is something that people live with, and that their immune systems fight successfully every day. Keep on top of your pap smears and follow ups, and HPV won't interfere too much with your life.
For our younger generation of daughters, consider the HPV vaccine. Once HPV was definitively linked to cervical cancer, the scientific world raced to develop a vaccine, and Gardasil was introduced in 2006. In 2009, it was approved by the FDA for young boys as well, since they are carriers of the virus and transmit it to women. It has been safely given to thousands of young women and men, with the understanding that it is most effective BEFORE the onset of sexual activity, and hence before exposure to HPV. This vaccine is the newest tool in our evolving fight against abnormal pap smears and cervical disease in women.
Dr. Papanicolau would have been proud.
The cervix is the opening to the uterus, and is found at the very top of the vagina. Back in the day, cervical cancer was the leading cause of death in women, and no one knew why, or how to test for it. Enter Dr. Georgios Papanicolau, who in 1923 was doing research on female guinea pigs and studying vaginal fluid to try to better understand the menstrual cycle. As chance would have it, one of his guinea pigs had uterine cancer and he realized that he could plainly see the abnormal cells under the microscope. It was an "a-ha!" moment for Dr. Papanicolau and a breakthrough in what ultimately became known as the Pap smear. Cells are obtained from a woman's cervix with a brush and studied under the microscope. Abnormal cells signal precancerous changes that can then be treated, thus preventing cervical cancer!
So what happened? Women starting seeing their doctors for annual pap smears, and cervical cancer rates dropped drastically- it was a public health success of tremendous proportions. But the cause of these cellular abnormalities was still a mystery. Then in 1976, German virologist Harald zur Hausen proposed that HPV was the cause of cervical cancer. As is often the case with important scientific discoveries, no one believed him, and he went on to prove his theory in 1983 with the discovery of HPV DNA in cervical cancer tumors. For this important work, he received the Nobel Prize in 2008.
Now we know: HPV is the cause of abnormal pap smears.
When you have a pap that comes back abnormal, it is because of HPV. So how does someone get HPV anyway? It is sexually transmitted. As a matter of fact, HPV is the number one sexually transmitted infection out there. The prevalence is high- it is estimated that between 75-80% of Americans have been exposed to HPV at some point in their lifetime. That means 8 out of 10 people walking around have (or have had) HPV!
Patients ask me all of the time what they can do to prevent getting it, and the answer gets tricky. HPV is small enough that even condoms don’t protect you entirely. The key would be not to have intercourse with anyone who has already been exposed- but how can you tell if someone has been exposed? While men certainly carry this virus, most never know that they have it, because it does not cause any symptoms at all. And it is not something that they are ever tested for, so when someone tells you that they have "been tested for everything", it usually does not include HPV. In most men (except for the HPV strains that cause genital warts), it does nothing. In women, it can cause cervical cancer. It is an inherently unfair setup!
I tell my patients not to stress about an abnormal pap smear, even if it means that they have been exposed to HPV. So have 8 out of 10 people out there! It is so common that I hate to give it the stigma of an std. It is something that people live with, and that their immune systems fight successfully every day. Keep on top of your pap smears and follow ups, and HPV won't interfere too much with your life.
For our younger generation of daughters, consider the HPV vaccine. Once HPV was definitively linked to cervical cancer, the scientific world raced to develop a vaccine, and Gardasil was introduced in 2006. In 2009, it was approved by the FDA for young boys as well, since they are carriers of the virus and transmit it to women. It has been safely given to thousands of young women and men, with the understanding that it is most effective BEFORE the onset of sexual activity, and hence before exposure to HPV. This vaccine is the newest tool in our evolving fight against abnormal pap smears and cervical disease in women.
Dr. Papanicolau would have been proud.
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