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A baby that is wanted and planned for, a child by choice and not by chance, that is what modern contraception offers men and women. But you have to know what's out there, how it works, and where to get it. This is really important now more than ever.

This is Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah Health, and this is the "7 Domains of Women's Health" on The Scope.

Women and men all over the world have wanted to plan their families for thousands and thousands of years, but methods used in Cleopatra's time in ancient Egypt probably weren't as effective as what is available now. If no method of contraception is used, women in sexual relationships that would make them pregnant could expect to have more than 11 babies. That's in these days of good obstetrical and pediatric care, where women are less likely to die in childbirth and babies are much less likely to die in the first five years of life. Eleven babies sound like too much? One more baby sounds like too much right now?

Let's talk about contraception. It's an egg and a sperm problem. You need to stop egg production, stop sperm production, or stop the sperm from getting to the eggs. These are the main ways that modern contraception works.

About 50% of unplanned pregnancies happen to people who are "using" contraception but using it incorrectly. This is the most common reason that methods like abstinence or periodic abstinence, think natural family planning, or methods like barrier methods like condoms or diaphragms actually fail. They weren't used correctly or at all. Methods that you have to think about at the time of sex are more likely to fail because you're more likely to fail to use them. If you combine two methods, abstain during your fertile period and use condoms all the rest of the time, your chance of getting pregnant by accident is much lower. Two methods are better than one, and this is a combo where men can be the important user. You can get condoms most anywhere, and anyone with some smarts and gumption can figure out their fertile period.

So let's talk about hormonal pills, patches, and rings. They are considered moderately effective methods or ones that have an annual failure rate between 1 in 10 to 1 in 100. That means if women use them, the chance of getting pregnant is about 1 in 10 to 1 in 100 per year. Of course, you might be at risk for pregnancy for multiple years, so these chances literally add up. Considering a lifetime of contraception using these methods, it was calculated that women would have about two unplanned pregnancies. These methods work by blocking ovulation and by changing cervical mucus so sperm cannot get to the eggs, but women don't always take the pills, or patches or rings correctly. They miss some days or they stop for a week as directed, but they stop for longer than seven days, and they are very likely to ovulate. But you could team up with your sex partner and use a moderately effective method and condoms and get much more bang for your buck birth control-wise.

Hormonal methods aren't right for everyone, and you should know by reading up or asking knowledgeable clinicians if they're right for you. Now, there may be immense hormonal contraception on the horizon, transdermal hormones to block sperm production. If it has about a 10% failure rate per year, and women taking the pill as they will, not perfectly, have a failure rate of about 10% per year, if both members of the sexually active couple use the method not perfectly, the failure rate would be about 1 in 100 per year. The two methods multiply in terms of their effectiveness. If they both used effectively, if they both, men and women used hormonal methods effectively, it would be about 1 in 10,000 women per year, and that is effective contraception.

Now for highly effective methods, these methods have failure rates of about 1 per 1,000 women per year. They are so good because you don't have to think about them and using them correctly almost always happens. These include copper IUDs, hormonal IUDs, and hormonal implants under the skin. The hormonal implants' primary method of action is to work by blocking ovulation. The IUDs' primary method of action is by blocking sperm. Copper in the copper IUD kills sperm on their way up to the egg, and the hormonal IUD blocks sperm from getting through the cervix. The IUDs and implants are highly successful at preventing pregnancy but require a trained clinician to put them in. They last a long time, the copper IUD for 12 years, the hormonal IUD for 5, and the implant for 3, but they are immediately reversible as soon as they come out.

Now, all contraceptive methods have some side effects and risks, but none have as many risks and side effects as an unwanted pregnancy. Uh-oh, did you just say, "Oops?" Did you forget to take your pills? Did the condom slip off or stay in his back pocket? Was sex forced on you and you weren't using anything? Emergency contraception is for people who had unprotected or under-protected sex. They are pills over the counter or by prescription, that must be used in the first three to five days after the unprotected sex act, and the earlier, meaning the next day or the day after, the better. The copper IUD and hormonal IUD can also be used for emergency contraception, but they aren't FDA approved for that use, and you have to find a clinician to place one in a timely manner.

Using contraception means some work on your part. You have to know what you can use and want to use. You need to know where you can get them. You need to know how you can pay for them. All this information is available from many sources, but an overall good resource is bedsider.org. Many clinics around the country provide contraception on a sliding fee scale based on the ability to pay. Most insurance plans pay for a significant amount of the cost of contraception. There's a national family planning grant called Title X, that provides low-cost contraception to anyone who needs it, and it's available in most states. But you have to lace up your boots or put on your flip-flops and do it. Children deserve to be by choice and not by chance now more than ever. Thanks for joining us on The Scope.

So you just had your Pap smear or your mammogram and it wasn't that bad was it? Or your colonoscopy. Okay, it really was that bad, but you didn't remember it. Are you wondering when you can stop doing these tests?

I asked a woman I know, who is in the health and fitness business, when she thought she could stop doing her cancer screening, you know, Paps, mammos, colonoscopy. She said, "Never," with a smile. She never wanted to stop her cancer screening, "It isn't all that bad, and it makes me feel safe," she said. I replied that cancer screening decisions about when and how often is a cost, risk, benefit analysis, and there are some data to inform that decision. She said, "You go with your brain, I go with my heart."

Well, let's go with the brain for a little while, okay? Let's start with Pap smears. The recommendations about Pap smears have been changing as we know more about what mostly causes cervical cancer -- the HPV virus -- and how fast it grows, usually not too fast. Cervical cancer does not increase with age for a lot of reasons. Sexual activity and the number of partners doesn't increase with age. Well, usually. And the cervix in postmenopausal women may not be as receptive to the virus. So there are good reasons to say that when you get to 65, if you've had normal Pap smears for the past 10 years, that means you actually have been having Pap smears in the past 10 years, and you haven't had an abnormal Pap in 20 years, you can stop testing. There's some pretty solid numbers to back this up, and the U.S. Preventive Services Task Force makes that recommendation.

Okay. How about colonoscopy? Well, colon cancer does not decrease with age. But if you don't have any family history of colon cancer and if your previous colonoscopies, that assumes that you've had some, have not shown any polyps or precancerous lesions, you can stop at 75. That's the recommendation of the U.S. Preventive Services Task Force and the American College of Physicians.

Lastly, mammography. Breast cancer does not decrease with age. It increases with age. The aggressiveness of breast cancer is less in older women than it is in younger women. But women still will get treated, which can be aggressive in and of itself. The U.S. Preventive Services Task Force said there's not enough evidence to recommend for or against mammograms at age 75 and older. But about a quarter of deaths from breast cancer each year are attributed to a diagnosis made in women after the age of 74. Women as they get older are less likely to get mammograms. About three-quarters of women 50 to 74 have had a mammogram in the past two years, but only 40% of women over 85. Of course, many women over 85 are in poor health, and mammography is just not on the list of things to do. And clinicians are less likely to recommend mammography if a woman is in poor health. The American Cancer Society suggests women should continue mammograms as long as their overall health is good and they have a life expectancy of at least 10 more years.

Well, how long am I going to live? I went online and Googled, "How long will I live?" There are lots of calculators because insurance companies and pension plans really want to know. Well, I tried a life expectancy calculator that was developed by the University of Pennsylvania and has been mentioned in the mainstream media. It asks sex not gender, age, height, weight, alcohol, smoking, diabetes, marriage status, whether I exercised, ate my veggies. I didn't fudge my weight or height. This calculator said I was going to live till 93 and I had a 75% chance of living to 85.

Another life expectancy calculator from confused.com asked me just a few questions, not my height or weight,or smoking, or alcohol, or diabetes. It did ask my relationship status, and options included happy relationship and married, but these were mutually exclusive. You could only pick one. Well, this one had my life expectancy of 97. And the calculator from Northwest Mutual, a well-respected life insurance company, cranked me out at 98.

Well, I really don't want to hang around the planet all that long. But I really hope that my savings will take me up there, and I'm going to have to have mammograms for a while yet.

Thanks for joining us for the "Seven Domains of Women's Health" on The Scope.

PCO, OCP that is a palindrome, something that's the same when you read it forwards and backwards, but it also refers to a common hormonal problem in women, and something used for management. This is not a quiz game, but this is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is the "7 Domains of Women's Health" on The Scope.

PCO, polycystic ovaries and polycystic ovary syndrome is a hormonal condition in women of reproductive age. It's not a disease, but a syndrome, meaning a constellation of symptoms and findings without a single common cause. The symptoms and the findings that define PCOS include irregular periods and evidence of increased androgens or male hormones. Some definitions include having multiple small cysts on the ovaries that can be seen on ultrasound. However, not all women all over the world have access to an ultrasound to look at their ovaries, so many experts just use irregular periods and evidence of androgen excess. Also, young women who have lots of eggs, have lots of follicles. So, on ultrasound, they look like they've PCOS, but they don't. So the ultrasound part is kind of controversial.

Irregular periods mean that menstruation comes more than 35 days apart, and not on a schedule. Now, some women feel that their cycles are irregular, if some months they have periods on the 15th of the month and some months on the 17th, but PCOS means that the cycles are much more irregular and often without ovulation. If women who have PCOS usually don't ovulate, they don't make the hormone progesterone, which is made by the ovulation cyst, and is important for keeping the uterus healthy each month. So having regular periods makes the uterus healthy, and having irregular periods can lead to unpleasant or dangerous bleeding and a not very healthy uterus.

The excess androgens part of PCOS means that women have more than normal levels of hormones made by the ovary that are like testosterone. Now, all women make male hormones. In fact, the female hormone estrogen is made out of male hormones. However, women with PCOS have many small egg follicles that are stuck in development that makes male hormones. That's the polycystic part of polycystic ovaries. These little follicles usually do not ovulate. They don't make the estrogen at the level of an ovulating follicle, and they don't make progesterone to keep the uterus lining healthy and that causes irregular periods.

So what are the main symptoms of PCOS? Well, irregular periods and excess hair growth on the face and other parts of the body. If a woman with PCO is trying to get pregnant and doesn't ovulate, she may be infertile. Many women with PCOS have gained weight, and this complicates the problem of irregular periods and extra male hormones. Some women have insulin resistance and may be prediabetic, partly related to the PCO part and partly related to obesity.

Now, PCOS is very common, as many as 1 in 20 to 1 in 10 women have this syndrome. It was probably less common in years past when women were much less likely to be obese, and not all women experienced PCO to the same degree. Some women have slightly irregular periods with only minimal signs of excess male hormones, and some women have extremely irregular periods and very significant hirsutism or excess body hair.

Okay, that's the PCO part. What about the OCP part? Oral contraceptive pills have estrogen and progestin in them. The way OCPs work for contraception is to block the development of follicles, so ovulation doesn't happen and they control the uterus lining, so periods are regular and light. The way OCPs work by suppressing the development of little follicles, those little cysts that can make male hormones, make them useful in controlling symptoms of PCO. Also, women with PCO have estrogen but lower amounts and the higher estrogens in the OCPs can help counteract the effects of male hormones. The progestin in the OCPs help control the lining of the uterus, so women can have regular periods. There you go.

Now, clearly OCPs do not cure PCO, but they are very useful in the control of symptoms. There's even some evidence that women who are taking OCPs for the PCOS and then choose to try to get pregnant, may actually be more likely to ovulate the first several months after stopping OCPs. Not all women who have PCO are good candidates for OCPs. Some women with PCO who are obese and have high blood pressure, which may be a contraindication to OCPs. Some women don't like the way they feel on OCPs, although many women with PCO say they feel better on OCPs.

Are you guys getting tired of the PCO or OCP palindrome? Well, hang in there. We're almost done. Some women may have other contraindications to OCPs, including a history of blood clots or migraine headache. And of course, some women want to get pregnant. For women who are overweight with PCO, their first effort might be diet and exercise with the focus on weight loss. Women with PCO who lose as little as 10% of their body weight are more likely to ovulate and to have regular periods. Then, of course, they may choose OCPs for birth control. For some young women, a diet low in refined carbohydrates, high in vitamins and minerals and good nutrition, and regular exercise may make them feel the best. However, for some women, and many women, diet and exercise do not work to control their symptoms and OCPs may be the best option.

There are many kinds of OCPs, but they all work mostly the same way. The combination pills with estrogen and progestin work the way we just talked about. The lowest dose pill that does the job would be the first choice. The OCPs are different in the kind of progestin in the pill, and some women feel better on one pill than another. They all work to control periods and lower male hormone effects. So, because PCO is so common, most primary care providers, which include internists, family physicians, pediatricians who see teenagers, and OB/GYNS are familiar with the signs and symptoms and routine treatments. However, there are other options in treatments for symptoms other than OCPs and weight loss and exercise and diet. If a woman with PCOS is struggling to understand her condition, is not getting help with symptoms, or is struggling to get pregnant, she may want to see a specialist in PCOS such as a reproductive endocrinologist.

PCOS is complicated in all of the 7 domains of women's health -- physical, emotional, social, environmental, intellectual, financial, and spiritual. Having irregular periods, being infertile, having the body that you don't think is really you, all those things are affected. If you or someone you know is struggling, we can help. And thanks for joining us on The Scope.

It is that time of life, midlife, menopause, and you aren't sleeping so well. Is melatonin the answer?

Menopause and midlife aging happen at about the same time for most women, but they aren't exactly the same. Menopause is when periods stop because there are not any more eggs to ovulate in the ovary. It's the last period, and it happens at about 50 years of age in most women. Midlife is a little harder to define, but it is that middle of your life from about 40 to 70, after you are young, but before you get old. Maybe it's really from 30 to 60. It depends on where you are as to what range you will embrace. I embrace the 40 to 70, but 30 to 60 is probably better.

We are about as strong and as smart, and I'm not saying wise, as we're ever going to be in normal biologic function at about 30. After that, we begin to age with decreasing muscle mass, bone density, and cognitive speed.

We are usually really great sleepers until midlife. Of course, there are some kids who are naturally short sleepers, and there are those people whose sleep rhythms don't let them really fit into their daily lives. They're night people, but they have to get to work at 7:30 in the morning, so their sleep is disrupted. There are the years of infants and young children that wake us up at night. There are years of jobs that shift hours. But left to our own devices, we are often pretty good sleepers until the middle of our lives.

It's a combination of anxiety, all things for which you're responsible, adolescents in their 20s, finances, juggling stuff keeps us awake. Aches and pains with aging and stiffness keep us awake. And then menopause with hot flushes keeps us awake.

Now, what is melatonin? Melatonin is a small molecule that was originally thought to be made just in the pineal gland in the brain. Its function originally was thought to help us set our circadian rhythm, our internal clock. Pineal melatonin is suppressed by bright light. And when lights get dim, melatonin rises because of its own natural daily rhythm and the lack of suppression by light and helps us signal sleep time. As we age, we make less and less melatonin and that's the midlife aging part.

Now, we know that melatonin isn't only made in the brain, and its function isn't only to help our clock give us daily rhythms. It's found in our gut and may help our gut bacteria have a rhythm, and it's found in the placenta and the ovary and it's an important antioxidant in the body. There is much more that can be said about it, but let's get back to menopause and melatonin.

So you're a midlife menopausal woman and you're having difficulty sleeping. You're having a hard time getting to sleep and your hot flushes wake you up. You're not so interested in taking estrogen hormones for your hot flushes, but you should be and you've read about melatonin. Does it work? Is it safe to take? Can you get addicted to it? Can you take it for a long time?

Does it work? An international group of researchers published a summary of what we know about this in the journal "Sleep Science." Several studies done around the world suggested that a three-milligram dose of melatonin before bed helped with sleep. Women were given melatonin or a placebo and asked about sleep, physical symptoms, hot flushes, and psychological symptoms, and these all got slightly better when people took melatonin over placebo.

Of course, getting better sleep can help with joint aches, psychological symptoms, and hot flushes, but melatonin does a lot of amazing stuff and maybe melatonin was helping.

It was safe with few side effects. Some women in both the placebo group and the melatonin group had side effects of sleepiness and nausea and vomiting and headache, but the incidence was not different in the two groups. People who took placebo and people who took melatonin had the same rate of side effects.

Is it safe to take for a long time? The answer is probably yes. It is not addictive in the traditional sense. There's no evidence that a low dose leads to higher dose usage. There's no evidence that higher doses over three milligrams is more effective. There's no evidence of withdrawal.

The main problem is that there's no control over what's actually in the bottle when you buy it at the grocery store or the health food store. You might be getting melatonin or you might not.

The NIH has a Center for Complementary and Alternative Medicine with a short page about melatonin. They note that a 2017 study tested 31 different melatonin supplements bought from the grocery store and pharmacies. For most of the pills in the melatonin bottle, the amount of melatonin didn't match what was on the label and there were other compounds in the bottle. The biggest concern was 25% of the bottles had serotonin in them, and serotonin is a regulated drug with side effects that can be harmful at low levels.

Melatonin is widely used in Europe as a sleep aid, and supplements are regulated in Germany. So they have to have what they say on the label in the bottle, and no other funny stuff. In the U.S., they could sweep up what's on the lab floor, stick it in a little capsule, and you'd be none the wiser, and no one's watching.

So what do you do if you want to take melatonin? It would be good to talk with your clinician and make sure you don't have any contraindications. They should know that you're planning to take it and it should be on your medication list.

Although the USP verified label on supplements is not a guarantee that you're getting what you think you're getting, it's a start. The USP label indicates that the product has been subject to voluntary testing and meets U.S. pharmacopeia convention standards, that's the USP part, meaning the product is accurately labeled and free of harmful substances. This does not mean that it's been tested by the FDA, but it's better than nothing.

Now, of course, melatonin is found throughout the plant kingdom, and a wonderful paper in the journal "Nutrients" from 2017 listed the melatonin contents of common foods. Some mushrooms have a lot of melatonin. Portobello mushrooms are the basic white and brown ones that you can get at the grocery store have a lot. Seeds and nuts have a lot of melatonin. And pistachios win the top melatonin prize in the nut family.

Sprouted seeds also have a lot of melatonin and sprouted lentils are at the top. I can see a dinner salad with sprouted lentils, mushrooms, and pistachios being perfect to help you sleep. Your gut will love it and you won't feel guilty. Both of those factors are important for a good night's sleep.

It turns out that roasted coffee beans have a lot of melatonin, and coffee has some, but coffee is defeating the purpose.

So there are a lot of reasons you may not be sleeping well in midlife. The American Academy of Sleep Medicine would suggest behavioral approaches, such as bright morning light and daily exercise, a bath before bedtime, and no coffee after noon, limit alcohol at night, and no screen time just before bed to suppress your melatonin.

Having said all that, international studies suggest that melatonin in low doses can be helpful for midlife women struggling to get to sleep. So sleep tight, and thanks for joining us on The Scope.

Dr. Jones: So you ran out of your birth control pills and the condom broke or something like that. You really don't want to get pregnant right now or anytime soon. What do we know about your options?

Many women know about emergency contraception, and many don't, something you can do to decrease your chance of pregnancy if you had unprotected or under-protected intercourse. There are two types of emergency contraceptions approved by the FDA that are available in the U.S., and they are pills, and they decrease the chance of pregnancy if they're taken within five days of unprotected intercourse. But there are other types of birth control that would work and keep on working if you're looking for contraception for more than this month.

With us today is Dr. David Turok. He is an OB/GYN specialist in family planning and chief of the division of family planning at the University of Utah. Thanks for taking some time for us, Dr. Turok.

Dr. Turok: Thank you.

Dr. Jones: What were the background reasons to ask the question of whether the levonorgestrel IUD, which is what we're going to be talking about, would work for emergency contraception? What made you do this question?

Dr. Turok: Well, I speak with people a lot about emergency contraception because I'm very interested in it, and I think it's amazing that you can use something after you've had sex to prevent pregnancy. And every time I talk about it with people during grand rounds or during educational presentations, people always, always, always ask . . . because we know we have great data to say that the copper IUD works very well for emergency contraception, people always ask, "Well, what about the hormonal IUD, the levonorgestrel IUD? Can you use that?" So 10 years ago, we started trying to gather data on this topic, and finally we have an answer.

Dr. Jones: So people came to the clinic wanting emergency contraception and they walked into the clinic thinking that they might get some pills. How did you get so many women to participate in the study when they came for just pills?

Dr. Turok: Like in many aspects of life, Utah is unique. And currently, one of the forms of emergency contraception pills is available without a prescription. You can just walk into pharmacy or supermarket and get them. Sometimes it's behind the counter, you might have to ask, but you can get it without a prescription.

In Utah, because there are many limitations for people, young people especially, with insurance coverage, people seek out the cheapest place to get it, and that is Planned Parenthood where there's a sliding scale and where people have known for a long time that they can get the pills.

And we've done a few different surveys and a few different kinds of projects where we offer people walking in for emergency contraception IUDs, and it's around 12ish percent of people are interested in an IUD in that setting. And that's, I think, potentially driven in Utah by the fact that people don't have adequate insurance coverage and they're looking for opportunities to get better methods of contraception. And when there are low or no-cost options presented, people are interested.

So, at the peak before Plan B, one of the pills was available over the counter. Planned Parenthood statewide distributed more than 50,000 doses of oral emergency contraception. So people know, and lots of people come to Planned Parenthood clinics in our state for the service, and when you present them with IUDs, some are interested in it.

Dr. Jones: So some of them are really looking for something for longer than just this month?

Dr. Turok: Exactly. Yes.

Dr. Jones: Right. So you've known that the copper IUD . . . we've all known from data that goes back 20 years, really, that the copper IUD works. So you then offered them either a copper IUD or a hormone-containing IUD. And what did you discover?

Dr. Turok: So what we found in this study where we randomized people to get one or the other type of IUD, either copper or the hormonal IUD, we found that the pregnancy rate was low, very low, in both groups in the month after.

So with copper IUDs, we had 321 people who were assigned to that, and we got one-month outcome data on. And we expected in that group, zero or one would have a pregnancy. And it was zero.

And with the levonorgestrel group, we really didn't know. We had built into the study stopping points. Like, if there were a bunch of pregnancies early on, we were just going to stop. But what happened was there were 317 people who got the levonorgestrel IUD and there was one pregnancy. Lower than we thought and much better than the pills.

Dr. Jones: Right. That's important because the methods that are currently FDA-approved, that those 50,000 women who came to our clinics seeking pills, the failure rate or the ineffectiveness rate is much higher than what you found with the IUDs, either one of them.

Dr. Turok: Yeah. To me, one of the very cool things about the study is the other studies that got FDA approval for those oral methods, these were things that took a long time and hundreds of millions of dollars were spent to go through the FDA process to get that approval. And in this study, we took a method that was already FDA-approved and we just showed that it works for this as well.

And the upside relative to the pills is, as you know, that people who are getting this can get . . . this is not just better than the pills for this one event, but you can continue to use it as long as you want, up to seven years, or for the copper IUD, up to 12 years. And that is a set-it-and-forget-it method.

Then for the LNG IUD, there's this side benefit, which is why it's more popular than, I think, the copper IUD, in that it dramatically reduces or eliminates both menstrual bleeding and cramping. And that is a big upside. And that's why I think people really wanted an answer to this.

Dr. Jones: Well, we have some evidence from another big study that just gave women what they wanted when they asked for contraception and then followed them, that the IUDs were something like 20 times more effective than birth control pills in preventing pregnancy?

Dr. Turok: Correct.

Dr. Jones: So if a woman comes to our clinic for an emergency contraception and she wants long-term reliable contraception, would she be offered an IUD, do you think, in our clinics? Because now that the work was done around here, I'm hoping that our clinicians know that it's an option. Do you think it's going to be used in the clinics?

Dr. Turok: I want to say absolutely.

Dr. Jones: I do, too.

Dr. Turok: But I would also say as our team is working on getting this paper published, I would occasionally have these pangs of terrible thoughts that 10 years down the road, it's going to be like the authors of this paper and 10 other people that we know that know about this and nobody is going to ever have done any of it.

And so I started making lots of phone calls and sending lots of emails to people who I thought would be critical partners in disseminating the information. And one of the things that helps get the word out a lot is getting the paper published in a high-impact journal.

Dr. Jones: Right. It was published in "The New England Journal of Medicine," which is probably our premier medical research journal, I think, in the United States, or one of them.

Dr. Turok: One of the, I think, nice things about the study is "The New England Journal" publishes papers that change practice. That is their main motivator for selecting research articles. And you have a very low chance of submitting something and getting it published. But it was very reassuring to know that they felt this was important enough to be published there and that they were confident that it would change practice.

And there are lots of other organizations, professional organizations, a variety of health practitioners, and providers that can disseminate this to people who work with them.

I also have been working with the people from UpToDate to revise the article on emergency contraception to incorporate this and they were amazing. ACOG carried a piece on their listserv email and we're going to work with them to try to update Lark information in their emergency contraception information. So there are all kinds of ways to get the information out.

And a really important place to do that is also with Planned Parenthood Federation of America. As you know, they have something called the National Medical Committee that makes decisions on changes in practice. So I just sent an email and lately before this interview responding to questions from people who organize the National Medical Committee about this.

It's, I think, a great opportunity for Planned Parenthood Federation of America to lead on the dissemination of this because the information came exclusively from Planned Parenthood clinics. This is a collaboration between our team at the University of Utah and Planned Parenthood Association of Utah.

If you look at what gets published in "The New England Journal," the vast majority . . . and currently, probably nobody is a more fastidious reader and consumer of their publication than you. If you look at those trials that get published, most of them are these big, multi-site, and sometimes multinational studies with tons of sites and huge numbers of participants. This study is different.

Dr. Jones: It is. It's really amazing that you have a very local group who was completely committed to answering the question. And I think that that's a phenomenal thing.

I think, at The Scope, we're trying to get the word out also to individual women so they might be willing to come in and ask. So not only do clinicians need to know, but if individual women say, "By the way, do you think I could get this IUD today? Do I have to wait?" that changes practice.

Dr. Turok: Absolutely. So the education and dissemination of information have to be from push and pull factors from supply and demand side. And as I had mentioned, we're already working on trying to get providers up to speed. But there's lots of opportunity that we're going to be working on to make sure that people who are seeking emergency contraception will know about this.

Obviously, the internet is a fabulous place to do that. And there are also some organizations that focus specifically on emergency contraception. There's a U.S. Emergency Contraception Consortium and an International Consortium of Emergency Contraception, and they are fabulous at providing consumers information about different products and ways to access them. So we look forward to working with them as well.

Dr. Jones: Right. Well, Dr. Turok, I am very grateful for your time, and we'll work at The Scope in trying to get people the information they need. But the research to answer this kind of question takes years and takes a team of dozens of nurses, and clinic staff, and researchers, and above all, it takes hundreds of women who are willing to participate, answer questions, and follow up. To all of them, we are very grateful because "I hope I just didn't get pregnant" isn't a very good birth control method. And it's been a long time coming and I'm so glad to see it here. Thanks a lot, and thanks for joining us on The Scope.

Dr. Jones: I was talking to a group of 11 college students, all women, about family planning. They said, "We aren't really interested in family planning because we aren't planning any children right now." Really? What am I not getting here?

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Sometimes you think people you are talking to know what you mean. Well, that's a mistake for sure. I make assumptions that young people in college know how their bodies work and about contraception, but maybe I'm wrong.

Today in The Scope studio we're talking to Grace Mason, a college student who knows a lot about contraception and is learning a lot about what her fellow students know and don't know. She is the founder and President of the Campus Contraceptive Initiative here at the University of Utah. Welcome, Grace.

Grace: Thanks for having me.

Dr. Jones: So, Grace, by the time young people get to college with all that's out there on the internet, they're pretty well-informed about contraception. Right?

Grace: Well, you would hope so, but unfortunately since less than half of the United States mandates contraceptive education and sexual education broadly, a lot of students come into college without having any sex ed. And a lot of students don't experience medically accurate sex ed in that regard. So if they come out, they may come out of high school with misinformation.

And so when we hope that students will turn to the internet to get better information, there's also a lot of misinformation on the internet that they're quite easy to find as many different people will tell teenagers what they should believe about sex ed rather than what their bodies do and how their bodies function.

So I think that students frequently come in believing things or not knowing anything and hoping that anyone will tell them the truth about how their bodies work.

Dr. Jones: Well, there's a lot of sex in the media, and there are books and there are songs, but none of them actually represent sexual initiation or contraception at all. No one says, "Oh, yeah, what are you using for contraception?" They never had that on the TV. So I read that one of the main reasons that men and women don't finish community college in the way they planned was an unplanned pregnancy. How can we change that?

I mean, if people are coming to college, they planned their college. But now they have to stop or have an interrupted course because of a baby that they didn't plan. What are we going to do about that?

Grace: I think that it is a broad issue, and it's something that Healthy People 2020, it's a huge part of their initiative is reducing the unintended pregnancy rate and increasing the intended pregnancy rate, because at the moment, 45% of pregnancies are unintended. And for students in college, who are 18 to 25, they are the most likely to experience an unintended pregnancy and they're also the most likely to be uninsured.

So there's a variety of issues there when it comes to a lack of knowledge and education coming into college. There's a coverage gap. There is the expense of care, which tends to be about $600 or more out of pocket for uninsured students.

Dr. Jones: For contraception?

Grace: For contraception.

Dr. Jones: If they want a long-acting method. It's cheaper if you're using condoms, of course.

Grace: Of course, but condoms are less reliable, and a lot of students don't like condoms in the sense of like their pleasure. And as they are less reliable, students are hoping to find a method that works with them.

Dr. Jones: So tell me about the Campus Contraceptive Initiative.

Grace: So the Campus Contraceptive Initiative is a interdisciplinary group of students, researchers and providers who are all targeting that issue of college completion, graduation and promoting family planning.

And so we are working through research and education to expand access to services, because we find that a lot of students don't know about the different options that they have when it comes to contraception. And so when it comes to finding the best method, they first need to have the education and that step of these are all the methods available to you. And then what does it look like in pricing? What does that look like for coverage? Where can you actually get those services?

Dr. Jones: So you've been doing a survey. You did a little survey last year, and you've been working on one this year. Any clues from your science so far in terms of what are people thinking out there?

Grace: Yes. We have definitely found out a lot of interesting things. That first survey, that went out last February, we got about 330 students to respond, and they were asked questions about their current sexual health, their knowledge as well as their desire or interest in a low-cost contraceptive clinic on campus.

We found out that 1% of students are currently going to the Student Health Center on campus, and that really blew us away because we found out that a lot of students are going to their doctor, but we know that a lot of students aren't comfortable with telling their parents about the services that they get.

And so that we have this huge uninsured gap of students where if they were able to access care at the Student Health Center, maybe they're being turned away because of the out-of-pocket prices, maybe they're being turned away of not knowing their options.

Dr. Jones: The Student Health Center, it may be student health, but it still has to be paid for. So students, unless they have that particular kind of student health insurance, still have to come up with money, and maybe their parents, if they use their parents' insurance, then their parents are going to get the bills or get the copays or get the information at home, so privacy becomes an issue.

Grace: It definitely does. And we saw that students, when asked about if they could have low-cost, affordable methods, 95% of students said, "Yes, I am interested in that." And many of those students said that they would actually partake in a service like that.

But broadly students want to know about the methods. We found that it wasn't just the birth control pill that was popular. If we were to have this contraceptive clinic, it was options. Across the board students want options for their birth control.

Dr. Jones: So where can college students get information about contraception? What methods are out there? How they work and where and how to get them? What's good information? What could they do right now?

Grace: Well, I would say that there are two wonderful resources out there. Bedsider.org is one. They have an incredible comprehensive list of different options, how they work, the different varieties. For example, since the IUD, there are several different types of IUDs, being able to click on each one and seeing how they're different and what they might do.

And they are wonderful because they also can connect you with emergency contraception to your door or sending your monthly birth control to your door rather than going in clinic. And so they have a great set of resources. Also Planned Parenthood Learn, which is an offshoot of the broader Planned Parenthood website, also has a really user-friendly interface that can compare methods and look at methods and connect you to one of their clinics.

Dr. Jones: Okay. So both of these options have a place where you could put in your ZIP code and you can find out clinics where you could get healthcare?

Grace: Yes.

Dr. Jones: Well, that's good to know, and people need to know more. And having a reproductive life plan, a family planning plan is important if you want to have the family that you want when you want it, or if you don't want it, get the knowledge that you need and get it right. You worked hard to get into a university and you're working hard to finish, and this part of your life takes a little effort, but it's worth it. And thanks for joining us on The Scope. And thanks, Grace.

Grace: Thank you.

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Are you happy with your family size? Have you had all the kids that you planned or a few more? Are you considering having your tubes tied? Let's talk about that.

Prior to the development of effective hormonal contraception, women choosing to end their childbearing through sterilization procedures had major operations to remove their fallopian tubes or had hysterectomies. Although the history of female sterilization is clouded with cases where women may not have given informed consent, since 1960, about the same time that birth control pills came on the market, techniques for female sterilization became less invasive and easier to do with less risk. The term used for these easier techniques is tubal ligation.

Now, there are many techniques and the timing for this procedure, and about 30% of American women have had a tubal ligation. Techniques include taking a suture and tying it around a loop of tube and then cutting the tied-off loop of the tube out. And then there are a number of techniques like this to remove the middle segment of the fallopian tube so sperm cannot get to eggs and fertilize them. Other techniques include putting a clip to close the tube permanently, or cauterize or burning the tube in the middle to close it.

The timing could be shortly after a baby is born, within a day or so, while the woman is still in the hospital, or at the time of Caesarian section when the tube is right there, or anytime between children, when the procedure can be done by laparoscopy. But half of tubal sterilizations occur right after the baby is delivered vaginally or by Caesarian, and that comes to about 350,000 tubal sterilizations a year.

The word "ligation" in the term "tubal ligation" means to tie. This unfortunate term translates into tying your tubes. This has led some women to assume if you had your tubes tied, it would be simple to untie your tubes, like untying your shoelaces. Tubal ligation can be reversed surgically for women who regret having had a tubal sterilization, but it's expensive and it doesn't always work.

For years, it has been noted that tubal sterilization decreased the risk of some types of ovarian cancer by 30% to 50%. Now, that's significant. Now, we're getting to the main topic of this little podcast. The lifetime risk of ovarian cancer in the U.S. is about 1.3 out of 100 women. Ovarian cancer is particularly deadly because it spreads early, and we don't have any early detection methods the way we do with breast cancer, like a mammogram, or cervical cancer with a Pap smear. Ovarian cancer comes in different types, but one of the most common types, serous ovarian cancer, may often actually arise in the end of the fallopian tube near the ovary. For this reason, women who have genetically-linked risks of ovarian cancer, such as the BRCA1 and 2 mutations with familial breast and ovarian cancer, are recommended to have their ovaries and their fallopian tubes removed when they finished having their families.

Recent studies have suggested that women who are planning a tubal sterilization who have their tubes completely removed have about a 60% reduction in the risk of these serous ovarian cancers compared to women who didn't have a tubal sterilization or women who just had part of their tubes removed at tubal ligation.

Now, there are other advantages to having the entire tube removed if a woman is planning a tubal sterilization. Tubal ligations have a known failure rate, a pregnancy after the procedure of as much as 3 to 5 pregnancies per 100 women over 10 years who had their tubal sterilization at the time other than when the baby was delivered, with laparoscopy. Women who had their tubes completely removed have a much lower failure rate, almost zero. Women who have a tubal ligation also have an increased risk of ectopic pregnancy or tubal pregnancy if they do become pregnant compared to women who've had their tubes removed completely.

Now, we know that putting a little clip on the tube, burning the tube, or cutting a loop of tube is quite simple and takes a very short time. Anybody could do it. Removing the whole tube takes a little longer. Studies recently published looked at women who were randomized to removing the whole tube at the time of tubal sterilization or cutting a loop out at the time of Caesarian section an easy time to do it as the tube is right there to look at and operate on.

One study used an advanced technique to take out the tube completely and found that time was only about five minutes longer compared to the standard procedure of taking out just a part of the tube. Another study using older techniques suggested took about 10 to 15 minutes longer. There was not significantly more blood loss with taking the whole tube out compared to just part of the tube.

The other issue is that if the entire tube is removed, you cannot come back and have your tubes untied or put back together again the way you might if only a part of the tube is removed. Of course, these days, many women who choose to have more children after tubal sterilization will use in vitro fertilization and it doesn't matter if you have part of a tube or no tube. Although IVF is expensive, so is surgically putting the tube back together again. And in some cases, IVF may be more successful.

So if you're planning a tubal sterilization, your tubes, not your husband's tubes, that would be a vasectomy, consider the following. If you have a BRCA1 or 2 mutation or have a strong family history of ovarian cancer, you should have your entire tubes removed when you have your tubal sterilization, whether it's right after the baby is delivered or sometime later. And often, women also had their ovaries removed.

If you have concerns about ovarian cancer, and you're planning a tubal sterilization, talk with your OB-GYN about taking the whole tube out. If you don't have a family history of ovarian cancer and the concern of the risk of ovarian cancer isn't high on your worry list, think about the benefits and risks that were just mentioned and discuss your options with your OB-GYN. Many OB-GYNs are discussing tubal removal as an alternative to tubal ligation when women are planning a tubal sterilization. Whatever you choose, we're glad you are informed about new options and old options in planning your family, and thanks for joining us on The Scope.

updated: September 10, 2020
originally published: August 9, 2018

Dr. Jones: There's a problem that is very common in women after menopause. It can cause significant discomfort, it's very easy to treat with a medication that's widely available and low-tech, and it's really, really expensive. What's going on? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is about vaginal health on The Scope.

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Dr. Jones: Estrogen, my favorite hormone, is the primary hormone that keeps the vaginal skin healthy and elastic. The tissues in the vagina and the lower part of the urethra, the tube that comes out of the bladder are very sensitive to low doses of estrogens made naturally in women of reproductive years. Having these tissues be healthy and elastic is important for comfort during sexual intercourse, is important for the normal microbiome of the vagina, and helps women from getting too many urinary tract infections.

After menopause, women who don't take hormonal therapy with estrogen, and that's the majority of women actually, often find they have a sense of dryness or burning in the vaginal area. They may have painful intercourse. They may have more urinary tract infections. And the good news is the treatment is easy. Estrogen applied in very small doses to the vagina with the cream, a little pill, a suppository, or even a ring placed in the vagina that slowly releases small amounts of estrogens locally.

A big study that followed 50,000 women over 10 years, looked at these women who used local natural estrogen after menopause and compared their health outcomes to women who didn't use any estrogens. There was no increase in the risk of breast cancer, heart disease, or blood clots, diseases that can be slightly associated with postmenopausal estrogens taken in larger doses for hot flashes.

So what's the problem? It's a common problem, and it's a low-tech, easy fix. Now, if I wanted to take estradiol, my natural hormone, by pill for hot flashes, I could go to Walmart and get a 90-day supply for $10. If I wanted to use the same hormone vaginally, prepared to be absorbed by the vagina and this isn't rocket science, drug technology, it will cost $520 depending on how the estradiol is delivered. Now, $520 is the upper end, $300 is the lower end.

So what is the reason that the pharmaceutical industry puts such high prices on vaginal estradiol? It's because they can. Even women who might have a drug plan with their insurance might have to pay a lot for these drugs, much more than they would for oral contraceptives or birth control pills or oral estrogen. Drugs to treat sexual health for women like the estradiol products are frequently placed on a higher formulary tier, meaning you're going to have to pay a large percent of the list price. Although it may be covered by the insurance company, the amount that they might pay would be little.

The problem caused by vaginal atrophy, thinning of the vagina and the urethra are not only sexual. Women can have discomfort with some sports like bike riding, and they might have more urinary tract infections. Not only are the prices high, but they're going up, even doubling over the past five years, and the technology is not new.

The company that made the little vagina estrogen pill dropped the dose in half because the lower dose did a good job, but the price wasn't lower and it still keeps going up.

A new product just approved by the FDA with the rather odd, but sort of cute name called Imvexxy, it'll be available in July of 2018 and provides estradiol at a very low dose, the lowest of any product and could have made a big hit on the market if they'd priced it at a level that most postmenopausal women could afford. This drug is being priced about the same high cost as the other products. There is another product the FDA approved for vaginal atrophy, which isn't an estrogen, but is another naturally occurring hormone, DHEA comes in a vaginal suppository, and it's really expensive too.

So some women are turning to Europe or Canada to get these medications at a more reasonable price, even though it won't be covered by insurance, and it may not be strictly legal to import it. Also, many pharmacies that compound hormones with creams are selling the products at lower cost, but they aren't under the same control with respect to quality and consistency that the FDA approves manufacturers are.

So what is a woman to do? First of all, if you're a postmenopausal woman and having trouble with painful intercourse or symptoms of dryness or burning in the vaginal area or frequent urinary tract infections, you should talk to your clinician. They can easily check and make sure the problem is vaginal atrophy associated with low estrogen and not something else that might be treated in another way.

Speak up. If enough women complain to their insurance companies, maybe the word will get back to manufacturers. If your local compounding pharmacy can make vaginal estrogen at the correct low dose, that's an option. And this is the only situation where I actually recommend this particular option. There are some companies that are making these products generic, which will bring the price down a little bit, but not as low as the technology would suggest. They can keep the price up because they can.

Talk to your clinician about other options that might be available for your symptoms if you cannot afford vaginal estrogens or choose not to take them. Don't suffer, there are choices. Speak up, be heard. And thanks for joining us on The Scope.

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