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So your daughter just had her first period. What's normal, what's not, and what to expect now.

A girl's first period marks her entry into womanhood. It's called menarche. And many parents, especially moms, seem to have a lot of anxiety and questions about it. Many moms readily admit to me that they have forgotten what periods were like when they started. So if something doesn't seem right, they get incredibly nervous that something is wrong with their daughter. Some worry that their daughter has started too early or too late. Actually, any time between ages 9 and 15 is normal.

Some worry that their daughter doesn't have a period every month like clockwork and that they need their hormone levels checked or some sort of treatment to make their periods regular. Well, it is hormones to blame for this. However, it's because hormones are still settling themselves out. It can take two to three years before periods become regular. If there is a family history of irregular periods, they might never be regular. And that's okay too. Parents really worry if their daughter's periods are not regular. But unless their daughter is sexually active or they go months between periods after having them for about a year, there really isn't anything to worry about. Irregular periods by definition happen either less than three weeks apart or more than five weeks between periods. Otherwise, they're normal.

Moms also get concerned about cramps. Sorry, but cramps are part of periods. Your daughter should not miss school or stop being physically active because of cramps. Being physically active has been shown to decrease cramps. I have parents wanting me to write letters so that every month their daughter can miss school during her period. Periods normally last 3 to 10 days. So that's a lot of school missed. I try not to do these letters and instead discuss ways to help their cramps. Over-the-counter naproxen really helps and so does a heating pad.

Some girls will even have nausea or vomiting with their periods due to hormone fluctuations. Treating them supportively with anti-nausea medicines can help.

Moms also get concerned about their daughter's becoming anemic. This does not happen usually. Girls normally lose between 30 to 40 milliliters per period. This is six to eight teaspoons of blood. So while it looks like a lot of blood during a period, it's not as much as it seems. If your daughter has something called menorrhagia, that is excessive blood loss and that is 80 milliliters or more of blood loss per period. And these girls normally pass blood clots that are larger than a quarter. These girls will usually soak through a pad or tampon every hour for several hours during the heaviest portions of their periods. They may also need double maxi pads for protection. If this is the case, then you should talk to your daughter's pediatrician about ways to help.

I often get asked by moms if their daughters could have endometriosis or fibroids or other gynecological issues. As a pediatrician, I can do basic period management and gynecology. I can do oral or injectable birth control to help with periods. But often the best thing for me to do is to refer my patient to a gynecologist if it's more than I can address. They are much better at diagnosing and managing female concerns.

Finally, moms also ask me if their daughters need Pap smears now that they have started their periods. No. That used to be the case, and it's pretty traumatic for a young girl. The current guidelines are if a girl is 21 or has been sexually active for three years, then they get a Pap smear, and that would be done by a gynecologist, not a pediatrician.

Bottom line, most period concerns are actually part of normal development. Your pediatrician can let you know when something is not normal and refer you to a gynecologist who sees teenagers for additional help when needed.

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.

Shades of Grey. Gotcha. When you clicked, maybe you thought I would be talking about what goes on in a very popular book series. Nope, not even. I am going to talk about whether your kid really can turn your hair gray.

We've heard our mothers say that someone stressed them out so much it turned their hair gray, or that an acute stress turned their hair white overnight. There are some references to it in the "Talmud," the Jewish holy book, and supposedly Marie Antoinette, the last Queen of France, had her hair turned white overnight between the time that she was sentenced to the guillotine to the next morning when she met with the guillotine. Of course, that's very unlikely, and maybe being a queen during the French Revolution was so stressful that her hair turned white over several months and she covered it with a wig. And when she took it off at her final performance, her hair was white.

First, a little discussion on the anatomy of the hair follicle. The hair is produced under the skin in a hair follicle that's lined with pigment-making cells called melanocytes. Melano means dark or dark-colored and cytes means cells. Melanocytes are in our skin and make pigment either naturally, given our genetics, or when we tan. For those of us who are freckled, we have patches of melanocytes that make more pigment.

In the hair follicle, the melanocytes arise from stem cells that replenish the number of melanocytes. As these stem cells divide, some become melanocytes and some stay as stem cells. This is a strategy for cells that are renewed all over our body. As we age, we run out of stem cells, so we don't make so many new specialized cells like melanocytes. That means no more color to the hair as we age. At least that's the theory. Genes and diseases, like autoimmune diseases, can determine when and if you go gray.

So back to the stress theory. Some clever researchers at the Harvard Stem Cell Institute just reported some interesting studies in mice in the journal "Nature." So, first, they thought maybe going gray was the loss of the melanocytes from an immune problem. It's known that some people with immune problems go gray. So they injected mice with capsaicin, the stuff in chili peppers, which is known to cause an immune stress response in mice. They did this in mice without immune cells, and the mice went gray. So it wasn't the immune system in this case.

The second was to stress out the mice in another way. They were exposed to short-term pain or stressful living conditions in their cages, and they went gray. But was this due to cortisol, which our adrenal gland and mice's adrenal glands make when they get stressed out? Or was it something else? So they took out the adrenal gland of the mice, and they still went gray. By the way, the human race owes the mouse race a serious debt of gratitude for all that they go through for medical research.

So maybe it was the sympathetic nervous system. Each hair follicle has nerves around it. Your hair stands up when you're scared. And when the mice were stressed acutely, their nerves were flooded with norepinephrine. When that happened, all the melanocyte stem cells got programmed to make melanocytes. So there were no more stem cells left to make melanocytes in the future. Now, this didn't happen overnight, but a relatively short period of time. And then the mice didn't have any more stem cells. They didn't have any more melanocytes, and they went gray. So this is a plausible reason for the old wives' tale that acute or chronic stress can turn you gray.

So what do you do about this? Well, having gray hair is a sign of wisdom. You let the gray hairs figure it out. Maybe people who've been through a lot of stress and survived it have a visible cultural signal of their resilience -- their gray hair. Of course, we could suggest that you avoid all stress, but that's pretty hard to do and impossible if you have any kids or any kind of extended network of people you love.

So you can love your gray. For American women over 50, we don't do that so much. It's been suggested that at some time 90% of women over 50 dye their hair. When you finally decide to go gray, you can dye your hair white, but that would be a shock. You could color your hair but put gray highlights and then let it grow out. You could color your hair gray with colored highlights and let it grow out. Best of all, you shouldn't even listen to me because I'm clueless. Talk to your colorist about what's the best way to go gray gracefully, but don't stress out about it.

You've been so good about your family planning. You've always used birth control, but when can you stop? This is Dr. Kirtly Jones from Obstetrics and Gynecology here at University of Utah Health Care and this is The Scope.

So you've spent all your life planning your children. You had your babies when you wanted them. You didn't have any extra babies. You've really been good at it, but when can you stop? The answer is when you or your partner are using some form of really good birth control so you can stop. If your partner has a vasectomy, well, that's great.

Now, a really good form of birth control was menopause. So let's talk a little bit about your contraceptive method and menopause. First, fertility, we know, declines starting at about 30. We know that women who are trying to get pregnant sometimes struggle in their late 30s and certainly do in their 40s. The difficulty is that a pregnancy in your 40s that's unplanned is a definite problem because women in their 40s who get pregnant, even though they're not very fertile, do have higher risks of complications in pregnancy, like high blood pressure and diabetes.

They're actually more likely, believe it or not, to have twins. And they have more complications in terms of blood loss and a whole lot of other problems just with the pregnancy. And of course, we all worry about the difficulties in chromosomal abnormalities in our babies that increases in women after their 30s. So women are more likely to have complications in pregnancy. They are more likely to have a baby with a chromosomal anomaly like Down syndrome and importantly, they are more likely to miscarry. And by the end of your 40s, you are really likely to miscarry.

However, you don't want to get pregnant even though your chances are low. So when, even if you're being very careful, when is it time to stop? Okay. So let's now talk about menopause. Menopause is defined as when you haven't had a period for a year. Then that last period a year ago is your menopause. Now, you have to be of the right age.

So the average 20-year-old who hasn't had a period for a year is probably not in menopause. She hasn't run out of eggs. She may have another reason for not having her periods. But women in their late 40s and early 50s who haven't had a period for a year are very, very likely to be in menopause. So if you haven't had a period for a year, then you're likely in menopause and you can stop using your contraceptive method.

However, it's difficult to know if you're in menopause based on your periods if you're using a contraceptive method that changes your periods. So let's take, for example, birth control pills. Birth control pills block ovulation but give you hormones that make you have a period every month. So you can be in menopause, have no more eggs, be completely infertile, but because you're taking the pill, you'll have a period every month.

So how do you know, if you're on birth control pills, that you're in menopause? Well, the difficult answer is you have to stop your pills and see what happens. If you stop your pills, and you're about 52, and you don't have a period for six months, then you're in menopause. But what happens if you are 52, and you're still fertile, and you stop your pills, and you get pregnant? Well, the option is, of course, to stop your pills, see what happens, and use a different method, a barrier method, use condoms, use foam. Remember, you're not very likely to get pregnant because you're not very fertile and you're not very likely to stay pregnant because you're likely to miscarry. So that's one option.

The other option is to say, "Well, why don't I just stay on my pills because going through the perimenopause," those years when your periods are totally unpredictable and not very pleasant, "why don't I stay on these nice little periods that I like on the pill until I'm about 54?" We know that at 54, about 90% of women have gotten through menopause. At 50, the average age of menopause, only 50% of women are menopausal. But by 54, about 85 to 95% of women are menopausal. So you just stay on your pills and stop at 50 and you're very likely to be done.

Let's talk about an IUD that has hormones in it. For women who have an IUD with hormones in it, many of those women have very light periods or no periods at all so you may not know that you're in menopause. You may have some hot flushes because your estrogens have gone away. You may use a blood test, which doesn't work very well for women on the pill, but it can work for people with a hormone-containing IUD. You could do a blood test called FSH and if that is really high, then it's likely, not guaranteed, but likely, that you've run out of eggs and you're in menopause.

Or you can just stay on that IUD that has some hormones in it until you're about 54. And many women in their early 50s who have hot flushes may want to take a little estrogen and they have the progestin protection. They protect their uterus lining against abnormalities with that little hormonal IUD. So wait until you're a little older and then take your hormonal IUD out.

If you're taking a shot like Depo-Provera, about 80% of women on Depo-Provera don't have periods so you won't know when you're in menopause. Well, the same kind of strategy goes with Depo-Provera as it does with the hormone-containing IUD. You can just wait till you're a little older or you can stop, use a backup method. You can stop your shots, use a backup method, and wait and see if you start your periods again.

So this is kind of a complicated question. The good news is that for women who stop their method, whatever it might be, at 50, then, in fact, the chances of getting pregnant are very low. How low is low for you, though? If the chances of getting pregnant and having a baby is 50 to 1 in 100, is that a number that you're willing to take a risk for? Not me. For me, that's no, I wouldn't take a 1 in 100 risk of a baby, that with all the complications of a pregnancy at 50 is. So I was much more willing to push my contraception out to 54 and then say, "Now I'm ready to be done."

So it's a personal choice. It's one that you discuss with your partner, with your family, if that's what you want to do, in terms of what their thinking about future childbearing, what kinds of risks are they willing to take if you do get pregnant? But definitely talk with your clinician because there are some options that are really good ones to make this transition with low fertility, but still some fertility, and some good therapy for menopausal symptoms.

So many women actually use a low-dose birth control pill to help them with their menopause symptoms. So that's the difficult answer for a difficult question, but I want to say good for you for having been such a good contraceptor all these years. And thanks for joining us on The Scope.

updated: January 28, 2021
originally published: September 29, 2016

Dr. Jones: What do Utah women who've had lots of babies have in common with female paratroopers? This is Dr. Kirtly Jones from Obstetrics and Gynecology from University of Utah Health Care. And if you want to know the answer, stay tuned to The Scope.

Dr. Jones: So what do women who have lots of babies through the vagina, through vaginal birth, or maybe only one baby, have in common with female paratroopers who haven't had any children? Both groups are at increased risk for pelvic prolapse. This means their inside female parts are falling out. Having a vaginal birth and repeated trauma to the pelvic floor, as a female paratrooper can have, can cause the support to the uterus and the cervix to stretch and then drop a little lower in the vagina.

Commonly the cervix may be as low as at the entrance to the vagina and occasionally the cervix and uterus may actually be positioned outside the vagina. This is called pelvic organ prolapse. Not only can the uterus come down, but the bladder can come down leading to urinary leaking or difficulty urinating. Both situations can be uncomfortable. Today in The Scope radio studio, we're talking with Jan Baker, a nurse practitioner in the Pelvic Floor Clinic at the University of Utah. She specializes in the evaluation of pelvic organ prolapse and in the non-surgical management of this common problem. Jan, welcome to The Scope.

Jan: Thank you, Kirtly.

Dr. Jones: So how common is this? Not very many female paratroopers, but a lot of people have had babies.

Jan: Well, it's likely more common than our statistics tell us because this is, again, one of those unspeakable problems that women don't want to talk about. But it is thought that about one and a half to 1.8, almost 2 women per 1000 women have prolapse, some form of prolapse. But when we do studies of women with no symptoms of prolapse and they're examined, up to 50% of those women can have prolapse. Although it may not be where they're noticing it, but they have started to develop prolapse. So prolapse symptoms usually peak right around age 60, but about half of the women that seek care for prolapse symptoms are usually between the ages of 30 and 60. So it is quite common.

Dr. Jones: So what conditions can cause this? We mentioned having births and we mentioned being a paratrooper.

Jan: The biggest risk factor is childbirth, then just getting older.

Dr. Jones: Oh, great.

Jan: Because, unfortunately, the longer you're alive, the more and more gravity has its effect.

Dr. Jones: Gravity wins. Gravity always wins.

Jan: Gravity always wins, but obesity, menopause, family history, race . . . Latinas and white women are more likely to get prolapse, and a previous hysterectomy also seem to play a role in the development of prolapse.

Dr. Jones: So what are the symptoms a woman might have that would suggest that they might have this problem?

Jan: Well, the most common early symptom is kind of this mild pelvic pressure or maybe a mild kind of a backache at the end of the day. Maybe some mild urinary frequency, maybe feeling like they need to go to the bathroom a little bit more frequently.

Dr. Jones: And later on?

Jan: And then, later on, they may start to notice a bulge coming from their vagina, or they may start struggling with a bowel movement and that is usually what brings women to seek care.

Dr. Jones: Yeah. So what can be done about it?

Jan: Well, if the prolapse is not very bothersome, watchful waiting is a very good option. Education, though, at this time, can really be important. Because, although we don't know for sure, many experts in the field believe that weight loss, managing constipation, managing a chronic cough, reducing high-impact aerobic exercises such as jumping or running or jumping out of an airplane, or a trampoline, jumping on a trampoline. Using vaginal estrogen, smoking cessation and doing a pelvic floor muscle exercise might slow down the progression.

So actually talking to women about these things, maybe that might make a difference. You know, these interventions make sense because you're not continually putting pressure on the pelvic floor, but we don't have any good research to support their use. But they do make sense and they don't have any side effects.

Dr. Jones: Well, that's good. Actually, just knowing that what you have is there and it's common and it's not cancer, it's not a tumor. This is just life on the planet Earth and we can't move to a smaller planet with less gravity. So if a woman doesn't want surgery or isn't a good candidate for surgery because of her age or medical conditions, what are some of the non-surgical options?

Jan: So if the vaginal bulge has started to bother them, a vaginal pessary is a good option for her. And it's really good for those women who don't want to have surgery, who maybe cannot have surgery because they have medical problems that make it not a safe option.

Dr. Jones: Or they're going on a walking trip to Europe right now, no time for surgery. What can we do until I get back?

Jan: And maybe they can postpone, they want to postpone surgeries, but they want to be comfortable, exactly.

Dr. Jones: So can you help me with what's a pessary?

Jan: Well, a pessary is a device that fits inside the vagina and it's made from rubber, plastic or a silicone-based material. Lots of sizes and shapes. And what I do in the clinic is I fit a woman. We basically put a pessary in and see how it fits. The only reason a woman would know that she has the pessary in place is that she doesn't have the vaginal bulge anymore. She should not even know that pessary is in place. And what's interesting is pessaries have been used before Christ. And what they used were pomegranates, and more recently, potatoes have been used. Although, we don't recommend those use now because we have pessaries that have been developed by scientists.

Dr. Jones: A little cheaper, though, but having said that I would rather have something that was made out of silicone than something that might sprout. Well, okay, so how well do they work?

Jan: Sixty-three to 83% of women can be fit with a pessary and of those women that can be fit, 76 to 80% of those are satisfied with their pessary.

Dr. Jones: And how long can you use them?

Jan: Well, you can use a pessary as long as you want to.

updated: October 22, 2020
originally published: September 17, 2015