Expert Q&A:
Ask a Gynecologist
With Dr. Erin Grey, DO, FACOOG
Crissy Fishbane:
We are thrilled to be here today with Dr. Erin Grey. She is a board certified OBGYN who has been practicing medicine since 2011.She practices the full scope of obstetrics and gynecology, but has a special interest in teen and young adult gynecology as well as minimally invasive surgery. She is a North Carolina native, UNC grad, mother of two boys and in her free time, she teaches “girl-ology” and “guy-ology” which are puberty related classes for parents and children and something that we might have to have you come back in the future. I’m a former high school teacher, so to me, that is fascinating! I’ll go ahead and turn this over to you. We are super-excited to have you with us.
Dr. Grey:
Thank you, thank you. I’m excited to be here. It’s going to be a fun night. I have a couple of topics we can talk about and we can just get going. We are going to do a little bit of a game to break the ice and get some questions going and see what you want to know about.
(Slide 1: Your Friendly Neighborhood Gynecologist – Dr. Erin Grey, DO, FACOOG)
OK, so I’m your friendly neighborhood gynecologist, well not quite in your neighborhood, because I live in Salsbury, but close enough.
I put this together, as an ice breaker. We just need to get to know each other a little bit before we talk about some awkward things, which I’m totally fine with because I do this all day. Don’t worry, you can’t surprise me with any kind of question. Amy Schumer and Tampax did a campaign. Tampax did a study in 2020 and they came out with some data about what people know about periods. I was very surprised by these statistics.
So they said, virtually no-one, so 94% of adults, don’t know how many days the average period should last. 77% of adults think that a tampon can get lost in your body and it will never be found again. More than half of women, so 62%, can’t find a vagina on a diagram. And 13% don’t know anything about a tampon. And I’m hoping that that wasn’t just women, and then again, do men know that much? I don’t know the answer to that. And one in ten think that a tampon can take a woman’s virginity.
So if those facts are true, we’ve got a lot of talking to do with the general public, or we are not asking the right questions. If you have a question about any of that, I will answer it today for sure.
[Slide 2: Long Term, but Reversible]
These are some topics that are my most asked questions when I’m in the office. Some of them are in my heart where I just want to share some info.
This is going to be where you get to choose what kind of topics you are interested in and I have some info to give you about it. Don’t worry, you won’t have to answer the question about yourself or anybody you know. It’s just going to be pretty much me talking and hopefully hitting what you want to find out about. Okay?
You’re already starting to chuckle because you’ve read my captions. Who’s got little babies, less than a year old? Anybody? OK.
Anybody have toddlers, one to four years old? I have two, a two year old and a four year old, about to be five and three.
What about older than that, about five years old and up? A few of those? Alright. Is anybody expecting and you’re not sharing this just yet? Okay. So here we go!
(Topic #1) “So Who’s that Post-baby Lady?”
It’s not like, you just had a baby two weeks ago, this is like within that year or even three to five years after, what does that mean for our bodies? Remember, our bodies are amazing. They can create a whole human, with a little bit of help, otherwise is it all on us. And then the human comes out of our bodies and we sustain it with our breast milk, if that is what we decide to do, so, our bodies are pretty amazing. But that takes a toll. So there are a couple of topics we can talk about with that.
(Topic #2) “Crazy Aunt Flow”
You know those period questions. We’ll go over what’s normal, what’s not normal, what do we do about it.
(Topic #3) “Not Maybe Baby”
That’s contraception. So we are not really rolling the dice on that one.
(Topic #4) The next topic is “Ew, gross Mom”
That’s puberty or sex or something like that, okay? What do we tell them, how do we bring it up, a few tips and tricks.
(Topic #5) And the last one, the “Goo of You”
I still can talk about this without chuckling. I have to throw that out. Meghan came up with this so she gets all the credit for that topic heading. All I can see is you guys silently laughing, and it’s kind of hilarious.
Okay, does anybody want to make the first choice?
Cindi:
I do actually have a question. It’s not really a question, it’s kind of a statement, and I’m hoping this is going to make other moms feel much more comfortable. I didn’t know you weren’t supposed to wash inside the flap of the vagina.
Dr. Grey:
Well, you can. Oh, this is the perfect time. In my puberty class I have my puppet, we call her Gina (Dr. Grey shoes the puppet). You can use a washcloth and wipe clean here in the middle, but you do not want to use soap. You don’t want to get soap in there because it can mess with the balance. If you have been doing it, and your body does fine with it, then no big deal, you are not hurting anything. But if a person comes to me and says I’m having these problems, it’s irritated, then that’s something their bodies don’t need, something they should probably not do.
This is your vulva. Your vulva is like a face. On your face, you have a nose, a mouth and eyes. And the whole thing is called your face. (Showing the puppet) The whole thing is called the vulva. The top part is called the mons, where the hair grows and then you have your labia majora and your labia minora. So what we call the flap, that’s called the labia minora and then inside, you have your urethra, you have your clitoris up here where the small labia minora come together at the top, the urethra, and then the vagina. The anus is down here.
Crissy: I think every gynecologist should have one of those puppets!
Dr. Grey: Yeah, she helps me out. All the kids laugh, everyone in the whole room laughs when I bring her out.
Ok, what’s next for you all?
Crissy: I’m going to say, so let’s go “Crazy Aunt Flow.”
Dr. Grey: We are going to work through Aunt Flow and see what we come up with. (new slide: Aunt Flow, are you normal?)
Your period can be anywhere from 21 to 35 days apart. That’s from the first day of your period to the first day of the next period. Most people have a range from 28 to 30 days, 24 to 26 days, it’s usually not 21 days and then 35 days. Anywhere in between there is still considered normal. It usually lasts between four to seven days.
A range of colors is okay. People like to tell me,”I’m black on the last day,” “it was bright red for two days,” “it was like a maroon color.” That doesn’t really change anything. It’s just blood. It’s just different times of how long it’s been in there to come out. Mild cramping is okay. Obviously it’s a little bit annoying, but does not affect your lifestyle, so you are not missing work. Teenage girls are not missing school because of problems with their period.
Some other things are: you shouldn’t have to double up. Some people will be like, “I have to wear two pads or overnight pads at the same time.” Some people say “I have to wear a super-tampon and two pads” That’s probably too much. Now, some people will wear a tampon with a panty-liner just in case, and that’s okay. It’s when you are soaking all of that, that it’s not normal.
(Slide: Definitely Not Normal)
So, definitely not normal if you have:
- Less than 21 days between your periods, or happening less than every three weeks apart.
- Longer than 35 days, so they are not happening as often.
- The pad or tampon, if you are saturating it less than an hour or two, that’s way too much bleeding. That shouldn’t be happening.
- If you are missing school or work, that shouldn’t be happening.
- PMS versus PMDD, I put that in there because it’s something people don’t know a lot about.
PMS is like we put all of the symptoms of your period together. You feel crampy, you feel tired, you feel like you know it’s coming, you feel bloated. You may feel grumpy, you may feel sensitive, and then your period comes and it goes away. You take some ibuprofen and feel better.
PMDD is something called premenstrual dysphoric disorder and it’s actually one of our mental health diagnoses that goes along with almost a cyclic depression or anxiety that women can get for a week before their period happens. This significantly affects their life-style, but they think it should be fine, they should just be able to deal with it because it’s only for a week or because everyone has bad periods, but this just like a step above. These women need to treat their period cycle so we can treat the symptoms of depression and anxiety that can happen just before their period. They’re not wanting to do social things, they’re missing school, or it’s affecting their relationships. It’s the next level, bigger deal.
It’s a pretty classic diagnosis. When someone describes how they are feeling, I know what they are talking about, but no one has been like, “Oh I’ve heard of that before.” So that’s why I put it in there, because it’s something we don’t really talk about because we kind of make fun of PMS a little bit. That’s ok, but some women have a more serious problem and it’s pretty easy to treat. We treat it with either birth control pills, which actually fixes even the emotional problems with this, or a low dose antidepressant can help with that too. It just depends on what they want to do.
(Slide-Options: More Than Just No Babies)
We have some options. I call this “More Than Just No Babies.” You have to remember that some people are like, “Oh, I don’t want hormones” or ” That’s birth control and I’m past that.” Some say, ”I’ve had my tubes tied.”
These are medications that we use. They are hormonal therapies that we use to change things about the menstrual cycle. That’s one of the reasons we bring them up. People will say, “They just want me to take birth control pills.” That’s true, but there are reasons behind it.
The first option is an IUD. It’s a progesterone IUD. Called Mirena. Liletta is another brand of it. It looks like this (Dr. Grey holds her hand up and shows the IUD). It’s not red or green, it is actually white. We place it inside the uterus and it releases just the progesterone hormone. It is our lowest dose of hormone in our birth control medicines. The reason I bring it up here is that it can decrease menstrual bleeding by 80%. For some women, that’s no period. For some women that’s light periods. For a lot of people that can help with the heavy bleeding problem. The birth control pack: Like I said, it can help with some of the other period things, like the combination of diarrhea, bloating, or nausea people get with their period or the emotional side of it. It stabilizes out those hormones so it kind of helps with those symptoms too. Also, pain and cramping with the period.
This is NuvaRing. I tried to get a sample of one of those to show you the size of it, but there were no samples to be had. So this is it (Dr. Grey refers to the slide) The ring is a birth control ring that you put in the vagina. You wear it for three weeks and then take it out for a week. You have your period and you put back in a new one.
Then the last picture (on the slide) is a minor surgery procedure. This is when you are done having babies, we go in and we burn the lining of the uterus to stop your periods when they’re causing big problems. It’s a same-day surgery option. Obviously in some women, they choose to go one step further with a hysterectomy for certain kinds of significant problems with their periods.
I have the Depo Shot noted there (on the slide) too. Some women like to use that too because it is less frequent and it can help with the period flow by decreasing it. Any comments or questions? What else, what do you want to hear about? How about Ashley.
Ashley:
I’ll go with the “Not Maybe Baby”
Dr. Grey:
Okay, we’ll just go through this one too. Unless you have a question about something specific, so let me know.
(Slide Options: Shorter Acting)
There’s a lot of words on this slide, and I am sorry for that. You can either read through it, or you can just hear me talk. We talked about it a little bit in the last one.
The pill is a thing that you take daily. It helps with those extra period symptoms which I think people kind of forget about. The problems with it are it is easy to forget and you have to go to the pharmacy. I don’t know about you, but I hate going to the pharmacy. I think there is a lot of mail order stuff now to make it a little easier and we can give you a three month supply at a time, but still I don’t like to go to the pharmacy. So, that’s why I bring it up. But I like the pill, honestly, if you can remember to take it and I think it can do a lot for you. And we nowadays have a lot of different dosages and types of progesterone to find something that really works well with your body. It’s called THE birth control pill, but there’s like a million to work with. If one is not working for you there is usually another one that can and we can adjust some of the dosages in it and find something different.
I was talking with Meghan (Dr. Grey’s sister and also on the presentation) yesterday and she said, “What’s new with the pill since I was a teenager.?” And I said, “Your ability to remember to take it.” And she thought that was funny. She still does. See, she’s laughing. Women in their thirties can still use this and we can use this for other indications as well, cramping, bleeding, pre-period symptoms, PMDD, lots of stuff.
Crissy:
Dr. Grey, can I ask a quick question about the pill? What is the general consensus if you’ve been taking the pill long-term? Like if you are someone who started the pill back in high school. Are there long term effects from that?
Dr. Grey:
No. Not anything bad as far as we’ve found out. If you’re in your reproductive years it’s fine to continue to take the pill. Your risk is the same with taking it versus not taking it.
The biggest risk with the pill is an increased risk of blood clotting. Some people are just predisposed to that. It can be a genetic defect. It can be a fluke. It’s not that high, but it is there. It’s usually related to the dose of estrogen in the pill. But, taking it long term doesn’t change that risk. It is there. It’s going to stay the same.
What I like to share with people is that there are actually benefits to taking it so if you take it a cumulative five years, there’s a decreased risk of ovarian cancer, colon cancer and endometrial cancer. I think it’s something we don’t really talk about much but it’s definitely there. I think it makes people feel more comfortable about doing what works for them. So if the pill works, just keep on with it.
I even have some women who will continue it until they are about 51 or so. Usually we had to start it for a specific reason but have gone up to that age group. There’s not a problem with the pill. Now as you change as we age, that’s when you need to re-evaluate if the pill is the right thing for you. So, smoking after age 35, you shouldn’t take the birth control pill. Having something like hypertension, which is difficult to control, in your upper thirties and forties, you probably don’t need the birth control pill. That’s where your doctor needs to see you every year and make sure your medical history is up to date so we know that’s still the right thing for you.
The Patch, it still exists. Not a lot of people choose to do it. You wear one patch a week for about three weeks and then you take it off and have a period. Some drawbacks are it is an adhesive and some people can get a reaction to the sticker part of it. You have to remember to put it on. It is supposed to stay on for showering, exercise, swimming and all that. People who choose to do it and like it say that it does (stay on), but I have a few people that say it comes off. It’s just not that popular, but it’s a good option. Mostly it’s good for early 20s who’ve done the pill and can’t remember to take it.
The Vaginal Ring we talked about is called NuvaRing. You use it monthly, one ring. The pill, the patch and the ring are all the same hormones: estrogen and progesterone. So you are getting all the same period symptom benefits from it. You are just getting the medicine in your body a different way.
The drawbacks are a little increase in vaginal discharge. It doesn’t usually make people stop taking it as long as they are warned a little bit to know that they aren’t having a problem. If you don’t get it up high enough where it needs to be, if it’s too low, you can feel it, kind of like a tampon.
Then there is that Depo shot. It is once every three months. Some like it because it’s longer acting, and sometimes after the first one, it can stop your period. The drawback is it can cause some irregular bleeding that can really be annoying too. And if you are between babies or you are thinking about trying for a pregnancy, it’s the one that will have a longer time return for fertility, so we don’t really use it if you are going to be planning that in the near future. Those are the shorter acting ones.
And then our longer acting, but reversible, are the IUDs that we talked about, the Mirena, Liletta, and Kyleena. The Mirena and the Liletta are the same, just different companies that make them. The Kyleena is made by the same company as Mirena. It is a little bit smaller of an IUD. Lasts still five years. They made it for people who haven’t had a baby before. We’ve been using Mirena for people who haven’t had a baby before for a long time, but this one they just made a little bit smaller to see if it fit a little bit better. It can last for five years. The average time people use it for is two years. In general, you can put it in for a year and then take it out. And decide to have another baby. You can leave it in for five years and then take it out. This is the one that has the decreased flow of up to 80% so for about half of women, they have no periods with it.
Some of the drawbacks are that you might have a little bit of irregular bleeding, then rarely, but the internet will tell you that it may become malpositioned and we have to remove it. You get it placed in the office. It is not a surgery. Paragard is our only non-hormonal long term contraception. It’s a copper IUD. I don’t have a sample one of these, but it is the same in size and shape as the Mirena and it can last for 10 years.
I’ve actually seen people keep it in for the whole ten years. Ten years is a long time. It has no hormones. It is the best for people who don’t want hormones. If they have a medical reason that they can’t use them, if they’ve tried everything in the past and it just hasn’t worked for them, this is our go-to for that. Some women say they have slightly heavier periods, but it doesn’t make them want to take it out or to stop using it. There’s the same risk for it becoming malpositioned, which means it comes low within the cervix and that could be a cause of cramping or can grow into the wall of the uterus. You have to remember that those are the rare cases.
Everything has its drawbacks, right. This is how I talk to my teens, “Everything has its drawbacks and now you’re a grown up and you have to make the decision as to what side effect might be okay for you and what risk you are willing to take.”
Nexplanon, has anyone heard of this? This is an implant that goes in your arm, It goes right up here (upper arm just below armpit). It just has progesterone hormone. It can stay in place for three years. People who want long term birth control, but are weirded out by having something in their uterus, this is what they usually go with. It’s a bar and looks like this (Dr. Grey shows a sample) but it’s really flexible (she demonstrates). The real one is white. You can feel it under your skin. The biggest drawback for someone is irregular bleeding, which I think is just super annoying. I get a lot of phone calls about it. It’s not a big deal because it doesn’t hurt you. It’s not heavy, not painful, it can be annoying because it is unexpected and it’s usually light bleeding. Some people have no periods with it. That’s really nice. We can’t tell until we try it. The people I find that like this are younger, teen and twenty year olds, who really need something super reliable and are moving, like going to college, stuff like that, where they can’t do the pharmacy thing or pill thing and stuff like that. But we can put it in anyone. Those are just the people who like to try it. All right. So let’s see, any questions about those?
Cindi: Yes, they prevent pregnancy by having the hormones, right? That’s mainly how they do the prevention except for the Paragard, that doesn’t have hormones. How does that actually work to prevent pregnancy?
Dr. Grey:
So the Paragard has some copper on it. And that changes your cervical mucus and makes the sperm not be able to…sperm cannot get through it. And it also changes the environment inside the uterus and tubal motility. So like the egg and the sperm, it’s preventing them from meeting because they can’t get through the mucus as well and the tubal motility is not as good. So that’s how it kind of keeps them separate.
Cindi:
So is it true that there’s been a little bit of controversy around pro-life individuals that certain IUDs actually allow an egg and sperm to join but it prevents it from implanting in the uterus?
Dr. Gray:
So that would be the Paragard. It is a way we can do some emergency contraception, sort of like plan-B. Except that plan-B changes the environment within the uterus, so it can do a bunch of things because it is just a high dose of progesterone. That would be where the controversy is around and it is probably one of the ways it could work. It does have some other ways to affect implantation.
Other contraceptives like the pill, patch and the ring, those prevent ovulation. So you are not seeing an egg and there is nothing to meet. The IUD and implant with progesterone do that as well (prevent ovulation). So if that’s a problem, then we need to know so we can choose the right thing that works for you. That’s when you go to your doctor and say, “I heard this…” and don’t feel bad or scared asking about it. And then you say, “that’s not quite what I want,” and you move on to the next thing.
Everything has its drawbacks, right. This is how I talk to my teens, “Everything has its drawbacks and now you’re a grown up and you have to make the decision as to what side effect might be okay for you and what risk you are willing to take.”
Participant:
What are the different forms of birth control? You’ve got the pill to be effective against irregular periods or PMDD, what other types are effective against that? Obviously, not like paragard, but is a progesterone IUD, no because that’s targeted.
Dr. Grey:
Yes, so progesterone IUDs don’t have enough to do what you are talking about. Pretty much you just have this slide (Dr. Grey goes back to a previous slide called Shorter Acting) that’s going to affect those kinds of other symptoms.
The next slide, the longer acting, if you are using them for not just birth control, then it’s more so for a period flow. All these (listed on the Shorter Acting Slide) can help with mood, cramping, IUDs can help with cramping, but those kind of things.
Participant:
Dr. Grey, I have a question, too about this. So this is going to be super, super specific. I was on the pill from high school til my first child and went off to have a baby. I went back on the pill, but especially after having a kid, forget to take it all the time. So after I had my second child, I changed my mind and decided to try the Mirena, which has been wonderful for the most part, but something, I don’t know if it is a side effect or not, something that happened, and it could just be my age, I don’t know, but I’ve never had acne in my entire life. The only thing I can think of other than having my second baby, is having the Mirena and now I have full fledged teen-age acne. Is that a possible side effect of changing my birth control or anything like that?
Dr. Grey:
So did you have acne when you were a teen?
Participant:
No
Dr. Grey:
So, it’s hard to say, while I’m not giving any specific medical advice during this talk tonight, but one thought is that the pill and the hormones, it stabilizes the hormones. The pill, we actually can use it to treat acne if it is cyclically related, like it comes on with your period. Women who have PCOS, and they get skin breakouts where the hair grows with that, the pill can help with that because it stabilizes that.
Now, the Mirena is not doing that because it doesn’t have enough of the hormones to work everywhere. So, acne can happen for different reasons. We are like a decade older than we were before, so our bodies can be a little bit different. But sometimes, when it’s very close together that switch, that means the pill was probably just helping and now, you don’t have that help from the IUD. It’s not necessarily that the IUD is causing it, it’s just that what you were doing before was probably suppressing it a little bit. That’s just a potential thing that could be going on.
Participant: I’m actually working on setting up an appointment with my dermatologist, but I thought I’d ask the question, since you were here.
Dr. Grey:
For sure. That’s a really common question that I get . People think it’s coming from the IUD but they just switched off the pill, and if they decide to switch back it usually gets better. Or you can find something else to do with acne. So go to the dermatologist if you like everything else about the IUD.
Participant:
Great, thank you so much!
Dr. Grey:
That was a good question. Okay, so the next for “More Than Just No Babies” (slide). The next (slide) is like permanent stuff, like tying your tubes and vasectomy.
A tubal ligation is a laparoscopic procedure. We used to do a hysteroscopic procedure where we can go in through the cervix, but those are on hold for now. So they are all laparoscopic. This picture has clips. Some doctors use clips, some doctors use a ring which is what I like to use during the laparoscopic one, and then some use cautery, where we just cut the tube, so it just depends on whatever the preference the surgeon has. The failure rate is about 3 to 5 in 1000, less than one percent.
I try to really encourage people that this is permanent. So you need to be 100 percent sure that your family is complete. We have good long term options to use in the in between, but this is a surgery where we go into your belly and I want you to be 100 percent sure. Some people will be like, “Oh well, I can just get it reversed.” We do have a procedure that is a tubal reversal, but the pregnancy after is not guaranteed. Also it is another major surgery to have, and I don’t really think that is how we should make this decision.
The other thing is, you can do this after you’ve just had a baby. It’s called a postpartum tubal ligation. So if you are sure you are ready to be done, you can do this as a small procedure during that time. So it is either that day after you have the baby or the next day depending on what your doctor decides to do. It’s an incision about three centimeters below your belly button, it heals really nicely and it looks like a little fold under your belly button.
People ask if it’s painful. Your belly feels kind of sore, but everything feels sore right after, so it’s not really that much more. And then, if you have a C-section, you can just do it at that time if that is something you are thinking about.
The vasectomy is very underrated. It is a very simple procedure for the males to have. It is an office procedure for them. They can do it on a Friday and then they are back to whatever they want to do on Monday. It is not an abdominal procedure. The risks are much lower. We talk about this as an option for couples because the risk for women is higher than this one.
Crissy: I would love to dive into your body after the baby.
Dr. Grey: Okay. So this is what our bodies do when we are pregnant (shows slide of postpartum abdominal wall). The uterus starts to grow. What I want you to notice is this is your back (points to curve). As your baby grows and you get towards the end of your pregnancy, you get this bigger curvature in your back here (lower back) and here (upper back). It’s called a lordosis and a kyphosis up at the top. That’s what your body’s been used to. And then your abdominal wall has to stretch. These are your rectus abdominal muscles and they have to stretch here to allow the uterus to grow. It’s kind of amazing that we can do that. After we have the baby, our bodies have to go back to normal. It takes about six to eight weeks in general, for all the hormones to shift, but I really wish women would focus more on the physical and structural changes going on in their bodies because we can have lasting effects from them.
One of them is that you might just be unlucky and have something where the muscles separate more (points to pic where muscles have separated) called diastasis recti. That can cause you to have a little bit of a hernia, like when you sit up. Nothing too terrible, but you can see it, or it can be uncomfortable. We need to work on that or address it or know that it’s a problem.
I have women who come and are three, four, or six months postpartum and say, “I have this new back pain.” I think about what they have been doing during that time. Most of the time, unless you received “two thumbs up,” you have not gotten into a normal routine of exercise. I know that I didn’t for a long time after. Your abdominal muscles are weak. We know from everything you’ve ever learned, that your core helps with back pain.
So you have to get your back in better alignment and you have to strengthen the core muscles. If we don’t focus on that or do it all, we can potentially have back pain because our back stays in more of a curve and these muscles stay weakened so now we are holding an x-pound infant and we’re not used to doing that either. It’s (pregnancy) causing our bodies to not really make these changes to be as strong as they were before. I think that if you have friends who are talking about how much their backs hurt them after pregnancy, it is really important for them to let someone know or do some research on a postpartum rehabilitation or exercise even up to eight or nine months, if they are feeling weak.
I remember after I had my second, I was playing on the ground with him. I was on my hands and knees and I went to reach for a toy, and you know it’s just like that little bit further away, and I pretty much just collapsed. I realized that was not the way it needed to be, because I didn’t have that core tone that I needed for just that simple thing. That’s one of our exercises that you have probably done in an exercise or yoga class, lifting an arm and leg and reaching. The exercises that you need in postpartum are very simple but they are not just crunches.
That’s why a postpartum program, you don’t need it for very long, usually after three weeks, or four weeks, you can usually move on, but you have to start building that muscle tone. That is one thing I like to focus on that can carry with us throughout the years.
The Pelvic Floor. We did our Gina model. You met Gina. After we have babies, and this can happen whether we have a vaginal delivery or a C-section, some of the risk comes from just carrying the pregnancy, some of it is more so with a vaginal delivery. We can have a weakening of the pelvic floor. This is what we are looking at here (Shows slide of Pelvic Floor ). These are your pelvic floor muscles in between here, so here’s your bladder, this is where you pee from, your urethra, here’s your vagina, your uterus, and then your anus and your rectum. This is like a sling that supports everything so it fits up there and is working appropriately. And when it is not working appropriately, that’s when we have urinary incontinence. It’s super common. So in women who have had one baby, 9.7% of women who have had one baby will have urinary incontinence in their lifetime. After two, it goes up to 16% and after three or more babies it can go up to 23% of women will have some urinary incontinence. It’s not unheard of. You’re not weird. We all laugh about it but, yes, it can happen. That’s like leaking urine when coughing or sneezing, or feeling the urge to go to the bathroom to pee and you can’t make it because you leak. Symptoms come from different reasons but the statistics are more so for the first one, coughing, sneezing, laughing and jumping on a trampoline! I kid you not! I don’t know why all these women are jumping on trampolines but they come in and I ask, “Do leak urine?” They say, “Only when I jump on a trampoline.” They are very specific, but trampolines will get you. Wear a pad. You are not alone and there is a lot you can do.
We actually have specially trained physical therapists who just work on the women’s pelvic floor. Pelvic floor physical therapists — They’re good and they will teach women to do an exercise to help with incontinence. What I tell my patients is that if you go, and if you do it, it will work. But it’s hard to go to physical therapy, it’s hard to remember to do the exercises, but if you do it, it will work. Other than that, the option is surgery, once you are done having kids.
The last part is pelvic organ prolapse. That means we are weak here (points to pelvic floor on slide) or either the bladder or uterus is falling down, or you have a rectocele (rectum is falling down). (Dr. Grey shows where she means on the pelvic floor diagram).
It usually takes some time. Some women can have a little bit right after they have the baby, but then it goes back as their bodies shift back. It can come back after menopause. It’s not a super high percentage. It’s like 2.5% after you’ve had one baby, and then after three it can go up to almost 4% of people can have this. It’s a little bit scary because people think that all of a sudden everything is going to fall out. That’s not the case. So if you feel like something is kind of hanging down there or falling out, there are exercises that the physical therapists can help with that as well, or then we talk about surgery.
(Sex After Babies (and forever after that…) Slide)
Immediately after having a baby, estrogen levels are low when you are postpartum and while you’re breast-feeding. It’s not the primary hormone of breast-feeding. Remember that vaginal discharge is from that estrogen and so it helps provide us with some of that lubrication while all of that kind of goes down when we don’t have those estrogen levels, like after menopause. Estrogen goes away and that’s when you get that vaginal dryness and you have problems with intercourse, some people do. Once they stop breast-feeding then it usually goes back to normal. Your vagina can change. Something came out of there. It is okay, I promise. It will go back to normal, you may have a risk of the other problems that I talked about, but it’s kind of like a new normal. Low desire is very common. I talk to women about it at least a few times a day. Women have a higher expectation. If we all talk to each other about it, we probably have a similar desire, but we think that it should be much more or different. That’s a problem because we’re not talking about it, or maybe somebody’s partner who’s really comfortable talking about it tells her that she should be having it more, or something like that. I talk to all women all day long and I know that we all feel the same way.
I was in a conference and they were talking about this.They said some things that really stuck with me. One [thing] is: neutral is fine. So it’s evening time, and you’re like fine, you have enough energy to have sex or fold the laundry or something like that, and you’re like, I don’t really care which way it goes, –that is a fine spot to be in. You do not have to want it, or desire it, or whatever. When you get going with it, you should be aroused, it should be enjoyable, it shouldn’t be painful, but starting from a neutrality part is fine. It is okay. It is normal. It is all right. And then have a happy sex life, okay?
The second thing is, it’s kind of like going to the gym. You don’t always really want to go to the gym, sometimes you do, but after you go to the gym, you always feel good about your decision. Right? I think people can relate to that. It is important, though. You need that. Physical intimacy releases endorphins, helps you with connection with your partner, so those are all good things.
Also, communicate with your partner. I think it’s kind of sad sometimes, when I talk to women and they say they just don’t feel like doing it, or they feel pain, or something is going on with that. I say, “Have you talked to your partner about it,” and they say, “No.” They are in long term monogamous relationships and they don’t feel like they can bring these things up. That’s a problem. I think we need to get more comfortable. You don’t have to talk to everyone, you don’t have to get on here and talk to people like I do. I feel like we do need to communicate with our partners about anything that’s going on like that. You are a partnership. You are the ones doing it together. You both should be able to discuss it together.
You are going to think about it next time you go to the gym, aren’t you?
Crissy: Oh, I’m going to go up stairs and tell my husband about it.
Dr. Grey: Oh, you’re not going to the gym ever again {laughing}
Cindi: Will you come back again and talk about how to talk to kids about puberty?
Dr. Gray: Sure!
Crissy: I love the girl-ology – guy-ology plan. I think that would be really awesome.
Dr. Grey: I will just show you something, because I think it’s a really good resource. Girlology is a group, an organization that we work on helping, knowledge is power. This is their website [girlology.com] [Dr. Grey shows website page] I am a speaker for Girlology and I do the in-person classes. It’s founded by an obgyn and a pediatrician, together. They do things like: little tips, mom minutes, …they are all free on their website.
What sunscreen, how much exercise, they talk about finding anxiety in young girls and what’s up with her irregular periods. They really just have a lot of information out there about stuff. “Can I pop a zit?” “Why are so many kids vaping?” So check out that website before we talk again and hopefully that will help, if you have a preteen daughter, you could watch something together.
Crissy: Thank you so much, Dr. Grey.
Dr. Gray: You’re welcome.
Cindi: That was so much fun. It was lovely. Thank you so much.
Dr. Erin Grey is a board-certified Ob-Gyn who has been practicing medicine since 2011. She practices the full scope of obstetrics and gynecology, but has a special interest in teen and young adult gynecology, as well as, minimally invasive surgery. She is a North Carolina native, UNC grad (Go Heels), and a mother of 2 boys. In her free time she teaches Girlology and Guyology, which are puberty classes for parents and children.
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