Understanding Your Menstrual Health or the "5th Vital Sign" with Dr. Holly Ouilette

Welcome to the Get Healthy Tampa Bay Podcast with Dr. Kerry Reller! This week I am joined by Dr. Holly Ouilette to share her expertise on menstrual health, discussing the importance of recognizing the menstrual cycle as a vital sign of overall health. She delves into the complexities of normal vs. irregular cycles, the impact of hormonal imbalances, and the effectiveness of various birth control methods in managing cycle irregularities. Dr. Ouilette also explores non-hormonal treatments and the significance of tracking menstrual cycles for diagnosing potential health issues, providing listeners with a comprehensive understanding of menstrual health management.

Dr. Holly Ouillette is a gynecologist with Elite Women's Care. She is a skilled practitioner dedicated to advancing women's health. Dr. Ouillette is certified by the American Board of Obstetrics and Gynecology (ABOG) and specializes in minimally invasive surgery including da Vinci Robotic Surgery. During her residency training at The University of Texas Health Science Center in Houston she was awarded the title of Outstanding Resident Surgeon by The Society of Laparoendoscopic Surgeons. After residency she went on to gain additional training in minimally invasive surgery at The Women's Hospital of Texas Pelvic Restorative Center. Prior to her aforementioned training in Houston, TX she received her bachelor's degree at The University of Michigan followed by her medical doctorate at Wayne State University.

Before joining Elite Women's Care Dr. Ouillette practiced Obstetrics and Gynecology in a large referral hospital in Detroit, Ml. There she cared for patients of the highest acuity while training resident physicians. She was the associate program director for the residency program and was responsible for the medical training of 16 future physicians per year. Her passion for teaching will become apparent as she cares for you and takes the time to educate you on your medical conditions, making sure you fully understand your diagnosis and the treatment options.

00:00 - Introduction
00:47 - Background of Dr. Holly Ouilette
03:26 - Menstrual Cycle as a Vital Sign
04:52 - Understanding the Menstrual Cycle Phases
08:01 - Normal vs. Irregular Menstrual Cycles
10:21 - Managing Heavy and Painful Periods
11:59 - Age-Related Cycle Variability
12:38 - Significance of Irregular Periods
14:48 - Pain Management and Non-Hormonal Interventions
24:42 - Thyroid Function and Fertility
28:25 - Addressing Concerns without Hormonal Birth Control
38:06 - Access to Care and Patient Education

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Transcript

Kerry: 0:28

All right. Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller. And today we have a very special guest, Dr. Holly Ouilette. Welcome to the podcast.

Holly: 0:39

Thank you. I'm happy to be here.

Kerry: 0:41

Thank you for coming. And why don't you tell us a little about who you are and what you do?

Holly: 0:47

Sure. I'll kind of start where I'm at now and where I came from. So right now I work at Elite Women's Care. We have a few offices all around the greater Tampa Bay area and I'm in the Wesley Chapel location. I just started working in this area in November of 2023. So this location is a new location for our group, but our group has been around for about four ish years. Prior to coming to Florida, I was practicing in Detroit. I was working at an academic facility. I had worked there for about five years doing both OB and gynecology there. Here in Tampa, I'm just doing gynecology, no OB. And I was very involved with teaching in Detroit. And serving the underserved population. So I enjoyed that quite a bit. I did my training in Houston at the University of Texas. I did my residency. And then I did a fellowship in women's pelvic health at the women's pelvic restorative center at the women's hospital there in Houston. And prior to that, I did my medical school in Detroit at Wayne State University and my undergrad at the University of Michigan there.

Kerry: 1:59

Oh, go blue. Just kidding. I'm a Notre Dame graduate.

Holly: 2:03

Okay.

Kerry: 2:05

Yeah. No, that's awesome. Welcome to Tampa Bay area. So this is very exciting. You're now in for warmer weather, although I think this was the coldest winter we've ever had. It was just very long. I don't know, but it

Holly: 2:17

When I moved here, I'm like, this isn't the sunshine and warmth I was promised, but I knew if I held out, it would eventually come. And it's been nice the last few days.

Kerry: 2:25

yeah, definitely. I think today is finally been good, but I was like the longest winter. When is this going to end? Yeah. But anyway, so yeah, you're a gynecologist in Wesley Chapel area and your group is, I think they also have a location in Clearwater, Brooksville. Where else did you say? You said one other one.

Holly: 2:46

just Clearwater Brooksville and then Wesley Chapel.

Kerry: 2:50

Good. Okay. And you also have training in the da Vinci robot, which always some people find exciting. We get to watch it. Yeah.

Holly: 2:57

Yeah. I do robotic surgery at Trinity as well as Advent Health in Wesley Chapel. So that's something that I am able to offer my patients when they need surgery.

Kerry: 3:07

Very good. Cool. Well, we were going to talk about something simple today and I like how you approach this topic, I guess, really, because I was just, you know we're going to talk about the menstrual period And when it's normal and not normal, but why do you say that it's called the fifth vital sign? Can you

Holly: 3:26

Yeah. So vital signs are measurements of your body's most basic function. So as doctors, we look at vital signs because this is a quick and easy way to assess your overall health at this exact point in time. So things like blood pressure, body temperature, heart rate, and respiratory rate are your vital signs. And one could argue that your menstrual cycle is the fifth vital signs because irregular periods can reflect someone's overall health status. The menstrual cycle is controlled by a carefully orchestrated series of events throughout the entire body. So irregularities can signal that something's wrong at any point in the process. A problem in any organ in your body can lead to abnormalities in your menstrual cycle. So an abnormal menstrual cycle can be the first sign that something might be wrong somewhere else in your body.

Kerry: 4:16

Yeah, absolutely. And it's funny that you call it the fifth vital sign cause I was just talking with another provider, a doctor, and he said about how like pain was one of the vital signs, right? And that led into a whole discussion on addiction medicine, but thinking about your period as another vital sign can really tell you what's wrong, what's right, what's going on with your body. So I think that's, it's a great way to think about it. And then it can help people realize when it's not good and needs to have some attention. Can you kind of go into more detail and expand on everything that's going on with the menstrual cycle, the normal one, and then we can go from there.

Holly: 4:52

So we split the menstrual cycle into two phases. There's the follicular phase, which is the first half of the menstrual cycle, and the luteal phase is the second half of the menstrual cycle. The cycle starts on the very first day of your period. So whenever you come to your gynecologist and we're asking you, Hey, what was the first day of your last period? That's why we want to know that because we're wanting to figure out where you're at in your cycle at this point in time when I'm seeing you. So the first day of your period starts the cycle. The first thing that happens is the brain secretes a hormone called FSH that tells your ovaries to start preparing follicles. Now, follicles are little cysts in your ovaries that house the eggs and prepare them to be released. And that releasing of an egg is called ovulating. So if your doctor has ever told you like, Hey, it's normal to have cysts on your ovaries. This is why, because every month your ovaries are normally making cysts to get that process started. So then the ovary starts making estrogen, and eventually that estrogen signals back to the brain to slow down the release of that hormone called FSH. While all of this is going on, the lining inside the uterus that you shed every month is starting to thicken and thicken. An egg is then chose as the dominant egg to be released, and all the other eggs will dry up. So at this point in the cycle, we're halfway there. And you can see that things are already starting to get pretty complicated. The next thing that happens is the brain releases high levels of a hormone called LH. If you've ever been trying to get pregnant in the past and you've used those LH test strips, then this is what you're trying to detect. 36 hours after the LH spike, the egg is released. The egg then travels down the fallopian tube to be fertilized. The ovary then starts making progesterone. This progesterone changes the structure of the lining of the uterus that has been building up. Finally, the LH secretion slows and there's a fall in the production of estrogen and progesterone in the absence of a fertilized egg. This decrease in estrogen and progesterone then causes the lining of the uterine to be sloughed, and that's when your period starts. So this summary only mentions a few key players in the menstrual cycle. There's many other hormones that play a more minor role that weren't even mentioned. And as you can see, there's a complex interplay between the brain and the ovary and the uterus to make all of this happen.

Kerry: 7:18

Yeah, I think that is like a really good description. And I think sometimes when people are Googling about their menstrual cycle in the period and the hormones and everything, they see those curves and you're basically describing those curves of how we have that LH surge and then the egg is released. And I think with the, It's interesting. I mean, as far as usually, it's only one egg that's released. And I think that's important to know. I mean, obviously, there can be issues or situations where there's more than one. But I think that's the basics, right? And the follicles aren't like, just tell me about if the follicle is using the word cyst, like, does that have anything to do with what people might say I know we're going to get into this, but like polycystic ovarian syndrome, or does, is that the same

Holly: 8:01

Yeah. So those little follicles are what is developing every month in the normal cycle. Everybody is developing a lot of little follicles and then one of as the dominant one. Now, They can have a lot of follicles developing, even at times of the month that they're not supposed to have follicles developing. And they do tend to have more follicles developing because it is a little bit more irregular. So that's when you start to see all of those little cysts on the ovaries. If you do an ultrasound for somebody who has polycystic ovarian syndrome, it's the same concept, but it's a little less well regulated.

Kerry: 8:40

okay. Yeah, that makes sense. So you've described kind of like the normal situation. How do you define a normal menstrual cycle

Holly: 8:48

Yeah. So there's a few things that we look at when we're asking you about your menstrual cycle. The first one is frequency. So how often are you having a period? It's normal for you to have a period anywhere between 21 to 35 days. So that's considered normal. If your period's coming every 21 to 35 days, the next thing we look at is regularity or the variation in cycle links, this one can be a little bit more confusing. But the main thing is. Are your periods regular and are they following a certain pattern? That pattern might be different for different people but is there a pattern that's kind of normal for you? So a normal variation in cycle length would be something like my period comes, you know, every four ish weeks. Now, if one cycle, your period's coming three weeks and then the next cycle it's five weeks and then the next cycle it's four and then five, that's normal. That would be more of an irregular cycle length and variation between your cycle lengths. The next thing is duration. So how long are you bleeding for? People should not be bleeding for more than about eight days. And then the final thing is how heavy is your bleeding? And there's no way that we can measure how heavy somebody's bleeding is. And This is basically the patient telling us, I feel my bleeding is too heavy for me. So is your bleeding something that's interfering with your physical, social, emotional, or material quality of life?

Kerry: 10:09

Sometimes we ask like how many pads or tampons they go through and like what size, so what. I guess you're still saying that we don't really know how to define if that's normal or not, or when do

Holly: 10:21

And it's hard because there are some people who change their pads more frequently because they like to always have a fresh pad on. So when you do start to get into pad counts, which sometimes I do ask patients that other important questions are, well, when you change your pad, is it completely saturated? And are you using the thinner panty liner kind of pads or using those big, thick maxi pads? When I have a patient telling me, hey, I'm wearing a big, thick maxi pad and a super tampon at the same time, and I'm still bleeding through to my clothes. That's irregular. But somebody may say, well, I go through 10 pads a day, but I like to change it every two hours. Cause I don't like to have any mess down there. Then that's when I would start to question, well, how full is the pad and that kind of stuff. And again, for some people their bleeding may sound normal to me and I may say that sounds normal, but to them, if it's really interfering with their life, then that means it's a problem.

Kerry: 11:12

Okay. So even if it's quote normal for them, it's still bothering them through their, you know, interfering with their life. It's something to bring up, obviously.

Holly: 11:20

definitely. And we can talk about, hey, are there ways we can help to lighten your period so that it's not distressing you when you're at work? People can sometimes say, I'm really worried. I don't feel like I can focus on work because I'm worried I might bleed through my pad or my tampon. So if it's affecting your function at work, or a lot of people may even call off of work when they're they feel like their periods are heavy and we want to get them to a point where they're able to go to work, go in when they need to and not have to worry about bleeding. Yeah.

Kerry: 11:47

Absolutely. Yeah. You mentioned I don't know if you actually did mention, but there are there different age ranges where the length of the menstrual cycle is considered normal or a little long or short. Can you touch on that?

Holly: 11:59

Yeah, so at the extremes of reproductive age. So with teenagers and patients as they're nearing menopause getting more into the late 40s, the periods can get to be a little bit more erratic. Because there's just a lot of changes that are happening when you first get your period or when you're approaching menopause. So that can tend to be more erratic but when people are in the prime of their reproductive years. Then we expect their cycles to be pretty regular follow a pattern and the cycle length to not vary vary by more than like seven ish days each cycle

Kerry: 12:32

Okay. Yeah, that makes sense. So what can an irregular period indicate or mean?

Holly: 12:38

When somebody comes in and we start talking about whether or not their period is irregular I split it into two different categories. One category is are your periods coming more often than they should or are your periods coming less often than they should? So if their cycles lasting more than like 35 ish days, or they're skipping periods, if they're saying they're having months where they just never got a period. Then I would be worried that that might be something where the hormones that are talking from your brains to your ovaries might not be communicating the right way. So this could be something like a thyroid problem or a problem with a hormone that the brain secretes called prolactin. If a patient has signs of elevated testosterone, like acne or male pattern hair like hair growing in their facial hair or chest hair or belly hair. Those would all be signs of elevated testosterone. And then I would start to be thinking about polycystic ovarian syndrome, like we mentioned earlier. So those are things that we would potentially test you for. If you've come to a point where your periods have just completely stopped and you've gone many months without a period especially at a young age, then I would be more worried about something like primary ovarian insufficiency where the ovaries are just not functioning anymore. If we go to the opposite end of the spectrum where a patient is having periods more often than they should, let's say they're having bleeding every two weeks and they're bleeding many weeks out of the month then I would be more concerned about like a structural problem with the uterus. This would be things like fibroids or polyps inside the uterus, or even something called adenomyosis. Again, with this, we would also check your thyroid because your thyroid can do both things. It can make your periods more frequent and less frequent. So that would be something else to check. And then there may be times where we would be worried about cancer in somebody who's bleeding a lot, especially if they have risk factors and we would do potentially a biopsy to look for something like that.

Kerry: 14:34

What about pain with periods? Is that considered, I guess I wonder if you can add that to the different things you look at, right? Regularity, duration, volume. What about discomfort or pain? Is that normal or not? Or what?

Holly: 14:48

Yeah, so it is normal for people to have pain with their periods. But there can be extremes where it starts to become abnormal. So a lot of patients will experience cramping during their period and that's normal. For a lot of patients, this can be relieved by over the counter medications like Motrin or Aleve. And actually the best thing to do for this is to start that Motrin or Aleve about 24 hours before your period. If you wait until you get your period, then your body's already made a lot of the hormones that cause the pain. So starting at about 24 hours before helps to stop your body from even making those hormones. This only works if people have regular periods and know exactly when their period's gonna come. So it doesn't work for everybody if their periods aren't perfectly regular. But we start to get worried when people's pain is beyond the normal. So this would be people who are not able, like I said, to go to work because of their pain so severe, or patients will tell me they're lying on the bathroom floor for a day of their period because their pain's so severe, can't get out of bed. Then I would be worried about something called endometriosis, where the lining that's supposed to be inside your uterus ends up And we don't know how this happens being other places in your body and that can cause a lot of pain during your periods. So some pain is normal, extreme amounts of pain is not always normal and no matter what the pain level is, there is always things that we can do to help. We use a lot of birth control options, not only for birth control, but we use them for heavy pain or heavy periods or painful periods. So a lot of patients come in, Telling me about their painful heavy periods and I do offer them birth control a lot Not necessarily because they need it for birth control But because all of those hormones can also help with heavy and painful periods too

Kerry: 16:35

Yeah, I think that is an interesting point. And is there any way to I guess treat these, Things without using birth control?

Holly: 16:44

Yeah, so, some conservative things that you can do is exercise. Exercise has been found to be helpful So a lot of patients will be like it's hard for me to exercise when i'm in pain But I try to encourage them to kind of like push past that pain and go out and try to get that workout in because exercise has been proven to be helpful with painful periods. For people who have heavy periods, there's not a whole lot you can do aside from hormones to help with that. If you are overweight, losing weight can help with heavy periods. So that's one thing that kind of goes back to diet and exercise. A lot of patients will find for painful periods that like heating pads are very helpful to them. So those are some of the more conservative measures that you can take.

Kerry: 17:28

Otherwise, you really do have to induce the hormone in there to have effect to lighten it up and have less pain as well.

Holly: 17:36

Yeah. Unfortunately, there's not a ton of other options to help with that.

Kerry: 17:40

Okay. So how, I know what we were talking already, like, if you don't know when your period is coming, you can't start the medicine in time, but how can you know when something is off or how do you track your periods?

Holly: 17:51

Yeah. So nowadays a lot of patients will use like a period tracker app on their phone. And that is very helpful. But it doesn't even have to be anything fancy like that. You can just get a plain old planner from the dollar store and just write in there. When you're bleeding the most important day is the first day of your period. So that's the first day of like full period bleeding. Make sure you mark that down. And then you want to mark down any days that you're bleeding, even if it's outside of your period time. You don't have to go into a whole lot of details about the bleeding. You can put if it's heavy or light but we don't need a whole lot more details than that. So keeping track of your period is super helpful when patients come in with the app or a planner, I can really sit down and I'll sit there and I'll go month by month with them what has happened each month with their period, usually for the last six months or if they have up to a year that can be very helpful. And I can get a very good picture of what is going on and what kind of testing do I need to order and what kind of things do I need to worry about.

Kerry: 18:51

Can you give an example of some of the apps, or do you have any recommendations for anybody?

Holly: 18:56

You know, I don't know any of the apps specifically, but every single app seems to be really helpful when patients bring it in. I haven't found any where I thought like, hey, this isn't helpful. And I know a lot of them are free. So just go with the cheapest and easiest. And that's even like what I tell patients with when they're taking prenatal vitamins is they all want to go out and get something fancy. And I'm like, it doesn't have to be anything fancy. Just go with the store brand, the cheapest one you can get.

Kerry: 19:20

Yeah, they're just to mention, I think the Apple Health app has it on that, right? I think Fitbit has it on that, and I think there's one that's actually just called, like, My Period Tracker. Those are the only ones I can think of. So I don't know if in case anybody, you know, needs to do that, but yeah, I think it's definitely helpful to know already beforehand, before coming in to see anybody, what are your symptoms? What are the you know, associated symptoms you're having with the period and then the length and how everything is like if it's heavy or light or things like that. So coming with that information is very helpful.

Holly: 19:56

Yeah, and it doesn't even have to be an app. They, you know, everybody has that calendar on their phone. You could even just use that and put in there each day, like, I bled and it was light or heavy. And that's pretty much all we need.

Kerry: 20:07

Yeah, perfect. How do you know what to do when, like, when do they need to see the GYN for these problems? Yeah.

Holly: 20:15

Yeah, good question. So I give All of my patients kind of what I call a get out of jail free card once per year, which means that once a year it's normal to have an off period. Meaning either your period came a little bit earlier than usual or a little bit later than usual or you had a random episode of bleeding when you shouldn't be bleeding. If that happens once a year, I'm not worried about it. Of course, if your period's coming late, make sure you take a pregnancy test if you're sexually active to make sure you're not pregnant. But if the pregnancy test is negative, I wouldn't worry about one irregular period. A lot of times we just attribute this to stress. So like we talked about earlier with your period being a vital sign just like if when you're stressed, your heart rate might increase when you're stressed, your period can be a little bit off to however, if you're having irregular periods, month after month after month, that's when it's time to see someone. So we need at least three months of tracking your period to have an idea of what's going on. If you come in with just one month of abnormal bleeding, it's really hard to figure out what's going on. So I say three months is a good time frame of tracking your period writing down when it's coming and then bringing that information to us so that we can get a better idea of what's going on. Six months is even better. But some people don't want to wait that long and I understand that. Especially if you're in the older age group, so 40 and above, I'd say after about three months of your regular periods, come on in to talk about it. But if you're younger waiting six months is probably okay, and it gives us a little bit more information so we can have a better idea of what's going on. The nice thing about tracking it in your phone is nobody ever forgets their phone when they go to the doctor. So sometimes when people keep things like in a little planner in their calendar, It can be easy to forget, but nobody ever forgets their phone, so it's really easy for patients to pull that out and give me all the dates of what's been going on.

Kerry: 22:06

Yeah. So stress can be a big thing that kind of throws off the period, right? And then you obviously mentioned thyroid. What other things like lab abnormalities would you be looking for if there are any related to this?

Holly: 22:19

Yeah, so if somebody's period's off, sometimes if they're having really heavy bleeding, I'm going to be checking a blood count to make sure that they're not anemic from their bleeding because we see that pretty often with people with heavy periods, especially if it's been month after month of heavy bleeding. So I will check their blood count, especially if they're having symptoms of being anemic, feeling lightheaded, dizzy, like they're going to pass out. That will be one thing I would check with a heavy period as well as their thyroid. But with heavy periods, there's not a whole lot of other lab abnormalities. More so, I'm going to be looking at an ultrasound to see is there something structural that's causing these heavy periods, like the fibroids or something like that. Fibroids are really common. They're just gross of normal uterine tissue, but they can really do a number on your period and cause them to be pretty heavy and painful. On the other end, if somebody's missing periods, I'm going to be ordering lab tests such as a prolactin to see if that hormone that's secreted from your brain is elevated, I would definitely be checking a thyroid if I'm worried about somebody having their ovaries just not functioning anymore. I would be checking an FSH and an estradiol to see if they've gone into menopause early. And then if somebody's having symptoms of PCOS, I'm going to check their testosterone. But along with that testing, there's going to be a lot of other tests and labs I would order. To ensure there's not something else going on because with polycystic ovarian syndrome, there can be other things that can look like PCOS but are not. So I'm going to be doing a lot more tests to rule out other things but then also patient history to determine what the lab work's going to be because it's not the same for everyone.

Kerry: 23:58

Absolutely.

Holly: 23:59

And I get the question commonly, like my periods are off. Can you just do a full hormone panel and just check all of my hormones? And I try to explain to patients, well, you know, there's not one full panel we can do. That's going to tell us what's going on. I really have to tailor this to your signs and symptoms and order the labs that are specific for that. Cause if I get off ordering just a full hormone panel, we might get some testing back. That doesn't make a whole lot of sense. Okay. Based on what you have going on. So I want to make sure that I'm Picking my labs based on this specific patient symptoms.

Kerry: 24:32

Yes, that makes a lot of sense. Now, do you see more hyper or hypo thyroid, lower high thyroid problems associated with these things?

Holly: 24:42

It's funny. We have always been taught to check the thyroid every time. And I will tell you, it almost always comes back normal. The only time I see thyroid abnormalities is most of the time, somebody who's already had a thyroid, a known thyroid problem, and maybe they're not taking their medications as they should. And it's leading to an irregular period. But I'll say never once have I diagnosed the thyroid problem in a patient by their irregular period. So it's kind of one of those tests that we're trained to always order, but it doesn't give a whole lot of yield with it.

Kerry: 25:13

Interesting. Since we're on the thyroid topic, what about for a person who is trying to get pregnant and related to the thyroid?

Holly: 25:22

so The thyroid can get really complicated when it comes to pregnancy, and there's a lot of debate around thyroid issues in pregnancy. If you read our governing body ACOG, which is the American Congress of Obstetrics and Gynecology, the only thyroid abnormalities we really want to treat is overt hyper or overt hypothyroidism in terms of somebody getting pregnant, which means you have a thyroid abnormality and there's many labs that prove that thyroid abnormality versus you could also have what's called subclinical hypo or hyperthyroidism. And that's where maybe you have one little abnormality in your thyroid, but the rest of the test don't necessarily agree with that abnormality. The rest of the tests are normal. So with that subclinical hypo or hyperthyroidism as a generalist, we are really taught to leave that alone and not treat that for pregnancy. But once you start to get into some of the infertility literature and seeing infertility doctors, like a reproductive endocrinology infertility doctor, they will sometimes treat that. So the thyroid can get pretty complicated when it comes to pregnancy and even postpartum. We really try not to check people's thyroids postpartum. Because the thyroid can do all sorts of wacky things postpartum, and it can be hard to know what to do with those results, and a lot of times it ends up resolving itself after you're done with that postpartum period.

Kerry: 26:45

Yeah, that makes a lot of sense. I definitely have seen cases where I guess maybe they're going to more of the fertility specialist and they do end up treating it and then the patient is able to successfully conceive. So I guess it's all case dependent too. I do have a question about the fibroids. Is there a specific age slit that you see that more younger or older, like if someone's having heavy bleeding at a younger age, is it really fibroids or do you normally see that?

Holly: 27:13

that's a great question. So at a younger age, it's not normally fibroid. So in your teens and your twenties, it's very rare that we see fibroids. I don't even order an ultrasound on those patients because most of the time, that's not a structural abnormality. That's more of a hormonal problem. And if a patient chooses, it's And we try some sort of hormones, like a birth control to try to control that. And it does, then we kind of just chalk it up to, hey, that was a hormone problem. Now, if we're trying to treat somebody and they're not responding to treatment, that might be a time in a younger patient where I will say, hey, this is a little bit of an unusual case. Let's go ahead and get that ultrasound. But you're right. We don't worry about a lot of the structural abnormalities until patients get older. Usually mid thirties into their forties where we're seeing a lot more of the fibroids and structural abnormalities that are causing the bleeding. So it is rare that I order ultrasounds on the younger patients, and it is common that I order them on the patients who are a little bit on the older side because of that.

Kerry: 28:10

Okay. So I'm having a lot of patients that are younger coming in with irregular periods. And I mean, I kind of already asked this and maybe it's heavy, maybe they're just really not normal cycle, maybe they're having a lot of pain, but they all don't want to go on,

Holly: 28:25

I know.

Kerry: 28:25

birth control. So what are the suggestions there?

Holly: 28:29

Yeah, that is very common. And there's unfortunately not a whole lot that we can do outside of using birth control to control a lot of these problems. Like we talked about things like exercise can help with the pain coping mechanisms to help with the pain. So more like cognitive behavioral therapy to help with it, but actually like Being able to give them something that's not hormonal to help with the pain. There's not a whole lot out there. For heavy periods, there is something called transaminic acid, which is a little bit of a newer medication. And some patients do like that medication because you don't have to take it all month. You only take it during your period and you can only take it for about five days of the month. And it's a medication that helps you to not bleed as heavily. So that has been something that patients have liked because it's also not hormonal, but that's really only going to help with the heavy periods, not the pain. So yeah, I have that situation a lot too, where I know there's a lot of girls who do not want to be on birth control and they have the heavier painful periods and it is a limiting thing that we don't have a whole lot else out there to help them.

Kerry: 29:34

Okay, let's say they don't want to be on the oral contraceptives. What other methods are there?

Holly: 29:39

Yeah, so there's a lot of other methods. There is a patch that you can use that's the same medicine as the oral contraceptives It's something you put on your torso and you change once a week and you have a regular period on that. There's a ring which is a small ring that you put in and out of the vagina yourself and you change it once a month and you would have a regular period on that as well. When I'm talking to patients about birth control and hormones, I split it into two categories. There's one category where you're going to have regular monthly periods, and then there's another category where you're not going to have regular monthly periods. So the first question I like to ask patients is, are you somebody who likes to have a regular monthly period? There are a lot of people out there who do want to have that period every month because it helps them know that they're not pregnant, and it's a kind of a sign of reassurance. Then, There's other patients who don't really care if they have a regular monthly period. Some patients are like, if you can stop my period altogether, I'm happy about that. So that's the other category of birth control and hormones. That category includes things like an IUD. There's a progesterone IUD, which is a system that It's a small T shaped device that's inserted into the uterus. The nice thing about the IUD is that the hormones mostly work locally and you don't absorb a lot of them systemically. So this is one that I find helpful for patients who don't want a lot of hormones in their body. And they will take to this one a little bit more because the hormones are mostly working locally. So the progesterone IUDs are great for that. There's the Nexplanon, which is a small implant. It's about the size, size of a matchstick that goes in your arm under your skin. And then there's the Depo injection, which is an injection you can come in and get every three months. Those three forms will give you irregular bleeding though. So the first six ish months that you use those, you're going to have irregular bleeding, kind of anything goes. So I tell patients, Hey, I'm going to put this IUD in, and you might call me in two weeks saying, I'm still bleeding. And I'm going to say, that's normal. And you might call me in four weeks and say, Hey, I'm still bleeding. I'm going to say, that's normal. Okay. The first six months, that irregular bleeding can be a little bit crazy, but the good thing about it is it's usually pretty light. It's not going to be that heavy period bleeding that they're used to. It's light bleeding, like a light period or spotting. And then for birth control, there's also a copper IUD. I don't want to forget to mention that, but it doesn't really apply to what we're talking about here, because unfortunately, that one can tend to make your periods heavier and more painful. So we don't use it as treatment for painful or heavy periods.

Kerry: 32:07

That makes sense. There is also, I think, birth control oral again that you can skip periods, like They have that. Can you just explain those a little bit?

Holly: 32:17

yeah. So there's one out there where you can skip your period and you can skip it basically every three months. So it used to be called season equals the brand name. I'm not sure what the brand name is today because it's always changing. But basically you have almost three months of active pills and then just a few inactive pills. The inactive pills are when you're going to get your period. Those are placebo pills and you're only going to have your period every three months. But going back to just traditional birth control pills where you have your period every month, even with those, if somebody wants to, they can skip their period. And I tell patients, if we're giving you the hormones to skip your period, that's perfectly fine. It's completely healthy. I know a lot of patients worry about, hey, where's that blood going if it's not coming out? Well, If you're taking the right hormones, you're probably not even building up that lining. So there's not really anything to come out. So I tell patients if we're giving you the hormones, it's perfectly fine if you're not having your period. Now, if you're not having your period on your own, that's not okay. Come and let me know. But even with traditional birth control pills, patients can skip the placebo pills if they don't want to have their period. They can skip those placebo pills, just start the new pack and skip their period. Okay. A lot of patients like this idea, if they're going to be on a vacation when they're on their period, or let's say they're getting married, they want to make sure they're not on their period during their wedding. A lot of people will want to skip their period for that reason, or there's some people there who just don't want to have a period and every month they skip those placebo pills. The only problem you can run into sometimes with that is, You need a refill of your birth control a little bit before the insurance is willing to refill it. So I have tricks and ways to get around that. But that can sometimes be the only problem. And then sometimes you can have what's called breakthrough bleeding, where eventually your body might kind of force you to have a period and you might have some bleeding unexpectedly. So for, if you're not worried about breakthrough bleeding, that's fine. It's not harmful to you. You're just going to have a, some bleeding randomly for somebody who is worried about breakthrough bleeding. For example, I have some teens who are on the swim team and they don't want to bleed when they're not supposed to be bleeding. So if somebody's really worried about breakthrough bleeding, then I tell them, Hey, let your body have a period maybe every three months. And that can kind of prohibit you from having that breakthrough bleeding. That's unexpected. If you schedule a bleed about every three months, So there's a lot of ways we can play with the traditional birth control to help patients achieve their goals, whatever that might be. And even for patients who do have really painful periods like endometriosis, they don't want to get a period at all because anytime they have a period, that's seven days that they're out for the count, they're lying in bed. We can manipulate birth control so that they're not getting periods.

Kerry: 34:58

Yeah, it sounds like those special brands that allow it for every 3 months makes sense rather than waiting and skipping more than that. Right? Because then you're going to have that breakthrough bleeding. 1 thing that drives me crazy is all the different brand names and trying to prescribe it and making sure it's on the right plan. It's just like, back and forth through the insurance and the pharmacy, like, All the time. It's just picking to pick the new one when they came to me on like as a new patient and they don't know which one's on their plan. It drives me crazy.

Holly: 35:27

Yeah, that can definitely be frustrating. And I'm just honest with patients. I'm like, there's over 200 different birth controls out there. Like even as a gynecologist, I don't know any of them by name. If you're already on it, make sure you bring your pack with you so I can see exactly what's in it. And I'm like, you might be on the same birth control and the name of it might change from one month to another, and you're still getting the same medicine, but the name's just changing. So I'm like, I'm constantly having to look it up. One thing that is actually helpful that you may not know about is, you may or may not, is the Walmart 5 list. I don't think it's 5 anymore. I think it's gone up to 10. But even for patients who don't have insurance there's a birth control on that Walmart 10 list. I think it's Sprintec where they can go and get it at Walmart for 10 a month. So it's very affordable. And that can even be helpful for patients who are having trouble with insurance, finding something that their insurance is covering. So I always keep that in my back pocket too.

Kerry: 36:22

Yeah, they used to have like a target 5 list and a walmart I just haven't seen that lately, but I'm assuming that if they're still doing that with birth control, that does make sense. Yeah, easier. Good to know. I don't think I knew that. Thank you. So what else would you like to tell the listeners about this topic today?

Holly: 36:38

I would just say, don't be afraid to come to your gynecologist and let them know what's going on. Make sure that you're scheduling a separate visit from your well exam, because it is really hard to dive into the details of this during your well exam. So at your well exam, we have a lot of things that we need to accomplish just to. keep you well and make sure we're getting all of our preventative measures in. So if you're really having a lot of problems with your period, it's best to schedule a separate appointment for that so that we can sit there, pull out your phone, go through your calendar month by month, see what's going on, and really get a feel for how this is affecting your life on a daily basis and devote some specific time to that. So don't be afraid to come in. Let us know all the details. I know a lot of patients when they come to me, they're like, this is embarrassing to talk about. I don't want to have to talk about this. But it's something that we do every day. And we really try to be sensitive to your feelings about it and make sure that we are able to make you feel as comfortable as possible when you're here so that you can have the best experience.

Kerry: 37:42

Yeah, I think that's excellent advice. I think sometimes patients like hold up all these things that they want to talk about with a doctor and they come into their well visit and there's just not time to do it all. So it's much better to create a separate appointment for that, especially if you're in the insurance based model where you're only allotted a certain amount of time. So that's helpful. Yeah. And where can people find you if they want to, you know, see you

Holly: 38:06

Yeah. So like I said, my office is in Wesley Chapel. So if that's a convenient location for you, you can visit our website, elitewomenscare. com. We also have a Facebook page also called Elite Women's Care. And then we do have offices with my partner and our nurse practitioner in Clearwater and Brooksville. Those locations are more convenient for you as well. At the Wesley Chapel location right now, we can get you in as soon as the next day. So we have a lot of openings. It's a little bit harder to get into the other two offices because they have been there for quite some time. So yeah, either location and just visit our website or our Facebook page.

Kerry: 38:41

That sounds great. We'll put all that in the show notes and Dr. Ouilette, thank you so much for coming on the podcast today. We

Holly: 38:48

for having

Kerry: 38:49

you. Thank you for

Holly: 38:50

it was great. And like I had told you at the beginning I used to be in teaching before I took this job. So I love educating my patients. When you come in, I'm happy to kind of teach you all about female health and the menstrual cycle and any other questions that patients have. So I love teaching. And I'm happy to share that teaching with all of my patients.

Kerry: 39:12

Awesome. Well, thank you for sharing it with us today and everybody tune in next week and have a good one.

Holly: 39:18

Bye. Thank you.