“Pregnancy of Unknown Location and the Beta List” – with Dr. Caroline Friedman

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Dr. Caroline Friedman, welcome back to the podcast. You are the podcast sensation. How you doing?
Dr. Friedman: I’m good. How are you? It’s good to be here.
Dr. Fox: Wonderful. Although you were supposed to be here, here, but now you’re here, there over the phone because, alas, you are so busy with patients who wanna see you. You did not have the time to run over to our other office/recording studio.
Dr. Friedman: That’s okay. That’s my world.
Dr. Fox: Beautiful thing. So we’re gonna be talking today about…I think it’s a really interesting concept and a lot of people don’t even think about this as a possibility, but this concept of a pregnancy of unknown location, which sounds a little mysterious. What exactly is it?
Dr. Friedman: So when we talk about pregnancy of unknown location, it really refers to a very specific time in one’s early, early pregnancy when it’s really too early to see anything from the pregnancy standpoint on an ultrasound. And so we’re left with saying, “Well, we can’t really say exactly where it is or what it is because it’s too early to see anything.” And so most people think, “Oh, it’s pregnancy. You know, those are in the uterus. That’s what a pregnancy is.” And that’s true most of the time. But sometimes the pregnancy can be outside the uterus, or it can just end up being not a normal pregnancy, and things like that. So when it is in its early sort of vague phase, that’s what we call it.
Dr. Fox: Yes. It’s basically a time when we know someone is pregnant, meaning, you know, she missed her period, she has a positive pregnancy test, whether at home or on a blood test, she may or may not have symptoms of pregnancy. But since we can’t yet physically like see it with our eyes and an ultrasound in the uterus, we don’t know where it is. And the question is how concerning is that? Right? If it’s not supposed to be seen, what’s the big deal if we can’t see it yet?
Dr. Friedman: Right. And so generally speaking, it isn’t always something that is concerning if somebody just has a positive pregnancy test and is early in the process and, you know, isn’t having any symptoms, we wouldn’t expect to see anything. And so it’s just “normal.” The only time really it can be concerning is if there is potential that maybe an ectopic pregnancy or pregnancy outside of the uterus is going on, or the patient’s having some kind of symptoms like pain or bleeding, and we need to try to figure out what’s causing it.
Dr. Fox: Yeah, and I think also it’s important that, you know, normally, from the time someone misses their period, we wouldn’t see something on ultrasound to, let’s say, around…I don’t know, let’s say five weeks from then. So three weeks from conception or a week after missing your period. And by something I don’t mean like a baby with a heartbeat at five weeks. I mean, just it’s in the uterus, we see a little pregnancy sack. And so earlier than that, we wouldn’t normally even try to do an ultrasound. We wouldn’t say, “Oh, come in the second you miss your period, or have a positive pregnancy test.” We do an ultrasound and then we say, “Oh, it’s unknown.”
Usually, these things are occurring at a time when either someone has very irregular periods. And so we don’t really know when their last period was, or whether it’s reliable, or, you know, they got pregnant and they had an IUD in place, or they got pregnant after they were, you know, while they were nursing, or they came, you know, seven weeks after their period and we know they’re pregnant, but we can’t say, meaning it’s an unknown location and we would think that we should see it. And that’s sort of the time when these concerns get heightened, not so much if someone’s actually just four weeks. I mean, we don’t even think about it that way. And so if someone is in this…I’ll call it a situation. And as you said, it doesn’t mean it’s a bad situation necessarily, and we know they’re pregnant, but we don’t know where it is, what are the options, like, what are the possibilities of what’s going on, and then we’ll try to talk about how we figure that out?
Dr. Friedman: Right. So the most common thing that’s going on is it’s an early normal pregnancy and it’s just too early to be seen on ultrasound. The next option is that it’s a pregnancy inside the uterus, but for whatever reason, it’s not developing normally. And so we’ll turn into what sometimes we call like a chemical pregnancy, or a miscarriage, or something like that. And then the third option is what I referred to earlier, which would be an ectopic pregnancy, which is a fertilized egg, but implant’s somewhere outside of the uterus, whether it’s in a fallopian tube, which is most common, or sometimes even the ovary, or just outside of the pelvic organs in the abdomen.
Dr. Fox: Right. And that is the one, the ectopic pregnancy, of the three options, is really the only one that’s dangerous, right? The second option is not good, right? It’s not pleasant and it’s upsetting to have a pregnancy, it’s not viable, or miscarriage, or chemical pregnancy, but it’s not dangerous to have that. Whereas an ectopic, and we had a whole podcast and this can absolutely be dangerous, it can be life-threatening. And so that’s the one we really want to be sure is not going on. And then it’s sort of like, “Okay, if it’s in the uterus, hopefully it’s a viable pregnancy. But if it’s not a viable pregnancy, again, that’s a bummer. That’s sad news, that’s bad news, but it’s not dangerous news.”
One of the interesting things that comes up is, you know, before the age of, you know, this really advanced ultrasound we have, like this didn’t exist, essentially. I mean, it existed because they never knew where the pregnancy was early on. But, you know, how much of this is sort of us doctors, you know, doing too many ultrasounds, doing too many tests and causing all this increased anxiety versus, “Oh, it’s amazing. We’re gonna pinpoint this and figure out exactly what’s going on”? I know there isn’t a right answer to this question. I’m just curious how you think about it in your own practice when doing early ultrasounds?
Dr. Friedman: I mean, I think because we generally aren’t recommending ultrasounds before, you know, too much before the seven-week mark or so when we would expect to see something. We’re hopefully not getting to this situation more than we need to. I think it’s helpful to have the early ultrasound availability for patients who are having symptoms, or let’s say patients who’ve had a history of an ectopic pregnancy before in a very nervous or at a higher risk of having another ectopic pregnancy. It’s good to kind of be on the lookout, but I think the opposite side you mentioned is something for women to keep in mind. And I know that, you know, some of my friends or whatnot get frustrated if their doctor won’t see them right away after, you know, they find out they’re pregnant. But it can cause a lot of anxiety and stress obviously if we’re not really sure what’s going on in the early stages.
Dr. Fox: Yeah, I mean, I’ve thought about this a lot because, you know, in our own practice, we routinely do an ultrasound at the first pregnancy visit, even if it’s five or six weeks after their period and we don’t expect to see a heartbeat yet. And I think the reason we do it is, number one, it’s so important to know ahead of time if someone has an ectopic pregnancy, even if it only happens 1% or 2% of the time. Knowing it in advance is the difference between, ” All right, I have an ectopic that’s gonna be treated. I’ll be okay,” versus showing up in the emergency room three weeks later hemorrhaging in your belly.
And so I think for that alone, it may be worth all of the stress we’re causing just to sort of you could potentially save someone’s life, but even not just saving their life, save them from a really horrible, painful, and distressing experience. And I think also there’s other advantages, you know, diagnosing, potentially. Twins early is an important part. And, you know, there’s other variables. But I think this idea of when you do an ultrasound early that frequently you’ll be in the situation where we say, “Okay, we know you’re pregnant, we don’t know exactly where it is, we don’t know if it’s viable yet.” I think it’s about the counseling. I think some people walk away from that thinking, “I have a problem.”
And I think that it’s important on our end to say, “No, this is what we expect to see.” And I usually prep them before the scans, “Hey, listen, you’re five to six weeks. Best case scenario, I’m seeing a little tiny black circle on there, like we’re not gonna baby, we’re not gonna see, you know, whether it’s a boy or girl, we’re not gonna see heartbeat.” So, like, yet just have the expectations like, “That’s all I’m trying to see. And so even though I don’t know yet, is it a viable pregnancy? That’s okay. We normally don’t know this early and we’ll, you know, check again in a couple of weeks.” And it’s sort of setting those expectations I think is important. And then for women coming into the ultrasounds, that’s why, you know, for this podcast, it’s important to realize if you’re having an early ultrasound, it may be too early to get “the good news of the heartbeat,” and that’s okay, that’s normal.
Dr. Friedman: Right, right, [inaudible 00:08:35].
Dr. Fox: Yeah. And so you have someone in this, again, as we’re calling it a situation, and we don’t know exactly where the pregnancy is, but we know they’re pregnant. So what are the tools that you can use to differentiate between those three options, again, a normal pregnancy in the uterus, a pregnancy in the uterus that’s there, but not normal, meaning gonna be a miscarriage, and an ectopic pregnancy?
Dr. Friedman: Yeah, so, I mean, I think the first thing we wanna do obviously is try to get a history and figure out based on when one’s last period was and how regular their periods are, or if they, you know, think they know when they conceive based on intercourse, or, let’s say, if it’s an IVF pregnancy, they definitely know when they conceive. That can be very helpful because, like you said earlier, if we based on any of those things, they are expecting that the woman is eight weeks pregnant, we would expect to see something on the ultrasound. And so if we’re not, then that can be a little concerning or confusing. Whereas if someone comes in and says, “Well, I might be five weeks by my period, but my cycles are a little long,” which means probably ovulates a little later than what the typical pregnancy dating is based off of, then it would probably make a little bit more sense for us not to necessarily see something on the ultrasound.
So I think starting with a good history is really important. And then it also, you know, is important to consider patient’s symptoms, “Are they having pregnancy symptoms? Are they having any pain? Are they having any bleeding?” Because each of those can kind of help us direct where we think this pregnancy may end up going, although, you know, none of these things on their own are diagnostic.
Dr. Fox: Right. Plus also even if it’s, you know, the difference between someone who might have an ectopic pregnancy, who feels perfectly fine, versus who might have an ectopic pregnancy but has a lot of pain, we treat those differently. And so even if we still don’t have a higher degree of knowledge of what’s going on, we certainly are gonna take the one who has a lot of pain. And we’re gonna manage it differently because that could be more concerning situation.
Dr. Friedman: Right, exactly.
Dr. Fox: Okay, so after history and symptoms, what else to use besides that?
Dr. Friedman: And then we would, you know, do the ultrasound, we’d take whatever we find on the ultrasound. And then generally speaking, if it is a situation, like, we keep calling it, of a pregnancy of unknown location, we generally recommend checking the pregnancy hormone level in the patient’s blood. And so that’s called the beta-hCG level. And that is a hormone that’s secreted when you’re pregnant and it starts at zero and kind of builds itself up on a continuous basis in the case of a normal pregnancy. And we have various values that we know, you know, when based on the value of the hCG, we should expect to see something in the uterus. If it’s below that value, we might not. And so combining that result with everything else we’ve found out can help us to interpret it or interpret the picture.
Dr. Fox: So let’s pause here, actually, and take, like, step to the side for a second and talk about this hCG, this human chorionic gonadotropin, or beta-hCG. It’s sometimes called the beta, it’s sometimes called hCG, it’s sometimes called pregnancy test, it’s sometimes called pregnancy hormone. It’s all the same thing. And this is essentially what we’re testing for. Like, if you take a urine pregnancy test, the stick is testing for this inside the urine, for this hCG. Because if it’s positive in your blood, it will be in your urine. And so explain sort of how does that work? So it’s just a hormone that goes straight up the whole pregnancy until you can map it. You know, in what way is it useful to us to have those numbers, either on a urine test or gonna be a number be positive, or negative, or in a blood test, we get an actual number value?
Dr. Friedman: Right. So, in the blood results, it should roughly double every 24 to 48 hours or so. So, in determining what’s going on with the pregnancy, it’s actually most useful to interpret it based on the trend. So we really need two values at a minimum, and usually, more to sort of see what’s going on.
Dr. Fox: Right. So you’re saying like if someone comes in on a Monday and you get a blood test and the value is, you know, 200, that itself might not be so valuable. But if you check it again, Wednesday or Thursday, the follow-up test, you know, went from 200 to 800, that’s very good. It went from 200 to 20, that’s very bad. And 200 to 250, you’re sort of, “Ah, we don’t really know.”
Dr. Friedman: Exactly.
Dr. Fox: Got it. And that’s where the creation of the beta book came about?
Dr. Friedman: Right. Everybody calls it something different, but yes, it’s where we are sort of monitoring and keeping track of the hormone as we’re trending in for our patient.
Dr. Fox: What do you call it?
Dr. Friedman: I call it the beta list, actually.
Dr. Fox: The beta list. Yeah. When I was a resident, we called it the beta book because it was an actual book that one resident would hold. And I mean, God help them if they lost that book, it’d be like, you know, the lives and welfare of, you know, 100 women is inside that book. And that is frequently something that one person oversees because you really need to be trending these results in a lot of people. Yet now they tend to be like Excel spreadsheets, or something like that because you can, you know, for a lot of good reasons. But listen, we have that in our own practice. The residents have it, like everyone who sort of runs…takes care of many pregnant women is gonna have several of them getting their beta-hCGs trended. Some people do it routinely, actually, in pregnancy for every pregnant woman. Is that something you do in your own practice?
Dr. Friedman: I do not. I don’t think that it is that helpful for every pregnancy and, you know, sometimes can cause more inconvenience and anxiety and, you know, things like that.
Dr. Fox: Yeah, and also this part of it is, like you said, it normally doubles every 24 to 48 hours, but it’s not universal, meaning there’s some people who doubles little slower, some people faster. And so ultimately, you know, I find that they’re really…in terms of early pregnancy, there’s other reasons to get it like after pregnancy, after delivery. But just in terms of early pregnancy, it’s really only useful in that time period between getting pregnant and when you would see something on ultrasound if there’s a question clinically. Because once you see something on ultrasound, you know it’s not an…or almost always, “No, it’s not an ectopic pregnancy.” And then the best follow-up test is just to repeat the ultrasound. That’s the one you’re going to go off of in terms of making decisions, unless the beta-hCG is like plummeting down, then you’re like, “Sure, it’s not gonna be good.” But that’s not typical of my sorority bleeding. Got it. Okay, so that is the beta-hCG. And the other things, people sometimes will say, “Oh, I have this number, so I must be X weeks pregnant,” like, “Oh, if it’s 4000, I must be six weeks pregnant.” How useful is that? Do you ever do that, like, look at the just one value and say, “Therefore you should be this far pregnant”?
Dr. Friedman: No, definitely not. There’s a lot of overlap and it’s really not well-established and sort of different for everybody.
Dr. Fox: Yeah, no, I agree. Okay. So, basically, you have someone’s history, you have their symptoms, maybe an exam, their ultrasound, and their hCG. So how do you use this practically, like walk me through? So let’s say I come into your office and I’m pregnant, and I have a positive pregnancy test at home and maybe I’m six weeks from my last menstrual period. And I come in and you do an ultrasound on me and you don’t see a pregnancy inside the uterus. If you saw one inside the uterus, fine, we know it’s a pregnancy. And then if you do see heartbeat, great. If you don’t, I’ll come back in a week or two. But let’s say you don’t see anything in the uterus, so then what do you do?
Dr. Friedman: Well, so while we’re doing the ultrasound, we also wanna, you know, take a look at the rest of the pelvis, the ovaries, the fallopian tubes, things like that, to make sure we don’t see anything like a pregnancy there. And assuming we’ve done, then I would have a conversation about where we are, you know, what it means, what it could mean, what the three potential options are, and the next steps, which for me would be to do an exam, just to make sure I don’t feel anything abnormal going on, and then just send the bloodwork, the beta-hCG to see where we are. And I usually start by having you repeat it in 48 hours so that we can get the initial trend and then make a decision about repeating it or what to do next based on that initial trend.
Dr. Fox: Right now, the question I get a lot is, “Okay, so you don’t see the pregnancy inside the uterus. But if you don’t see it outside of the uterus, doesn’t that mean that it’s not an ectopic pregnancy, like doesn’t that rule it out?”
Dr. Friedman: Unfortunately, no, it’d be great if that was the case. But because it’s potentially still early, you could also have an early ectopic that we’re not yet seeing on the ultrasound. And so it’s always important to kind of keep that potential in mind, even if we don’t see anything obvious. But if we do see something obvious, then we definitely need to take it seriously and talk about different steps.
Dr. Fox: Yeah, I asked you that question, I knew the answer to it. But it’s really important because one of the potential downsides of ultrasound is that if we don’t see something, people may misinterpret it to believe that it’s not there, right? And that’s not the case, right? Ectopic pregnancies, we sometimes see an ultrasound, but probably less than half of the time when they’re there, do we see them? And either we don’t see them, because like you said, they’re also very early and they can’t be seen, or, you know, they could be hidden behind the intestines, or they could be, you know, in a fold and we think it’s the tube, but it’s there.
So we don’t always see them. And so like you said, if we see an ectopic pregnancy, it’s clearly a pregnancy, or we see a yolk sac, or an embryo with a heartbeat, all right, it’s an ectopic, we’re gonna treat it. But if we don’t, it does not rule it out in that sense. Okay, so I’m coming to you, I don’t have a pregnancy inside the uterus that you can see yet, you don’t see an ectopic, but you’ve told me I still might have one. You do an hCG. What if the first hCG comes back very high? Like let’s say it’s 5,000, 6,000, or 7,000, is there a number above which you’re basically like, “All right, like, this is a problem. I should be seeing something if it’s this high.”
Dr. Friedman: Yeah. Generally, we have what we call a discriminatory zone, which really just is a fancy way of saying that there’s a hCG level above which we would expect to see something on the ultrasound, and that’s about 3,500, or so, sometimes a little lower, sometimes a little higher depending on the, you know, quality of ultrasound and the sonographer. But if an hCG comes back, you know, in the 5,000, 6,000, 7,000, or higher range and we haven’t seen anything on ultrasound, then definitely we’ll be concerned that something’s a little abnormal.
Dr. Fox: Right. I think in that situation, what we tell people is, “All right, if your hCG is above that number and I don’t see a pregnancy in the uterus, it sort of rules out the normal pregnancy option. This isn’t a normal pregnancy.” And then we’re left with, “Okay, it’s an abnormal pregnancy. We just don’t know where it is. It may be outside the uterus, it may be inside the uterus.” And then, you know, the way you manage that might be a little differently because you no longer have an option of a normal pregnancy. So doing something like a DNC, where you actually scrape out the lining of the uterus, is an option because you won’t be terminating a normal pregnancy. So that exists if the hCG is above that number. But if it’s below that number, so it’s some number below 3,500, it’s, you know, 200, 600, 1,200, and you repeat it in two days later, so what might happen? Let’s say it goes up a lot in those two days.
Dr. Friedman: Yeah, so if it “doubles or more,” then we are hopeful that this is a normal hCG trend, which is representing a normal pregnancy. And if the patient is symptomatic and it’s rising appropriately, depending on what the level is, I’ll usually repeat it in about a week or so, or if it’s close enough, you know, getting closer to that discriminatory zone, we’ll plan for the patient to come in for another ultrasound in a few days to a week or so to see if we can see anything at that point.
Dr. Fox: Got it. So if it goes up by a lot, it’s good news, although not definitive. And then either you’ll check the blood test again, you know, if it ever went from 40 to 80, but you’re just still a ways off from getting to 3,500. But if it went from, let’s say, you know, 1,200 to 2,400, you can predict that in, you know, 2 to 4 days, it should be above whatever number you see. And then you could do an ultrasound and then you’ll, again, know it’s in the uterus, but maybe not yet know if it’s viable or not until you wait a little bit longer to find a heartbeat.
Dr. Friedman: Correct.
Dr. Fox: Okay, what if it goes down a lot? What if it went from 200 to 50?
Dr. Friedman: So, generally, if it goes down a lot, it’s often signifying, you know, some kind of abnormal pregnancies that’s really just taking care of itself. You know, you’re having a miscarriage essentially. We will often call that a chemical pregnancy if it’s so early that we have not yet seen anything on the ultrasound. But if it’s going down on its own, again, we usually just keep trending that to zero to make sure that it’s really totally negative, but we will really expect not to see anything on the ultrasound after that point.
Dr. Fox: Now, if it drops by a lot, does that mean it is not an ectopic pregnancy, or could an ectopic pregnancy drop like that as well?
Dr. Friedman: It could. But usually, if it’s an ectopic pregnancy, it will then plateau, which is why it’s so important to keep monitoring the hCG until it gets back to negative.
Dr. Fox: And when you say plateau, you mean it stops going down or up, it just sort of hovers around the same…
Dr. Friedman: Right, kind of hovers in the same region.
Dr. Fox: Got it. So if you have someone, let’s say, the first one, you know, they did was 600, and then two days later, it’s still 600, how do you manage that situation? Does that mean they have an ectopic, or does that mean it’s just more suspicious of an ectopic and what might you do?
Dr. Friedman: Yeah, so at that point it’s definitely more suspicious, but it’s not diagnostic. I would probably do another ultrasound, just to see if anything has come up in the meantime that we can see, probably, again, depending on patient stability and symptoms, consider repeating it one more time in 48 hours or so. But then that’s also when you wanna start having the conversation about, “Well, this is fairly concerning for an ectopic, so perhaps we need to do some kind of intervention. Whether it be medicine or surgery, we can get into that in a little bit.” But, you know, those both have pros and cons and differences in terms of diagnosis and diagnostic abilities.
Dr. Fox: Right. And once we’re having that discussion, it’s really only at the time when we are certain it’s not a normal pregnancy, right? When we know it’s an ectopic, we know how to treat it. And if we know it’s a normal pregnancy, there’s nothing to do obviously. But if it’s sort of the situation where we know it’s not normal, but we’re not sort of it’s an ectopic, or it’s an abnormal pregnancy in the uterus, there are options of what to do and there’s different treatments. But that’s when you start dealing with, you know, procedures, potentially, or medications. None of that you would do if there was still the potential for a normal pregnancy, unless you thought someone had the really crazy rare thing of two things at the same time, which has happened to have a normal pregnancy inside the uterus and an ectopic pregnancy at the same time, like twins, one inside, one outside. That is unusual, but it’s tough because then sometimes people have a normal pregnancy, but they also have signs and symptoms of an ectopic and you have to figure out whether to operate on them or not. And that’s tough. Have you had those in your career?
Dr. Friedman: I don’t think personally, but I know that we’ve had a couple of patients in our practice. That’s pretty rare. It’s like 1 in 10,000 or so, right?
Dr. Fox: Yeah, it’s really pretty rare. And it’s tough because since you see a normal pregnancy in the uterus, it almost always means they can’t have an ectopic. And so when they do have an ectopic at the same time, if they are that 1 in 10,000, the diagnosis almost always gets delayed until they have a lot of symptoms, because otherwise you never even think to suspect it and you don’t see it on ultrasound, and again, until it’s more advanced. So that’s a tough situation. But again, that’s very, very unusual in that sense.
And in terms of expectations, when someone finds themselves in this situation, how does it typically play out? Is this something that usually someone’s gonna have it figured out within a couple of days, a week or two, or can it go on for months? Like what’s your experience because sort of you’re our lord and czar of the beta list? So how does it work? Just so people understand sort of what to expect if they find themselves here, how quickly will it get resolved one way or another?
Dr. Friedman: You know, it’s a little hard to answer that in a black and white answer because it really depends on what you’re coming to the picture with and, you know, how early you were and what’s going on. But I would say that the vast majority of people have things figured out within a week or two, sometimes just a couple of days, you know, sometimes a little bit longer, depending on how things go.
Dr. Fox: Yeah, yeah. I think that’s an important point because sometimes I’ll tell women, “Based on the circumstances, all right, we’re gonna have this sorted out in two days, or this is gonna take a week, or you’re not gonna go for two to three weeks, based on the circumstances.” And that’s something we cannot always but often predict. Like if someone’s story, if someone comes in, and it’s a story very suggestive of a miscarriage. You know, they missed their period, then a week or two later they had, you know, bleeding and cramping and then they got lighter and then do an ultrasound, you don’t see anything and their beta’s, you know, 200. You’re like, “Listen, it really sounds like you had a miscarriage. I’ll check your beta in two days.” And if it went from 200 to 20, like, we pretty much know that’s what happened.
Whereas on the other side, you can have a story that’s completely confusing. You don’t know what’s going on. I tell you, “This is gonna take a couple of weeks to sort out.” And I think if you’re in that situation yourself, not only is it important to make sure that you’re getting these tests, but maybe say, “Hey, you know, what’s your gut? How long do you think this is gonna take to figure out, or what do you think is happening and how are we gonna learn that?” And you may get a better sense, again, just so the expectations align with the reality of what’s going to be. Got it. Very nice. All right, Friedman, czar of the beta list.
Dr. Friedman: Yeah, sorry to anybody who keeps getting calls from me about getting your beta drawn, but we’re doing it in your best interest.
Dr. Fox: Yeah, this is something where sometimes doctors will chase you down for this because we are always fearful that there’s someone floating out there with an ectopic pregnancy that we don’t know about. And so we tend to get very protective on people on this list and their numbers. So please be kind to us. If we make you get many blood draws, it’s not just for our records. It’s for your health and wellness.
Dr. Friedman: Exactly.
Dr. Fox: All right, Caroline, thank you so much for coming back out to the podcast, taking time out of your busy schedule to all the people lined out the door to see you. And I’m sure we’ll have you back on, because as I said, you are the podcast sensation.
Dr. Friedman: Good. Can’t wait.
Dr. Fox: Take care. Thanks. Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com, that’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.
The information discussed in “Healthful Woman” is intended for educational uses only and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.