“Breastfeeding: Supporting Women vs. Lactivism – with Courtney Jung PART 2

Courtney Jung and Dr. Fox discuss the potential downsides of breastfeeding advocacy and the fine line between promoting breastfeeding and shaming women who can’t breastfeed. They also discuss choice regarding breastfeeding and how race and class factor in.

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Nathan: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics of 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. Two things you said I think just are so important and hit home with me. The first about, you know, who your book spoke to. We had a couple on our podcast a little bit of time ago, the Briefs. They had their third child through a gestational carrier, that she wasn’t able, after her second child, she has complications, so she had to do her third. And she was…I remember because I spoke to her towards the end of that pregnancy, so she’s anticipating her gestational carrier is about to deliver, and she was distraught that she wasn’t gonna be able to breastfeed. And she was talking about various, you know, medications you could take to do this, do that. And I remember just asking like, “Well…” you know, like and she, you know, she breastfed her other kids and she was, you know, really supportive. And I said, you know, “I think that’s great but what’s your concern?” You know, she, you know, gave the whole list and I said, “You know what? Read this book.” And so, I literally I went to my shelf, I pulled out the book, she was in my home, I gave her your book. And, like a day later, she gave it back to me. She’s like, “I was up all night reading this book. Thank you.” And like that was it, she’s like, “I’m good now.” This is, you know, she has a different perspective. 


And, you know, thank god that the baby’s beautiful and healthy and wonderful. And I think she’s definitely disappointed in the sense that she’s not breastfeeding because she had a really good experience or a positive experience with her other children but it’s no longer that sense of shame, guilt, you know, horror that somehow she’s, you know, unable to provide for her children that she could before. And I think that that’s really where the book is so critical. It’s not meant to be, you know, as you wrote it, and I don’t recommend it to people sort of like, “Here’s your argument not to breastfeed,” like, “don’t breastfeed.” No, it’s, if it turns out that it’s not the right thing for you, for either because you can’t, like physically you can’t, so you can’t produce enough milk, or circumstances are such that you can’t, or because of work you just can’t, it’s okay. Like, you know, these are choices people make and, in the grand scheme of things, for the health of our children, it’s not, you know, the biggest health decision we’re gonna make in their lives. It’s a decision but like everything. And so, that’s the first point, and so, that really hit home with me when you mentioned that. And the second thing is this idea about, “Is this a liberal or conservative position?” And I look at it the same way you do, it’s really how do you view the idea of choice. I mean I think in truth, in great truth, it’s not liberal or conservative, I think, in theory, you know, everyone sort of agrees with the idea of choice is just sort of where we choose to enforce it in that sense. 


Courtney: I like the irony of you saying where we choose to enforce. 


Nathan: I mean it’s really…because, I mean, you think about it which position is truly the, quote-unquote, feminist one? Is it, you know, the idea that breastfeeding is empowering, which is true in a sense, or the idea that you have a choice over how to feed your own children? And they’re both sort of, quote unquote, liberal or feminists or whatever positions but they should work together, they’re not opposed to each other that, if someone makes the choice to not breastfeed, you know, that doesn’t mean that there’s something horrible going on. 


Courtney: Right, absolutely. I think it’s important to think of both of those as potential or real feminist positions. Right? You know, and that they needn’t be contradictory. Some women absolutely do feel like, “I am a woman, hear me roar,” you know, “watch me for I am breastfeeding my child and this is the power of my body.” And I get that, I totally do and that’s cool. But it’s also the case that some women will choose not to breastfeed and some women can’t breastfeed. And that does not make them less women. That’s what’s really really important. It doesn’t make them less women and it doesn’t make them less parents. 


Nathan: Right. And I really think that there are problems with the messaging. There’s a great quote at the end of your book, it says, “But it is not choice that is the enemy, there’s a difference between supporting a woman’s decision to breastfeed through policy changes, like improved maternity leave, flexible work schedules, and on-site daycare facilities, and compelling women to breastfeed by a demonizing formula, ‘A woman should breastfeed because she wants to, not because someone tells her she has to.’” And I think that’s just the difference…I mean I know, in my own hospital, there’s a big initiative and, you know, the hospital I deliver at is a, quote-unquote, “baby-friendly hospital,” which is itself an odd name. But they had all these posters on the wall saying, you know, “Breast is best,” “everyone can breastfeed,” “you should breastfeed,” you know, “it’s great for your baby,” “everyone wins.” All these types of signs. And I was taking care of a woman…and, you know, the poor thing, she’s HIV-positive, she’s not supposed to breastfeed her child because it’s recommended she not breastfeed if she’s HIV-positive. And not only does she have to, you know, have a baby and work through the fact that she has HIV and now worry about as her baby and HIV, now there’s a sign on the wall telling her she’s a bad mother for not breastfeeding as well. And I’m like, “This is horrible.” This is like a good idea gone totally bad for such a…and it’s not an insignificant subset of people, there’s a real subset of people who can’t breastfeed. And now it’s just shame that we’re putting on them and it’s really horrible. I was so upset by that. 


Courtney: Yeah. I have a niece who I adore who had breast cancer, a few years ago. She has the breakage gene, so, you know, she got breast cancer when she was 32 or so. And she had a double mastectomy, and chemotherapy, radiation, etc. And then, a couple of years after that, she got pregnant, which was, you know, absolutely amazing and wonderful and so life-affirming. And when she went to interview, she, you know, hired a doula like people do, and she was interviewing a doula. And she explained that she had had a double mastectomy. And the doula actually said to her, “Well, then how are you going to breastfeed your baby? What’s your plan?” and she said, “I’m not going to breastfeed my baby, I’ve had a double mastectomy.” You know, and it’s just mind-boggling that people…you know, it’s not possible that you’re not going to breastfeed your baby. And then, what happened, you know, she also felt terrible. The day that, you know, she was in labor, she and I were texting and she texted that she…I said, “Are you excited? This is incredible,” you know, “in a few hours, you’re gonna have a baby,” and she said, “I just feel really awful that I’m not going to be able to breastfeed.” And I was in the car and I pulled over and I called her and I said, “Kia, [SP] listen to me. I need you to listen to me right now, your baby is not going to be any worse off for you not breastfeeding her. There’s not going to be any bad outcome. But your baby may be worse off if you feel shame and sad that you’re not breastfeeding her because she may be able to pick up on how you feel and your mood. And you need to feel confident and happy about everything that you’re doing with this baby because you’re doing everything right.” And she’s like, “Okay. All right. I got it. Okay, I’m good. I’m doing this.” 


Nathan: Not all women have you to call them. I mean they have your book potentially, someone recommends it to them, but it’s… 


Courtney: You know what? I would be honestly happy to call, to get everyone on the phone… 


Nathan: Let’s do it. 


Courtney: …and give them that little speech. 


Nathan: Yeah, I can’t agree more. 


Courtney: Because I feel it’s like, “Oh my god, the pain that this is causing women, it’s just unbearable. I cannot stand how this is making women feel.” And that, you know, strangely enough, I didn’t even know that until after the book was published.” You know, because it wasn’t until then that women started emailing me and calling into radio shows and, you know, literally in tears, saying, “I feel so awful.” It can make you cry what we’re doing to mothers. It’s just so wrong. 


Nathan: Yeah. And I think that it’s something that so many people have to be mindful of. I mean think of that simple thing where, you know, a hospital is trying to support breastfeeding. Which is great, right? They wanna make it easier, they have lactation consultants who are there, and the nurses are all trained to help women. And it’s fantastic, like that is a great idea to have the hospital, the postpartum area, help women with initiating breastfeeding and doing it. Great. But then, someone has the bright idea, “Okay. Now let’s sort of reward hospitals who do this better and give them a baby-friendly distinction. That’s what we’re gonna call it, and you win like a baby-friendly distinction. And in order to do this, you have to do A, B, C, and D.” But number one part of those things are withholding formula to women who, let’s say, choose not to breastfeed or can’t breastfeed, and then, they have to sort of, you know, beg for it or go through this whole long explanation of why it’s okay for them to do it. And just the name. Like, “Okay. Does that mean, if I’m not breastfeeding, I’m not being friendly to my baby?” like, “does that mean I’m being mean to my baby?” Like what does that even mean? What’s the messaging we’re giving women who can’t or choose not to breastfeed? 


And then, it has the exact opposite effect of not being supportive. It’s the opposite of supportive for all those women who aren’t breastfeeding, it’s literally a chain. And it’s terrible. You know, it’s a great idea, on the front end, and it becomes horrible for the other women. It’s hard and this is something that it starts with, I believe, the medical profession. I think that, as doctors who take care of these women, both obstetricians, pediatricians, I think we have to be honest with women about the difference between sort of the recommendations on the book. Right? the recommendation is, “Exclusively breastfeed your child for 6 months.” Okay. That’s what the American Academy of Pediatrics says. Fine. But between that and the nuance of, “Well, why?” right, you know, “what is the benefit? How great is the benefit? What’s the magnitude of the benefit? Is it gonna work for you?” and, “if it doesn’t work for you, to sort of, you know, put it in context that it really is okay and we’re not talking about a risky thing to not breastfeed and that formula is safe and the industry is regulated.” You know, all those things that go into that so that women feel confident with whatever choice they make. But then, it goes up into the level and all the policy makers who, either on a hospital level or on a, you know, population level, start making these policies, they have to be very mindful of the other end of the equation. I guess that’s what you call the political scientists. 


Courtney: Who would’ve thought that the political scientists would wade in on this. 


Nathan: Right. And there’s two other aspects I want to touch upon and the first you mentioned at the very beginning, which is a hugely important topic and is, in a good way, been raised again, at least in this country, and this idea of race and disparities and the fact that, as you mentioned, it seems to be that breastfeeding has become a way to divide people by race and potentially even discriminate against people of color for example. Because if they, as a community, they’re breastfeeding less sort of by definition, we’re shaming them more. And I was wondering if you could, you know, touch on that, sort of what you learned based on that initial conversation you had which sort of, you know, struck you to where you are now. 


Courtney: Right. So, in the United States, it is the case that breastfeeding is associated with class status, with levels of education, and race. So, white women who have higher levels of education and who are middle-class or upper-middle-class are much more likely to breastfeed than black women and women who are poor and women who have less education. So, there are clear race and class disparities between breastfeeders and non-breastfeeders. So, you know, what we would say, in political science, is that breastfeeding is highly correlated with race, class, and education. So, what we’re doing, in the United States, is we’re elevating the breastfeeding practices of white middle-class educated women to be the national standard. And then, we’re saying everybody, “Who doesn’t meet that white middle-class standard of feeding practices is not doing right by their baby, is a bad parent.” And so, what I would say is that breastfeeding is then doing the work of policing the boundaries of race and class. So it’s reproducing discriminatory tropes about who’s doing the right thing and who’s not doing the right thing in the United States. 


And then, when you elevate breastfeeding to a public-health issue, then it becomes something that we need to do in order to be good citizens. So, you know, the United States…or “The Journal Pediatrics,” which is the journal of the American Academy of Pediatrics, published a study, a few years ago, stating that if, you know, more women breastfed longer, if all women breastfed for as long as they’re supposed, then the United States would save 13 billion dollars a year. And so, then every single woman who’s not breastfeeding is a bad citizen who’s costing…you know, not just endangering the life of her own child but also costing all of us a great deal of money. So, you know, then there, again, you’ve got some people, namely white middle-class people, are not just better parents but then they’re also better citizens. Right? You can see how this all works. Right? So yeah, it’s interesting how something as seemingly innocent as breastfeeding, right…like what could possibly be wrong with advocating breastfeeding? But then, when you weave it into the existing sort of fissures of class and race in the United States, you can see how breastfeeding also, the language of breastfeeding and breastfeeding advocacy actually gets used to reinforce the ideas we already have about race and class differences. 


Nathan: Wow. And it’s so interesting because, again, you wouldn’t think that that would be an intended consequence of the people who are, you know, advocating it with such zealotry. But it is, this is ultimately what happens when you take it to that degree. And it can cause a lot of harm, which is, again, why we have to be so careful with our messaging. And that’s from bottom up, from top down, just across the board we have to be really careful. Which is, you know, again, why I love your book and what you did in writing it. I wanted to read the last paragraph of your book sort of to put like a period on what you said before talking about breastfeeding, “It’s nowhere near as important as loving your child very much and letting her know it, it’s not as important as putting your child to sleep on his back or securely buckling the seatbelt or finding a good nanny or daycare, it’s not as important as talking and listening to your child, it’s not as important as putting dinner on the table, making sure the crib is safe, keeping an eye on her growth and building self-confidence, it’s not as important as putting a roof over his head. And it’s definitely not as important as simply carrying a great deal.” And I think that that’s such an important message for parents, for parents to be, for our policy makers, for our doctors, for everybody to put this in perspective into context about what truly is important for public health, for our children’s individual health, for our own health, and not to focus so much on just one small aspect and to go overboard with it. And so, that’s such a huge message, an important message, and one of the many reasons I highly recommend “Lactivism” as a book for anybody who’s interested on this topic or anybody who’s just nursing or thinking about it, or thinking about not doing it, just to get more information. Again, it’s not meant to convince people not to, it’s just I think really good information and perspective. So, thank you. You know, since you’re interested in this topic and we’re in the pandemic, we were discussing before that there’s a lot of really interesting information coming out about breastfeeding during the pandemic. 


Courtney: Yeah. So I’ve been doing a little bit of research on that because it occurred to me that we might be, you know, in a different moment now. And it turns out…I think a lot of people are assuming that, during the pandemic, moms are home, and so, breastfeeding is sort of unproblematic now. Right? That breastfeeding rates are going to surge during the pandemic or they have surged during a pandemic. I think that what I’ve found is that there are two things that are happening in the context of COVID. And the first thing is that women are expressing greater interest in breastfeeding. So, there’s a lot of evidence that there’s been an uptake in phone calls to breastfeeding advocacy groups and breastfeeding support groups and organizations, like La Leche League, about how to increase milk supply, so reduce the dependence on formula, and also how to start breastfeeding again if you’ve already stopped breastfeeding. And the reason for that, presumably, is because people are, you know, in the context of a global pandemic, people are really concerned and hopeful that breastfeeding is going to be protective against infection. Right? There’s a lot of interest, people are more committed than ever to breastfeeding. 


But at the same time, a lot of the supports that were in place before coronavirus have disappeared for women in the context of…you know, since March in the United States and in Canada. Also in Europe. Most hospitals cancelled their prenatal and breastfeeding classes during the pandemic. And a lot of hospitals have adopted a policy of discharging patients even as soon as 6 hours after an uncomplicated birth in order to get mothers out of hospitals because of the risk of, you know, contracting COVID in a hospital environment. So you can imagine completely what the logic of this is but what it means is that, that access that you were talking about before, you know, it’s been a pretty standard part of postpartum practice in hospital for at least a decade now, I would say, to have a lactation consultant come in and talk to a woman after giving birth. So, most women who are giving birth in the time of COVID are not getting access to that first consultation with a lactation consultant. So they’re not getting that crucial first lesson on how to latch the baby and, you know, how to tell if your baby is actually eating, you know, looking at her neck and stuff like that. So they’re not getting that. 


And then, once they get home, all they have access to is, you know, Zoom consults with people. So nobody’s actually…there are no in-person supports for breastfeeding anymore. And they also are isolated from friends and family who might be able to help, give support, etc., etc. So, really a lot of that breastfeeding support that we took for granted, before the pandemic, has disappeared during the pandemic. And another thing that is different is mental health, which I guess, you know, should not be surprising to us. But there was one study of new mothers that showed that 15% of new mothers register signs of depression before the pandemic, but over 40% scored at or above the range for depression during the pandemic. So, under normal circumstances, experts say that postpartum depression affects one in seven new mothers. And now the numbers that we’ve got with 40%, that’s about three out of seven or, looked at another way, just over one in three. So we’ve got depression at much higher levels than we normally have. 


And that same study also found that moderate to high anxiety jumped from 29%, before the pandemic, to 72% among new mothers during the pandemic. And, you know, we know that mental health and anxiety are closely related to breastfeeding in the sense that, you know, anxiety and depression can impede milk production and can impede a mother’s emotional capacity to breastfeed. But it’s also the case that, you know, many people have pointed out that pressure to breastfeed also contributes to postpartum depression. So that’s a tangled nest there between mental health and breastfeeding that works…I mean and by “tangled” I mean, you know, it works in both directions. There’s a lot more, there’s a lot going on out there with breastfeeding and new mothers in the time of coronavirus. The pressure is higher because we’re in a global pandemic and breastfeeding is considered to be protective against so many bad-health outcomes. So the pressure is higher, mothers’ commitments to breastfeeding are higher, and the barriers are also higher in the sense that the supports are not there and depression and anxiety are way up. 


Nathan: Yeah, I mean I think that that’s so important, what you’re talking about on many levels. And this idea that, you know, with the pandemic, there was such a drastic and sudden change in how we normally do things. And when you do that in a society, there’s a lot of consequences to that. Again, some of them are good. meaning we probably lowered the rate of people getting COVID by them getting out of the hospitals, so, you know, in the one sense, that’s good but essentially all of these, you know, support systems that were in place for women who were planning to breastfeed or interested in breastfeeding…again, which we’ve always said are good, like it’s good to have support systems in place and, you know, encouragement and support and, you know, whatever it is that they might need to help them. And so much of that was done either during educational classes in person…you really can’t do it over Zoom, you know, the lactation consultants tend to be very good when they’re hands-on literally, showing you, you know, the position of the baby and…and it’s not…you know, you could do something over Zoom but clearly this is something that’s gonna require ideally hands on. And also, just those first few days in the hospital, which is when…you know, the first 24 hours in hospital, the baby doesn’t tend to eat very much because there isn’t breast milk, there’s just the colostrum. So there’s very little volume coming out. So they work, you know, on the latch. And also a lot of the babies, the first 24 hours, are very sleepy, they don’t tend to have as good of…you know, some do, some are…you know, they pick it up right away. But many babies, it takes a little bit of time, and those first 2 days in the hospital was a time when many women would, you know, either on their own or with the help of the nurse or lactation consultant figured out. So, when you remove that suddenly, that doesn’t happen. And so, then they go home. 


And on top of that, the support systems that women typically had in place even at home, right, whether it’s their mother, their sister, their aunt, their friend, a lactation consultant coming to their home, they’re not there to help them either. And so, women are left, you know, them or they and their partners, to figure it out, so to speak, on their own. And that’s another huge barrier. And like you said, with mental health, part of mental health is just the stress of the pandemic itself. Number two is many women need support at home to maintain their mental health. You know, it’s hard to sleep at night, some of them had C-sections and much more difficult recoveries, let’s say. And so, if you’re on your own, so to speak, it’s harder to maintain good mental health. And, you know, general isolation leads to that. But what I think is fascinating about all this is, like you said, it’s pulling in different directions but this is also one of the consequences of this sort of corona-COVID tunnel vision we had that, you know, everything was focused on lowering the risk of people catching this virus. Obviously that’s a good thing for people not to catch the virus and I’m not even saying that the policies were wrong, this is just, you know, commenting about it in general. When you do that, there’s so many unintended consequences that could have serious implications to people’s well-being and health. And if breastfeeding is truly such a public-health issue, well, that sort of fell by the wayside during this other public-health issue. And it’s sort of like, “Well what is the message? What really is important?” And I don’t think that there’re people who are, on a population level, equipped to figure this out quickly and to act. I think there’s so much that we don’t know and so much that is hard to figure out that, you know, everyone just sort of says, “All right, we’re all doing this,” and everything else, you know, hope it works. 


Courtney: You can hardly fault hospitals for thinking, “Let’s get,” you know, “mothers in and out quickly,” because hospitals are dangerous places because they’re also treating, you know, COVID patients. That makes total sense. And yet, you know… And yet. 


Nathan: Yeah, I certainly don’t blame the hospitals on this. And I don’t even…I don’t blame government or public health, I mean everyone’s…obviously we’re faced with something that is new, that was…I think the word being thrown about is unprecedented, I hear it 14 times an hour. But it’s true, like no one’s, you know, had this before, and so, they’re just trying to make decisions on the fly. And every decision that we make on a population level is gonna have ripple effects that are, A, predictable and, B, unpredictable. And again, so be it. Right? If we’re trying to, you know, save everyone from, you know, getting very sick with this virus, okay, you gotta do what you gotta do, but there are gonna be these effects. And like I said, they’re very hard to work out on the front end because it would take months of committees and huge numbers of people trying to figure this out. And by the time you figured it out, it’s already…you missed your opportunity, you know, to intervene. And so, this is something that just happens but people have to be mindful of it that this is gonna be a consequence, potentially, in this era and maybe how to adjust for it as best as possible. 


Courtney: Yeah, absolutely. I mean so much has changed during the pandemic. You know, things that we never imagined possible have happened. And it would be really nice if one of the things that changed during the pandemic is that we started to respect women’s choices around infant feeding and we thought, “You know, what? This has been a really tough time. A lot of people are facing, you know, this pandemic under really different circumstances with different pressures and different obligations and different resources.” And therefore, we should just basically say, “You’re doing the best you can, you’re dealing with this and in the way that’s best for you and that’s good enough for me.” 


Nathan: Yeah. I think that’s a really good point and also I think, you know, a pandemic like this, not only is it true during the pandemic, but it gives people this perspective about there are problems and then there are big problems. Right? And so, you know, whether a woman does or doesn’t breastfeed, call it a problem, don’t call it a problem, it’s a decision. But, you know, big problems is, “Are we gonna have, you know, thousands and hundreds of thousands of people dying from a virus as a public-health issue or what are we gonna do with school for all of these children now?” Right? Which is a huge issue. “How are we gonna educate our kids in this environment, both, you know, academic education, social, emotional?” All of these things that I think most people would agree are bigger issues that our society is facing, and to sort of put some of these others into proper context. 


Now, I know one of the things I was always saying is, when the pandemic hit, it’s, you know, March-April, it was literally like a week after, in New York City, they had this whole thing about plastic straws and plastic bags. And I remember, in March-April, I said like, “We’re not talking about the plastic bags anymore, we’re done with that conversation.” That has been bumped down 12 levels. Because everyone was so angry about the straws and how we’re gonna use them and not using, what we’re gonna do. And I’m like, “You know, you are living in times of luxury if we’re arguing about plastic straws.” Right? That is like…times are good if that’s our biggest issue. And then, suddenly, boom, pandemic hits. We’re like, “All right, we can deal with the straws, you know, in another year.” And I think it’s the same concept, you know, that we we realized how fragile life can be and how fragile society can be when there’s something thrown into it that’s different. And life and death chronic, you know, health, education, poverty, you know, and now [inaudible 00:30:37], you know, social unrest and racism. These are such huge issues that have come to the forefront. And it really puts into context a lot of the other things that we’ve been arguing about for years, again, out of a sense of, I would say, luxury. 


Courtney: Yeah. It would be really great if the pandemic had the impact of changing the conversation around breastfeeding and just, as we’ve said, respecting people’s choices and giving moms more leeway. 


Nathan: I’m so happy you agreed to come on. I really appreciated this conversation. As I said, I read your book and loved it immediately, I recommend it to many people. Do you have any plans for doing anything with this further or are you sort of, “I’m out of the breastfeeding world.”? You know, “No more,” you know… 


Courtney: I don’t know, I don’t know. If anything happens, I might wade in again. But I feel like, you know, I’ve said what I needed to say. When I first started thinking about it, I thought, “Oh, there’s not gonna be enough there to write a whole book about this,” really I’m just gonna be like writing a pamphlet or I’ll be a pamphleteer. And then, it just, you know, took on a life of its own. But now I’m done. I’ve said what I needed to say. But if something happens, if something changes, don’t worry I’m keeping my eye on it and I’ll wade in again. 


Nathan: Excellent. Well, again, the name of the book is “Lactivism,” for my listeners. If you have any, you know, questions about this or comments, you can always send them to us at the podcast at our email at hw@healthfulwoman.com. I can always forward them on to you. But this is a really important topic, it’s something a lot of people talk about. And I just think it’s really great that you took this project on and you did it the way you did. And it was great to meet you and I really look forward to speaking to you again. 


Courtney: Thank you so much, Nate. I appreciate it. 


Nathan: 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 H-E-A-L-T-H-F-U-L W-O-M-A-N .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. 


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