“Induction of labor and the ARRIVE trial” – with Dr. Anum Naseem

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. Dr. Naseem Anum, welcome to the podcast. This is your maiden voyage onto this podcast. It’s great to have you.

Dr. Naseem: Thank you. I’m happy to be here.

Dr. Fox: Wonderful. So, you joined us recently from the great state of Illinois, from Chicago, from Northwestern. And because of that, you obviously felt like personally attached to this ARRIVE trial because it was sort of based primarily out of Northwestern. It was multi-centered, but it was really not as… Is this something… Do they have, like, t-shirts there like I’m part of the ARRIVE trial or banners on the wall? How does it work? Do people talk about it a lot there?

Dr. Naseem: Yeah. We actually all get tattooed ARRIVE trial. It’s part of our initiation as interns. Yeah. And it was definitely a big part of my training. And yeah, I feel like there is a certain pride with the ARRIVE trial, you know, coming from Northwestern and how much we talked about it there and how much it really changed practice there.

Dr. Fox: That’s awesome. So, before we get knee-deep into it, for our listeners who have not met you yet, unless they’re patients of ours and had the pleasure of meeting you in the practice, but for our listeners throughout the world, who are you? Who is Dr. Naseem? Where are you from? What’s your story? What do we need to know about you?

Dr. Naseem: Yeah. So, you know, you already kind of gave it away that I’m a midwesterner. I’ve heard you say in the podcast before means that I’m pleasant, right?

Dr. Fox: You’re pleasant disposition. We’re very polite people in the Midwesterners. Yeah.

Dr. Naseem: Yeah. So I was born and raised in Michigan. I was there for undergrad, med school, and then I had the privilege of being at Northwestern for residency. So I was there the past four years and I ended up here mainly for family, friends. My sister lives here and wanted to change the scenery too. What more of a change of scenery than Manhattan?

Dr. Fox: Right. Have you been mugged yet? No? Not yet?

Dr. Naseem: Not yet. Not yet. I have been safe. I’ve seen a couple of cockroaches on the sidewalk and that scarred me enough.

Dr. Fox: Okay. Okay. That’s fine. All good. Yeah. It’s a transition going from the Midwest to New York. Some of it is great, like, some things are awesome and some things are a little surprising.

Dr. Naseem: Yeah. Yeah, I know. I’m very happy to be here. It’s been a wonderful transition and everyone here at the practice has been phenomenal. So, yeah, it’s been great.

Dr. Fox: And how has it been transitioning from residency training, which its own culture, its own world? It’s really something unlike anything else on the planet being a resident to, like, now you’re sitting in an office, you know, wearing fancy clothes when people come in and ask you your opinions and you’re taking care of them under private practice. How has that been going for you?

Dr. Naseem: Well, I definitely sleep more, so I’m grateful for that. But yeah, it’s been good. I think the best part is having continuity now. I think it’s hard with residency where you’re really on, like, a rotation schedule. And so you don’t really have consistent patients. And I think one of the best parts has been seeing patients multiple times, delivering to patients, seeing them for their postpartum visit, meeting their baby at the six-week visit. And that continuity, I think, has been really special. So, yeah, I’m really happy with this new transition.

Dr. Fox: Well, we’re happy you’re here as all the patients, obviously. And what we’re talking about, as you mentioned before, is this ARRIVE trial, which was really like the big trial to talk about induction of labor. But let’s take a step back to life before the ARRIVE trial. Also, when you were training there, was this pre, during, or post-ARRIVE trial?

Dr. Naseem: This was very much post. So, yeah. From the get-go, everyone was there for their elective induction. But I mean, we heard a lot about the prehistoric times before the ARRIVE trial. But yeah, I definitely trained in a post-ARRIVE era.

Dr. Fox: Yeah. I mean, just to give our listeners a flavor of the prehistoric times, as you refer to it. And you know this, obviously, but when I was training, it was essentially like the word of God, that if you induce someone’s labor, you’re going to increase the risk of a C-section. And that’s the downside. Now, sometimes you did it right. If there was a good reason to do it and we would weigh, you know, how strong is your reason to do it? And you’re sort of going back and forth. And it was something that we talked about, but it was always assumed. In fact, it was “known” at the time that if you’re inducing the labor, you’re going to increase the risk of a C-section. The reason that was known is there was a lot of studies that I would say were incorrectly done where, basically, they took a bunch of people who were…they looked at the labor floor and they said, “All right. These six people are in labor and these six people are getting induced.” And then they would see what’s the C-section rate. And they would do that over the course of a year, not just on one day. And the people in labor had whatever C-section rate and people getting induced at a much higher C-section rate. Why is that not the best way to look at this? Why is it not a good study?

Dr. Naseem: Because that’s not the option that people are faced with. It’s not do you want to be induced or do you want spontaneous labor? Everyone’s going to choose spontaneous labor. I think the decision point is you get to 39 weeks. Do you want to be induced or do you want to wait? And do you want to wait to see what happens and wait for labor? And I think those are two very different questions and I think they need to be studied in different ways because, yeah, it is true that labor is more favorable, you know, less time in the hospital, less intervention needed than an induction. But the question isn’t which one would you rather have? It’s how long are you willing to wait for labor to come on?

Dr. Fox: Yeah. And that’s a really important point. And people started to chip away at those studies again a long time ago and they would say, “All right. Listen, it’s not really fair to compare someone who’s in labor to someone who’s getting induced because the person who’s getting induced, they don’t have an option to otherwise be in labor. They have an option to just go home. Right? You don’t know what’s going to happen to them. They might go into labor the next day, but they might get induced a week later with a bigger baby like all those… And so it can work against them as well. And so they sort of started reanalyzing the data to try to find, “All right. Let’s see if we can analyze women who are around 39 weeks seen in an office and some of them are sent to be induced and some of them are sent home. Let’s look at it that way.” And in those studies, they didn’t see an increased risk of a C-section. It seemed to be the same. And people said, “Huh. Maybe it’s not as bad as we thought.” And that was sort of the impetus, I would say, to do this big, massive undertaking of a study. And it was the big deal. What did they have to do in this study to really answer this question? Does induction increase the risk of a C-section? It’s actually why they did this study, but it was one of the things they looked at. So, what did they have to do?

Dr. Naseem: Yeah. So, this study, it’s a randomized control study, multi-center, meaning, it was done in 41 different centers across the U.S., both academic, community hospitals. And those are both just fancy ways of saying that this was a very high-quality study, kind of like the highest-quality study that you could have when you’re asking a question like this. And so they recruited about 6,000 women and they randomized them to either having an elective induction at 39 weeks to 39 weeks 4 days versus expected management, which is just another way of saying doing nothing, waiting to see, you know, is labor going to come on its own or will you have an indication for induction later on? And so…

Dr. Fox: What do you mean by that? What could happen?

Dr. Naseem: Yeah. And so I do think… Yeah. I probably should define, like, what do we even mean by an elective induction? So, this population that we’re talking about is, first of all, it’s low risk, nulliparous, meaning first-time pregnant moms. That’s the study population. There are definitely medical reasons to have an induction and that is a totally different conversation. I think there’s another episode on medical induction, probably on the podcast, but what we’re specifically looking at is elective induction. So, you don’t have a medical reason, but for different reasons, maybe you just want control over the time of your delivery. You want to be able to have an idea of, like, what date and time you want to come in. You can make plans around that. Or you’re just done with the pregnancy, which I think is a very valid reason for wanting induction. So, things like that. So, it’s not a medical reason like, let’s say, if you have diabetes, high blood pressure, some sort of fetal issue where, you know, you need an induction for, like, medical reasons. Those are, I think, two very different things. So, what we’re specifically talking about today is this low-risk first-time pregnant too, which I think is an important point. So, again, an induction in someone who’s had a baby before is a different conversation than someone who hasn’t.

Dr. Fox: Yeah. It’s less likely to lead to a C-section. When someone’s had a vaginal delivery before and you induce them, the likely that it’s going to “fail” is much, much, much lower than if it’s someone’s first baby. So, we had to recruit 6,000 patients who are first-time moms, low risk, and then randomize them into two groups. So, explain what that means to randomize someone, like, logistically.

Dr. Naseem: Yeah. So, I mean, you’re basically, you know, you enroll a patient, say, that, you know, do you want to be a part of the study? These are the two, like, options that you will be randomized to. And they have to basically be okay with either option. And then, you know, kind of, like, flip a coin, and then they’re told, like, this is what you’re going to…you’re either going to have the induction or we’re going to just leave it alone and see what happens.

Dr. Fox: Right. And this is a big undertaking because, you know, if you think about that, so if you’re a researcher, you have to tell the patients, “All right. You’re going to enter the study.” And you don’t know which one you’re going to get. Right? So, you have to be okay with us saying option A, you’re getting induced within two days or whatever, or option B, you’re not getting induced. You’re going home and we’ll follow you regularly and, you know, see what happens. And their doctor has to be okay with it. Right? And so it’s a very big undertaking to recruit 6,000 people who they’re okay with both options and their doctors are okay with both options. And why is it so important to randomize people rather than letting them or their doctors choose which option they want? Why not say, “Well, which one do you want?” And say, “Okay, 3,000 women wanted this and 3,000 women wanted that, or 3,000 doctors wanted this or whatever. Why do we have to randomly do it?”

Dr. Naseem: Because that introduces a level of bias when you let someone choose. Let’s say if you’re choosing induction, then, you know, you probably have a more favorable opinion about an induction that might influence kind of your experience because that was a metric that they looked at, you know, what your experience was, undergoing either your induction or your labor. And so I think it is important that you randomize and kind of take that choice away so you can remove a certain level of bias.

Dr. Fox: Yeah. I think also one of the interesting things is sometimes if people or doctors left to choose, they’ll sort of put their own two cents into it, saying, “Oh, her service is a little bit open, so her, I’m going to, you know, induce and this person I’m not, or this person, you know, I’m a little bit more worried about her for whatever reason or my gut tells me it’s the right thing to do.” And so what you get in her as a researcher, you worry that if you find a difference or you don’t find a difference, that it is, you’re not certain it’s due to whether they got induced or not, but it could be due to other variables like differences. And so when you randomly divide anything into two groups, everything sort of works out the same way.

If you took a big box of 6,000 marbles of different colors or M&Ms of different colors and you poured out half of it onto the table, another half onto another table, and you counted, you’ll have the same number of reds and greens and yellows and blues just because that’s how things work. But if you selected, say, or I’m going to put all my oranges on one table and my greens other, it’s not going to be the same. And so it’s a really important and makes it very, very difficult. So, it is a big undertaking to do. So, they did this. They randomized 6,000 into one versus other. And what happened? Just again, the one that got induced, right? So, they basically just went and got induced and they were pretty much any way the doctors felt that they need to be induced, they induced them sort of standard operating procedure. And the ones that got told to go home, what was the end point for them? What would happen to them ultimately if they didn’t go into labor?

Dr. Naseem: So, the end point was between 40 weeks and 5 days to 42 weeks. Just somewhere between, like, 41 to 42 weeks, basically. So, that was kind of the endpoint.

Dr. Fox: Okay. So, that’s what they did. And what did they find?

Dr. Naseem: Yeah. So, what they were studying, so what they call the primary outcome was specifically looking at neonatal outcomes. So, is this a safe option for babies?

Dr. Fox: Right? Is it better? Is it worse? Yeah. Okay.

Dr. Naseem: And they found between the two groups, there was no difference. So, they used a composite outcome, meaning that they group together all these different potential outcomes for babies. So, things like NICU admission, you know, need for, like, respiratory support, seizures, you know, other, like, all these various complications just because they’re all, like, pretty low risk, and so it’s hard to, you know, do them individually, so you group them together and have kind of, like, a composite outcome. And they found that there was no difference between the two groups. I believe it was about, like, 4% in the induction group, about 5% in the expectant management group. So, that’s very good data. It tells us when you ask the question, “If I have an induction, is this safe for my baby?” This data is very high quality to tell us that it is. If you choose not to have an induction versus if you do, there’s no difference for your neonatal outcome.

Dr. Fox: Right. And then that was their primary outcome, but they, obviously, of course, looked at the rate of C-section between the two groups. And what did they find?

Dr. Naseem: Yeah. So, secondary outcome, they’re looking more at maternal risk. So, that included the rate of C-section as well… The two ones that were, like, most notable was the rate of C-section and the rate of hypertensive disorder. So, the rate of C-section was actually lower in the induction group, which I think was the big shocker of this study because as you mentioned, in the prehistoric era, it was always thought that induction, you know, essentially leads to C-section. And this was actually pretty good data saying that that’s not true, that having induction actually had a lower rate of C-section. I do think there’s an important caveat that this was a secondary outcome. So, technically, this study wasn’t powered to look at, you know, C-section rate. The primary outcome was about neonatal risk, but it just tells us that there was this association. So, it’s not to say that having induction means you’ll have a lower risk of C-section. And I think that’s, like, a really important point to make.

Dr. Fox: Yeah. I think the difference was… It wasn’t a huge difference. It was, like, you know, 1% lower or something like that. But I think the main takeaway was for pretty much everyone was not so much that it lowered it, but, like, it definitely didn’t increase it.

Dr. Naseem: Exactly.

Dr. Fox: Right? So, not only did it not increase it, but if anything, it lowered it. And so when you look at this and this is, you know, thousands of women, a lot of people, and to induce them and not have an increased risk of a C-section was really pretty mind-blowing at the time for the obstetric community. And then what did they find with, which is unexpected, right? That was all maybe was expected by some, but unexpected by most, I would say. And then what did they find with hypertension?

Dr. Naseem: Yeah. So, hypertension was a little bit more expected. So, lower risk of developing hypertensive disorder and induction group, which makes sense because if you’re waiting then, you know, potentially, you know, you just have more time to develop hypertension.

Dr. Fox: Yeah, yeah. Hypertension related to pregnancy.

Dr. Fox: Yeah, exactly.

Dr. Naseem: The more time you’re pregnant, the more time you have to get hypertension. So, that lowered it. Okay. So, the study basically showed no big difference either way for the babies if you induce the 39 weeks versus waiting. Not an increased risk of C-section. And if anything, a slightly lower risk of C-section and a slightly lower risk of getting high blood pressure, which is sort of expected at the time. So, that’s what they found. Okay. Let’s go to the mothership where it was leading the study, Northwestern. How did you guys take this data and apply it to clinical practice? I’m genuinely curious to know what was going on there because I know what we did in our practice. I’m curious what you guys did over there.

Dr. Naseem: Yeah. So, we talked to everyone about elective induction. When we get closer to term, we bring up this option that, you know, once you’re at 39 weeks, we have really good data to show that you have this option of induction if you would like and, you know, it’s a safe option. So, you know, it exists. And, you know, just looking anecdotally, I actually don’t know the numbers off the top of my head at Northwestern, but, anecdotally, majority of our patients were undergoing an elective induction.

Dr. Fox: Really? That’s what they chose.

Dr. Naseem: Yeah. But I mean, obviously, you know, at Northwestern, there is a bunch of different private groups that deliver there, and so you’re not kind of in on the conversations there. Like, I can tell you, like, conversations I had with patients or, you know, that the faculty groups had, but I’m not sure if… We always presented it as this is an option, but I don’t know if, you know, certain practices were saying like, “You should do this,” or kind of, you know, being a little bit more leading with their counseling, which, you know, we can definitely talk about kind of pros and cons of that. But I think another big takeaway from this study, and I think kind of comes into, like, the big criticism of this study is the practicality of it. So, yes, elective inductions are fine, they’re safe, they’re, you know, good, but practically speaking, is this a good option?

And at a place like Northwestern, it’s one of the biggest labor and deliveries in the country, like, that was a practical option. We had the bandwidth, the capacity, the staff to be doing these elective inductions. But in a lot of other places around the country, that’s not true. And it really creates a bottleneck and, you know, makes it so that, you know, it’s just difficult to withstand like this increased volume that you have because, you know, we know with an induction, you’re going to be on labor and delivery for longer because, you know, you have to first induce labor, then you have to labor. Versus if you’re coming in labor, you’ve kind of done some of that work at home. So, it’s known that, you know, with an induction, especially an elective induction, someone who’s never had a baby before, you can expect to be on labor and delivery for 12 to 24 hours. And that really takes up a lot of space and resources.

Dr. Fox: Yeah. I mean, there’s a lot there to unpack. And, you know, I think one of the… I don’t know if it’s a criticism of the study, but this is not the study, but sort of a criticism of those who said this study shows we need to induce everyone at 39 weeks. Because I don’t think the study showed that is, yeah, like you said, it’s fine on the patient’s end, but what if I now have every labor room occupied with someone getting induced and now someone else shows up and labor and there’s no room for them and they’re delivering, you know, in the hallway? That’s not so great for her and for the baby and this or that. And so, you know, we live in a real world where there’s a hospital with X amount of labor rooms and Y amount of people who are going to deliver there over the course of the year. And if the average time in a labor room is, let’s say, 6 to 8 hours, if you show up in labor and now you’re making it 12 to 24 hours, you need 2 to 4 times as many rooms and you may not have that. So, that was sort of, like, one thing.

I think another and not so much a criticism of the study, but sort of a very typical thing that happens when you do a study and then try to bring that out into the into practices, you know, in the setting of a study, people are very tight, right? The people enrolling patients and managing these patients, they know they’re being studied, they know their data is being followed, like, they know it’s part of, like, an important process and they usually follow things to the T, right? And so they’re like, “All right. We’re going to do an induction. We’re not going to do a C-section unless A, B or C. We’re going to wait this much, you know, time. We really need to know.” But sometimes it doesn’t work like that on some labor floors. And sometimes whether it’s the doctors, whether it’s the nurses, whether it’s the patients themselves, you know, people who didn’t enroll in a study and participate in a study, they’re just getting induced, they may not have the same level of patience to wait for an induction. And they may not be cool with 24 hours start to finish. And they may say after 12 hours, “I’m out. Enough. Do a C section.” Again, could be the patient, could be the doctor, whoever.

And so sometimes results that you see in a clinical trial, you might not see some other hospital that starts to implement this without all the same, you know, things going on. And so that was, again, not a criticism of the study that says, “I didn’t do the study,” but sort of a be careful before you sort of, like, implement this everywhere, because not everyone’s going to have the same level of patience. And I think that’s a very important aspect. I mean, the average time in the hospital was, like, 18 or 20 hours or whatever it was for these people getting induced. That’s a long time. And so people need to know that going in.

It’s interesting. So, you know, when this came out, I was practicing here, it’s in New York City, and there’s no room for anybody in New York City. We’re all packed, right? Crowded. It’s like, it’s like in your apartment buildings, everyone’s on top of each other. And that’s just the reality of it. And that was a real question. Should we be, like, on one end, recommending everyone going to do some 39 weeks and you could justify it by saying, “All right. Listen, we’re not increasing your C-section risk. We’re lowering your risk of hypertension. Or should we be offering it to everyone at 39 weeks, which isn’t so much a recommendation, but hey, if you want it, it’s an option and it’s safe and A, B, C, and D. Or should we be keeping our mouth shut about it? And just if someone brings it up, we could talk about it, Buzz. And you’re sort of going medicine here. It’s beyond the medicine because it’s, like, “Well, can we do this? Can we possibly do this? Are we going to run out of rooms for people who need a medical indication?” And so every place sort of figured out for themselves what is the right way to do this?

In our practice, we didn’t have a ton of people clamoring for 39-week inductions to begin with. It just wasn’t our population. And so it wasn’t so much of a thing, but, you know, I think that, at least personally, the way it really, really helped me in practice was when I was discussing induction with people, either because they wanted it or because they had a medical indication to do it, it was a lot easier for me to tell them with confidence, “Hey, as long as we’re patient, we’re not increasing the risk of a C-section. Whatever your risk is, it is. And if we induce you, it’s not going up.” I didn’t tell them it was going down because we’re inducing because it’s such a small percent chance, but it really wasn’t increasing. And that was really helpful. There’s still people who don’t believe this data also. You hear that? You get people, “I don’t buy it.”

Dr. Naseem: Yes. Definitely. Definitely. Yeah. When every labor room was full at Northwestern and the nurses are grumbling, we definitely heard it. Yeah. I mean, I think that my approach to counseling patients about this is kind of what you’re saying. Like, I kind of, you know, more than, like, option B where I think it’s important that people know that this is an option, you know, because for some people, this is something that they would want and they just never knew that it existed. I think especially the idea that you could be induced as early as 39 weeks. I think a lot of people think, like, “Oh, like, what’s my due date? I can only really be induced if I go past my due date.” But you actually do have, you know, this option and a very safe option to be induced as early as 39 weeks.

And, you know, for some people, again, who want some level of control or, you know, are just uncomfortable and just want to be done with the pregnancy or just don’t want to take on that additional risk past 39 weeks when we know there’s really no benefit of seeing pregnant, I think it’s reasonable to offer, but I think it should be more of just a conversation, like, “This option exists, but it’s not for everyone.” I think a lot of people… It’s important, you know, people have ideas about how they want their birth to be their labor and, you know, we want to be able to support that as much as possible. So, I do think that the takeaway, I feel, that shouldn’t be that we recommend this to everyone. I think it’s just that people know it exists and if they want it, that’s great. And if they don’t, that’s also great.

Dr. Fox: Yeah. I mean, I’m very similar. I landed in the same place and I’ve said on this podcast before in different contexts. What I tell most people is that, again, unless there’s a reason to deliver earlier, and there are for a lot of people, especially in our practice, because we have, you know, the nature of our practice, a little more high risk. But in general, for everyone out there who’s pregnant, it’s really any time between 39 and 41 and for some people 42 weeks, right, from a week before to a week or two after the due date, you can support inducing at any point, right? Meaning as early as 39 or waiting as long as 41 to 42. And it’s reasonable, like, that window is reasonable.

And there are some arguments for doing a little bit on the earlier side towards 39 weeks and some arguments for waiting longer. And some of those are, like, medical things like, “Well, if I do more towards 39, I have a lower chance of getting hypertension.” Obviously, anytime you’re pregnant, there is always a minuscule chance, a very small chance of a stillbirth or something happening. It’s very, very rare. And we try not to, like, scare people about that. But someone says, “Listen, I’m really worried about that.” Okay. So, if you deliver earlier, that’s less likely to happen. And on the other end, if I wait longer, there’s a higher chance I’ll go into labor on my own. If I was looking for less interventions in labor, like not an epidural, probably a higher chance of that happening. If you want less time on the labor floor, you just want the experience to go into labor. Fine. All reasonable during that window.

And I generally let people choose for themselves. Obviously, if I think medically one is better than the other, I’ll weigh in, but assuming not and see how they play that. And then I always tell them, “If you’re choosing on the earlier end, 39, it’s possible the hospital will put you on the lowest priority, right? Because they have X amount of rooms available to be induced. They may put you on the bottom of the list, and so you may not get the night you want or the day you want or whatever it is, just because,” they’re like, “Listen, great. You want to be induced to 39 weeks, but we have to induce these twins and this hypertension patient, this diabetic before you.” And so, okay. That’s just a reality of the hospital that you’re delivering at and for some hospitals more than others.

And I think it is important for people to have a say in this for their birth, right? Because it is reasonable if they want to be induced at 39 weeks and it is reasonable if they want to wait till 41 or 42 weeks, again, based on what’s going on. And I think that’s really the takeaway from the study, not that one must or should induce at 39, but that they can and that they should be confident that they’re not doing something horrible to them or their baby. It was a big, big thing. So, do you, like, walk around and brag about this and, you know, like, “Hey, I’m from Northwestern,” because you can’t really brag so much about your sports programs.

Dr. Naseem: Oh, wow.

Dr. Fox: I went to Columbia. We can’t brag about anything there, so it’s fine. So, yeah.

Dr. Naseem: Yeah. Yeah. Yeah. No. I mean, ARRIVE trial really doesn’t come up too often in, you know, everyday conversation here in New York, but, yeah, maybe I should bring it up more.

Dr. Fox: Wonderful.

Dr. Naseem: Now the whole podcast knows.

Dr. Fox: Good. Excellent. Well, ARRIVE Trial, it’s a New England Journal of Medicine. It was published in 2018. It was a landmark study. Anum, thanks for coming on to talk about it, and looking forward to having you on again.

Dr. Naseem: Yeah, it was my pleasure. Thank you so much.

Dr. Fox: 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. It 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.