New to the MFM Team, Dr. Sadia Mobeen joins Dr. Nathan Fox on the podcast to discuss the likelihood and reality of experiencing tears, or lacerations, during childbirth. Most first-time mothers can expect at least a small tear, but these are often quickly resolved. In more severe cases, our doctors discuss the options for repairing damaged muscle or skin as well as ways to help prevent tears from occurring in the first place.
“Tears, lacerations, and episiotomies” – with Dr. Sadia Mobeen
Share this post:
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. Sadia Mobeen, welcome to the podcast. How are you doing today?
Dr. Mobeen: I’m doing good. How are you?
Dr. Fox: I’m good. So as you know, you recently joined our practice and we’re really excited to have you, and we’re really excited to have you on the podcast. How’s it going so far?
Dr. Mobeen: It’s going great.
Dr. Fox: That’s awesome. So we’re gonna be talking today about tears and lacerations during delivery and episiotomies. But before we go into that topic, just because this is your first time on the podcast, I do this with all new guests of the podcast, tell us a little bit about yourself, sort of where you’re from, how you got into medicine, and whatnot.
Dr. Mobeen: So I was born and raised in Brooklyn, New York. I went to medical school in North Carolina. The reason why I went into medicine, I saw that women’s health, at least in my community, was not really a big concern for a lot of people. So I wanted to go into women’s health and work with patients and kind of stress the importance of taking care of yourself and women’s health and going for your pap smear, getting your breast cancer screening done. So that’s what kind of drove my push to do women’s health.
Dr. Fox: And so that’s how you picked OB-GYN, I guess?
Dr. Mobeen: Yes.
Dr. Fox: All right. And were there any doctors in your family beforehand?
Dr. Mobeen: No, but now all my siblings. So I’m one of nine and…
Dr. Fox: Oh my God.
Dr. Mobeen: Like, seven of my siblings are doctors. So we have every specialty from general surgery, internal medicine, ICU, ER, you name it, family medicine.
Dr. Fox: Wow. Where do you fall in line of the nine of you?
Dr. Mobeen: So I’m number two. I’m the oldest girl. So there’s one boy and seven girls, and I have my youngest sister is going into OB, so at least I got one of them.
Dr. Fox: Wow, that is amazing. So God bless. All right, so here we are, one in nine. Well, we’re glad to have you. Let’s get the rest of them and we’ll have a whole practice. A whole OB practice.
Dr. Mobeen: Let’s do it.
Dr. Fox: Let’s do it. All right, so let’s talk about tearing at the time of delivery. I think that most people who are embarking on having a baby kind of know that that’s out there, but how do you explain it to women that…what’s gonna happen? Why does it happen? What do we mean by tearing? What is that?
Dr. Mobeen: So by tearing we mean that at the time of when you’re delivering the baby, the vagina, the labia, like, the pelvic structures can have a tear, which means that they’ll have a cut, but it can be either, like, manmade where we do an episiotomy versus the baby can just tear the vagina on its own as it makes its way. Usually I tell first-time moms that this baby’s gonna make the way for the other babies and sometimes along the way it’s a little bit bumpy and it can cause some cuts, but we do our best to put it back together after the baby delivers.
Dr. Fox: Right. And then just in terms of terminology, because we said both tears are, sort of like the colloquial term, and then laceration is sort of the medical term, but those are the same thing, right?
Dr. Mobeen: Yes.
Dr. Fox: A tear and a laceration are the same thing, just, you know, we say laceration just sounds fancier and makes us sound smarter. And then what you were talking about where we do the cut, that’s what an episiotomy is. Meaning if someone tears on their own, we don’t call that an episiotomy, we call it a tear or laceration. Whereas if we do it, we call it an episiotomy. So just for everyone listening. And how common would you say these are? Is it with every birth or most births? What would you say?
Dr. Mobeen: So episiotomies are not very common at all anymore. They occur in, like, about 5% to 10% of births. And usually, we do it, like, it’s a restrictive thing where we do it. If there’s, like, a medical indication in terms of we’re gonna do an operative delivery where we help assist the baby out with instruments, or if there is some trouble getting the baby out, or if the baby’s heartbeat goes down and we need to get the baby out quickly. I like to just talk to my patients around 37, 38 weeks, you know, explain labor and then just kind of touch base on the indications of if we need to do it, just so they’re aware, just get the conversation started.
Dr. Fox: What if we’re not doing an episiotomy and she’s just gonna give birth on her own? What is the likelihood, would you say, she’s gonna have a tear at her birth? A spontaneous one?
Dr. Mobeen: A first-time mom, usually the tear rate is, like, pretty high, like, I’ve seen 605, 70% just the first time even if it’s a small one. Yeah, most of the time they do usually and it’s a thing that happens normally. We usually repair it after the baby comes out and they usually don’t have any long residual side effects from it, from what I’ve seen.
Dr. Fox: No, I agree. I say to first-time moms almost to expect that there’s gonna be some tearing, and some are lucky and there isn’t, but usually there is. Hopefully it’s a small amount and we’ll talk about how we, sort of, grade them or, sort of, describe them in terms of severity. But it’s almost expected on first-time moms. Once you’ve had a baby, you know, second, third, fourth or whatever it is, it goes down. The likelihood of tearing, it’s not zero but it gets lower. And like you said, some of that is just the stretching that happens at the first delivery sort of makes the other deliveries a little bit easier in terms of tearing. And so how do we classify tears? Like, we have these degrees. Yeah.
Dr. Mobeen: We classify them based on the degree, like if it’s just the skin and the mucosa, just, like, the superficial layer would be a first-degree. If it involves, like, the muscles goes a little bit deeper, that’s a second-degree, which are the two, like, the most common tears that happen. But then we have something called OASIS, which is tears that involve the rectal sphincter, external or internal. And then for the third-degree, we have different levels, A, B, or C depending on how much of the sphincter is involved, how much of the external sphincter and internal is involved. And then the fourth-degree is just all the way to the rectum. So that’s just how we classify them.
Dr. Fox: Yeah, totally agree, first and second-degrees are pretty much all of them, you know, that’s gonna be 95%-plus of the tears that people are gonna have. And those are the ones, like you said, pretty straightforward to repair. They usually heal very well. They don’t seem to have much in the way of long-term consequences for women. I mean occasionally people can have complications or pain afterwards, but that’s pretty rare. But the third and fourth-degree is where it really starts potentially getting to be an issue. And that sphincter you’re talking about is basically, trying to describe it over a podcast, essentially if you think of someone’s bottom, the anus, there’s, like, a donut-shaped or a circular muscle that goes around it and that’s basically what holds it closed. And if someone’s…like, to tighten your bottom, that’s the muscle that’s gonna squeeze. And so usually after birth that’s totally intact. Great. But if that muscle gets torn, either partially or totally, that’s what we call the third-degree. And then if it actually tears straight through into the rectum, we call it a fourth-degree. Why are those a bigger problem for women afterwards?
Dr. Mobeen: So the reason why they are a problem is that we’ll have leakage of stool when they don’t wanna leak stool. So if it’s not repaired properly or even if it is repaired properly, they can still have a chance of having leaking of stool.
Dr. Fox: Yeah, it could be a big deal. I mean, this is something that people do not think they’re gonna be dealing with in their young adulthood if they can’t keep in their stool or their gas, and it’s horrific, right, if someone has this. And if they have this, you said it could be either not repaired properly, or it could be repaired properly and then there is a rate of it just not healing well or not having that strength back. And then sometimes people end up getting further procedures to make it better or sometimes, you know, all this physical therapy to make it better. So trying to avoid a third and fourth-degree tear is something that we think about all the time. Sometimes it’s unavoidable but sometimes it is. And again, there are degrees within the third, meaning a very small partial tear of that sphincter, you know, what we call, like, a 3A or, you know, based on how you categorize that usually heals well, but the more it’s torn, the bigger the deal it is.
And again, all of these, the third and fourth-degree make up probably, depends on exactly the circumstance, less than 10% and probably, you know, maybe even less than 5% of all births. Most people who tear don’t have that, they just have the first and second-degree tear. OASIS, which is a term you mentioned, and we were just talking this morning with the residents about it, it stands for obstetric anal sphincter injuries. That acronym did not exist when I was training, but that’s, sort of, the term that’s thrown about in medicine now. Let’s start with the first and second-degree tears that most women are gonna have if they have a tear during labor and delivery. So when you’re doing a birth, right, when you’re there attending the birth, number one, how do you try to prevent tears for someone who’s in labor? How do you try to help or not have a tear if that’s possible at all?
Dr. Mobeen: Some of the things that I do do is that while they’re pushing, I’ll do, like, something called a perineal massage where you, like, just massage the perineum to help the muscle stretch. Something else you can do is you can put, like, warm heat in between contractions just, like, at the perineum to kind of also help the muscle relax and stretch. Other times when they’re pushing and they’re delivering the head, you, like, protect the perineum to keep it from tearing. These are just some of the things that I use. And sometimes you can try everything and it will still just tear, but we try our best not to.
Dr. Fox: Yeah, I mean, all of those methods are pretty common. It’s hard to know how well they work, right, in reality because there’s so many people who deliver babies around the world and people do it differently. This is one of those things where it’s really not well studied. There’s a lot of debate whether stretching helps, you know, or doesn’t help, whether the heat helps or doesn’t help, protecting the perineum, as you said, you know, help or doesn’t help. And I think everyone has a lot of, sort of, their own techniques and their own beliefs about what works and what doesn’t work and it’s hard to know. That’s why there’s a lot of variability in this. But ultimately all of us at the time of birth are trying to minimize the amount of tearing, but it’s not always clear because, again, it’s probably different in each person who’s delivering based on the size of the baby, the position of the head, her own anatomy.
So there’s a lot of factors that go into it and might be different for each person and so it’s hard to know for sure, but it’s something that we do. I think that for us trying to avoid the third and fourth-degree tear is really the bigger one because that’s the one that’s gonna have potentially more difficulties after birth for her and it does make the repair a lot harder, and that’s, sort of, like I said, protecting the perineum, that’s really meant to avoid that portion of it ideally. And we’ll talk later about certain types of episiotomies that are sometimes done to do that. And then after birth, what is your philosophy about repairs, about repairing the perineum and the vagina?
Dr. Mobeen: So usually I’ll tell the mom that the baby made a little bit of a tear or a cut as it was coming its way down. If they have an epidural, then usually that’s sufficient anesthesia for them, but if they don’t, I’ll just tell ’em, “Hey, I’m gonna give you some local lidocaine,” and then I’ll…My philosophy is that I repair everything even if it’s not bleeding. I think the best philosophy is to, like, put everything back the way you found it. So I’ll identify all the different tears and I’ll start repairing the ones that are bleeding first, but then at the end, once I’m done, I’ll repair the areas of, even if it’s like a superficial tear, I’ll just put it together so it looks nice cosmetically.
Dr. Fox: Mm-hmm. And then what do you tell women in terms of expectations after…again, we’re talking about first and second-degree tears here. What’s their expected recovery? What should they expect? Those types of things.
Dr. Mobeen: So I usually tell ’em that the stitches are gonna dissolve on their own. It takes about two to three weeks for the stitches to dissolve and that it’s really important to keep the area clean. They get that squirt bottle to make sure they get up in there and use it, but I usually tell them that it’s gonna be a little bit painful for the next two to three weeks as they’re healing. So usually we’ll tell ’em not to put anything in the vagina, no sex or tampons or using anything else, and that usually by six weeks the tears should heal on its own, and the discomfort level should be very minimal.
Dr. Fox: Yeah. I tell ’em very similarly. It heals quicker than people think it might. Even some larger second-degree tears, fortunately, there’s a lot of blood flow there and there’s a lot of mechanism for it to heal, so it tends to be pretty quick, you know, as injuries or, you know, lacerations go, but yeah, it’s definitely painful based on how big the tear was, exactly where it is it could be painful, again, to different degrees.
Dr. Mobeen: I tell them the vagina’s very forgiving and that usually if we put it back together it usually heals really well.
Dr. Fox: Yeah. And then what about for third and fourth-degree lacerations? What would you tell them differently, let’s say?
Dr. Mobeen: Well, I would tell them, like, I would try to tell ’em to use a stool softener for the next six weeks or so and that not to strain because they do strain when they go to the bathroom, usually high fiber diet, stool softeners that they can potentially tear and open up the laceration that we repaired. And that if they have any foul-smelling discharge or anything, let us know because there is a chance because the sphincter was involved, especially depending on the degree that it can get infected, which is why I also give them antibiotics if I’m having a third or fourth-degree laceration repair just at the time of the repair.
Dr. Fox: Yeah, that’s a good point. We don’t normally give antibiotics at the time of repair of a laceration, but if it’s a third or fourth-degree, there’s some evidence that it improves outcomes because that’s an area where fatty bacteria get in there and can really break down. And I agree that’s…you know, a third or fourth-degree, we’re much more concerned that it wouldn’t heal as well. Again, most of them heal fine and most people that have a third or fourth-degree laceration are gonna heal great, have no issues afterwards and they’re okay, but there is a percentage that don’t and it’s something that you wanna be on top of pretty early. So these are people we usually are gonna, you know, bring her back, take a look, and sometimes if there’s any issues, try to get on top of it quickly, things like pelvic floor therapy to sort of strengthen the muscles around there.
But it’s definitely something that’s a higher risk in terms of recovery. And so I think one of the takeaways is if you have a birth and have a tear, right, to ask your doctor, ask your midwife, what kind of tear did I have? You know, what degree, was it first, was it second? And if it ends up, you know, first or second, they say average, normal, typical, okay, you sort of know what to expect, but if you start hearing things like third-degree, fourth-degree, anal sphincter, they start talking about those things, you really have to, sort of, ask a lot of questions like, okay, how much was it? Which aspect of recovery? When should I come back? Do I need pelvic floor physical therapy? How are you gonna assess this? That’s something that really needs to be addressed. Hopefully they’ll do it proactively and tell you these things, but if not, it’s something to definitely ask about and to talk about early.
Dr. Mobeen: Agreed
Dr. Fox: Agreed. I like that. So those are tears, those are lacerations, those are spontaneous. So let’s now shift and talk about episiotomies. You said before the episiotomies, when we do the tear ourselves, like a surgical tear so to speak, usually in surgery we do it with a scalpel, but not in deliveries, usually it’s with a certain kind of scissors. Why would we do that? What would be the reason to do that versus letting someone tear on their own?
Dr. Mobeen: So there are certain incidents where episiotomy may be necessary. One of them is if we have some trouble, after the head delivers, getting the shoulders out, we can do an episiotomy to create more space, or if we’re gonna do something called an operative delivery where we assist the delivery with either, like, vacuum or instruments and we need more space. The studies, they show that if you were to make the manmade tear that increases the risk of having a third or fourth-degree laceration.
Dr. Fox: Yeah. I mean, it’s really interesting the history of this. If you go back…and I’ll tell the history, I’m older than you so I get to do it. If you go back in time, you know, 30, 40 years, pretty much anyone who delivered, their doctor or midwife, did an episiotomy. That was, sort of, the standard. And there was a lot of reasons behind that. One was it was thought that they would heal better because it’s, you know, more of a surgical tear, like in one place versus, sort of, these jagged, spontaneous tears that could happen in multiple places. Number two, there was real concern about getting the baby out quickly. We didn’t really do any fetal monitoring and it was hard to know if the baby’s tolerating the labor. So the thought is let’s deliver the baby as quickly as possible. So there was a lot of episiotomies, a lot of forceps and vacuums, sort of, to deliver the baby very quickly. And those are like, sort of, the main reasons.
I would say probably about 20-plus years ago they started doing these really big studies where they looked at doing episiotomies routinely, which had been the practice at the time versus doing it, what we call restrictive, which is, sort of, only in certain circumstances and exactly what those circumstances are were kinda left to the delivering provider, right? Whether that’s because of a forceps or they just thought it was the right thing to do, whatever it is, but not all the time. And in those studies, they showed that the group of women who had the episiotomies done routinely actually had a higher rate of third and fourth-degree lacerations. The thought is they were having episiotomies routinely going straight down towards their bottom and then when the head came out, it would be easier to tear all the way down towards their bottom.
And so because of that, really routine episiotomies fell out of favor. And I would say nowadays in the U.S. it’s unusual to find anybody who’s doing them routinely, like, 100% of births. And then the argument sort of became, well, what does restrictive mean? What does that mean? And so in the studies, it was like 20% of women were having episiotomies. And then subsequent to that, some people said, well, maybe that number should be 10%. And then other people said maybe it should be 5%. And then some people went as far as saying maybe it should be 0%. And we don’t know actually what is the, you know, ideal rate of episiotomies and, obviously, you know, that’s a population number. In any particular person, it’s either yes or no, but there’s definitely a lot of differences in practices surrounding episiotomy nowadays.
And I would say, again, probably nobody’s doing it 100% of the time. I don’t know anyone who’s doing it 100% of the time. I don’t think it’s correct to say 0% of the time. There’s some number, whether it’s 10% or whatever, that probably need episiotomies and one of the difficult things is to be able to explain who that is, right? Because different people feel differently about this and there’s a lot of variation of practice. And just, again, we were meeting this morning with the residents and it’s hard. Like, how do you tell someone, this is someone who needs an episiotomy? And a lot of it is just sort of experience that, okay, I think in this particular situation, if I let things go on their own, it’s gonna tear worse than if I did an episiotomy. And how do you know that? Again, a lot of it is experience.
The one situation you mentioned about operative delivery, particularly, like, forceps, which take…you know, you have to have a lot more space, we do episiotomies more commonly, but again, the interesting thing about that episiotomy is we direct the tear away from the bottom. We call that a mediolateral episiotomy. So explain that. What is the difference between a median episiotomy and a mediolateral episiotomy, or conceptually, what are we doing differently?
Dr. Mobeen: So what we’re doing differently is the median episiotomy, were going straight down within 25 degrees of the sphincter. We go straight down, but mediolateral is about the 60-degree…like, an angle that’s about 60 degrees away from the sphincter. So the theory, and which is proven, is if we do it a little bit more laterally that when they deliver that it won’t tear down to the rectum.
Dr. Fox: Yeah, I mean it’s, sort of to try to visualize it on a podcast, if you think of, let’s say, if the vagina’s like a clock, let’s say, and the middle of the clock, like, the center of the clock is where the vagina is, the rectum’s at 6:00, right? So it’s right straight down at the bottom is 6:00. And so in a classic episiotomy, you’d make a tear, like, from the middle of the clock, not all the way down to 6, but towards 6 in that direction. And so with the mediolateral, you actually direct the tear to, let’s say, 8:00 or somewhere, you know, in that range to avoid the tear extending to 6:00. Those episiotomies towards the side tend to hurt a little bit more than the ones going straight down. So if you had a choice, if all things being equal, you would prefer to have an episiotomy going straight down towards 6:00, but that’s the one that also has a risk of extending down to the rectum. So that’s another part of the judgment call. If we think someone needs an episiotomy, which one are we gonna do?
So for me, typically if it’s gonna be, like, a forceps delivery and that’s the reason I’m doing an episiotomy, frequently I’ll recommend doing it off to the side, the mediolateral, because the reason I’m doing it is to avoid getting into the rectum or the sphincter. Whereas if it’s for just, let’s say I think she’s gonna start carrying in multiple directions and I think maybe it’s easier to have a, you know, smaller episiotomy in one place, then maybe that’s one I’ll do a median. Again, it’s really individualized. There aren’t hard rules for this because it’s different for each person, but that’s sort of the concept of it. So in your training, when were the times that you guys would be doing episiotomies?
Dr. Mobeen: So there were a couple of times we did episiotomies. The most common was if we had something called the shoulder dystocia, where after the head of the baby comes out, we have some trouble getting the shoulders out. So we would cut an episiotomy because we need to get our hands in there and actually maneuver the baby to help facilitate the delivery, or if we were doing an operative delivery, we would assess the perineum and if we felt like we needed some more space and we wanted to prevent, like, a tear towards the rectum, we would more commonly a mediolateral episiotomy. And lastly would be if the baby’s head was at the perineum and the heartbeat kept going down, in order to speed up the delivery, we would talk to the mom and do an episiotomy.
Dr. Fox: Yeah. These are all really good reasons to do them. And I think that, you know, what comes from this conversation and I think one of the other, sort of, messages that is important to get out there, you know, a lot of times I’ll meet with someone during their prenatal care and they’ll either mention it or they’ll put it, like, on a birth plan, for example, that says absolutely no episiotomy. And that’s commonly written in birth plans or stated by people. And I think that, you know, when I see that, for me, it’s an opportunity to have a conversation with them and say, “All right, listen, I see that you wrote this. Let’s get, you know, very specific about what you mean.” You know, and I’ll say, “For example, here’s a situation where it might be important, or here’s a situation where I think it’s, in my best judgment, the right way to do it and I’ll explain why, or for example, if I wanna do forceps, you know, and if I don’t think it’s safe to do without episiotomy, then you may end up with a C-section.”
And so a lot of people don’t know that, they’re sort of, told from the lay press, “Episiotomies are bad,” and therefore they’ll put in their birth plan, I don’t want an episiotomy. But I think that one of the real takeaways is I think what people mean to say is I don’t want one done routinely, right? And I agree. That’s probably why she’s having a birth plan. I don’t want an episiotomy done for the hell of it, right, just because that’s what you do all the time, because that’s really not how people practice. And I think a better question or better thing to put on your birth plan would be, what are the reasons that you might recommend an episiotomy? And let’s talk about that.
And you can, sort of, get a sense from your doctor or midwife, is this something that they’ve thought about? Do they seem reasonable, thoughtful, experienced, right? Because if someone says, “I do it all the time,” you should be wary. If someone says, “I’ve never done one,” you should probably also be wary because it’s probably not how practice has been. And so if they say, “I do it some of the time,” say, “Well, when?” Like, “For what reasons?” And that’s something that they should be able to talk to you about, you know, intelligently in a way that sort of makes sense to you. And then you can make a decision about whether this is reasonable or not. But I’d be very cautious about putting, like, a hard stop on all episiotomies because that might not be in your best interest.
Dr. Mobeen: Exactly. If it’s indicated and that’s a conversation that, you know, it’s good to have when you’re not in the situation and the immediate situation to kind of discuss maybe when your term, just so that you know, like, what the indications are. And it’s, like, reasonable expectations on both parties,
Dr. Fox: Right. So if this is something you’ve never thought about and you’re fine and you’re like, my doctor’s great, whatever he or she does, I’m good with, okay, no worry. You know, you don’t have to do anything, but if this is something that’s on your mind and you’re concerned or you’ve heard about this, definitely bring it up. And probably the time to bring it up is during prenatal care. Like, you said, not in the middle of delivery, not in the middle of pushing. If you didn’t bring it up during prenatal care, maybe bring it up at the very beginning of your labor or something when there’s time to talk about it. But just to get a sense of what is the, sort of, philosophy and practice pattern of the person or people taking care of you just to make sure you’re all on the same page.
Again, ideally you do that, you know, during your pregnancy, during prenatal care so you can sort that out. But I think you’ll find that for most people, their doctors or midwives are gonna be very reasonable about this. That’s how we’re trained. You know, we’re not really trained to do them routinely. Everyone’s trained to do them in some restrictive fashion. The exact nuances of that are gonna differ because, you know, a lot of these things differ, but sort of philosophically, it’s pretty similar in that sense that most people are gonna have some reasons that they think it’s appropriate, good reasons, and otherwise they’re probably not gonna do it.
Dr. Mobeen: Yep, well said.
Dr. Fox: So just as a review, again, we spoke about lacerations and tears and that they’re common. Most of them are this first and second-degree. Most of them we repair, feel well, gonna be no long-term consequences. The third and fourth-degree are less common, usually heal well and everyone does fine, but there is a higher chance of complications, so we’re on top of those. And then episiotomies are something that we do the tearing, not done routinely anymore. They’re done in some percent of the time, which varies, and definitely something to speak to your doctor or midwife about. Sadia, thank you for coming on the podcast.
Dr. Mobeen: Thanks for having me.
Dr. Fox: How’d it go? Was this your first podcast?
Dr. Mobeen: Yep, it’s my first podcast. I hope I get another invitation.
Dr. Fox: You’ll be back. Wonderful. All right. Thank you so much. We’ll have you again. 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 firstname.lastname@example.org. 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.