Men's Health Review and STIs

0:00:01.0 Professor Walden: Took a minute. It took a minute to go live there. (laughter) I was like, oh no. Hi guys, we are here. So, we’re getting ready. I’m letting everyone kind of drop in and join us as we get ready to do this thing. Give me one second to make sure. I always like to make sure it’s broadcasting… To make sure. There we go. Fantastic. Alright, as usual, we are here. I know that guys are at… People are at work, and you guys are coming in and hopping in and might be a little bit late ’cause I already got some emails and some messages saying so, so that’s absolutely okay. Hey Trisha. So, I know you guys are jumping on here and I just… I’m excited. So today we have lab Liz (laughter), that’s how I refer to her in my head. So Liz is here again and she is going to talk to us about contraception. So I know this is like a big, bad world out there, especially for us general family nurse practitioners. It’s just a lot and there are a lot of options, and she’s gonna give us some feedback and just kind of some information.

0:01:28.5 Professor Walden: Hopefully we can kind of narrow some things down and remember, don’t worry, everything is personal preference, right? So at the end of the day, you pick what’s good for your patient and what works for you guys together. You collectively come up with that decision. But in order to have some background information, she’s gonna give us some. So I’m very, very excited about that because it is not a strong point of mine. And Liz is fantastic at knowing all of the things. I know that you guys think I know all of the things, but she knows all of the things as well, so I love listening to her. So with that being said, let me give you her background, if you are not aware. So Liz has been a family nurse practitioner and primary care provider in the federally qualified health center setting since 2015. She’s also the founder and CEO of Real World NP LLC, an education company for new nurse practitioners and primary care. She’s been a nurse since 2009. She’s obtained her BSN from Boston College and MSN from UCLA.

0:02:35.9 Professor Walden: And we always go through this boo (laughter) I went to USC, guys, so they are rivals, okay? She’s passionate about inclusive care, mentorship, teaching, and particularly enjoys women’s health and GI topics. When she’s not pouring over textbooks or crafting educational videos, you can find her snuggling her German Shepherd mix, Charlie, or playing with her daughter, Emilia. So I am very excited. I know you guys already know who she is, a lot of you, and you guys love her as well. So hey Liz.

0:03:08.9 Liz Rohr: Hello!

0:03:09.7 Professor Walden: So we’re so excited to have you. People are hopping in, and so they’ll probably slowly be joining as well as we move along, but I’m really excited about contraception in this discussion. Again, not in my wheelhouse. Not a strong point for me, but if we talk about kidneys I’m your girl. (laughter) So with that being said, I am going to turn it over to you, but I’ll put…

0:03:36.8 Liz Rohr: Awesome!

0:03:37.1 Professor Walden: Your PowerPoint up.

0:03:38.3 Liz Rohr: Cool!

0:03:40.5 Professor Walden: See that. And I know they are excited ’cause I see them already.

0:03:45.6 Liz Rohr: Cool! I don’t think I see the chat. It says private chat, but I’m not seeing anything, so I was gonna ask some questions like what people were struggling with and all that, so I can kind of… ‘Cause there’s a lot to say, and I have some focuses that I can focus on, but it depends on the desire.

0:04:05.2 Professor Walden: So what I’ll do is I will… I’ll kinda pop back in, you know.

0:04:08.6 Liz Rohr: Sure!

0:04:08.8 Professor Walden: Check on things.

0:04:09.7 Liz Rohr: Perfect!

0:04:10.3 Professor Walden: When people start responding, I will absolutely Kind of mention that. Why don’t you go ahead and pull your PowerPoint up.

0:04:16.7 Liz Rohr: Sure!

0:04:17.5 Professor Walden: That’s on the screen. And then…

0:04:19.5 Liz Rohr: Can you see this?

0:04:20.6 Professor Walden: I do. There you go. Alright, and I will back off, so guys, here we go. Contraception. Super exciting. Take it away.

0:04:27.6 Liz Rohr: Awesome. Thank you. So I can’t actually see… Well, I can’t see the chat, so I actually don’t see my picture either, so I don’t know if I’m on there or if it’s just the slides.

0:04:37.2 Professor Walden: You are. You are.

0:04:38.3 Liz Rohr: Okay, cool. So… Okay, I’m just gonna get started. So in this talk, this is based on a talk that I did at a conference, and it was a very information-packed. So I think what I was thinking about for this presentation is starting with the foundations of having those contraceptive counseling conversations, kind of a very efficient way that you can approach these so that they don’t feel super overwhelming. And then depending on what people would like… I would love to hear if you wanna put in the chat like what is frustrating for you, what you’re struggling with, what would be really helpful, or any specific questions you have about contraceptive counseling, ’cause unless I… Unless I hear from the people, then I’ll probably focus first on the contraceptive counseling conversation. And then I’ll focus on the long-acting reversible contraceptive methods, so IUD and Nexplanon. Focusing on those to start and then we can check in and then see if you’re feeling like I wanna do more, I wanna process, I have more questions, things like that.

0:05:49.1 Liz Rohr: So let us know in the chat what you want. To hear but again, I’m Liz Rohr. You’ve already heard this, I’m gonna skip over that. So in this presentation, we’ll be covering how to apply counseling techniques and how to select those contraceptive methods for your patients. And then my hope is that you can identify effective contraceptive methods for your patients according to those counseling conversations. And then how to manage common side effects of various contraceptive methods. And again, depending on time and depending on the desire, I’ll primarily be focusing on those long-acting reversible contraceptives ’cause I think most people have the hardest time with that. It’s a little bit tricky. First though, I wanna talk about some pitfalls, and I’m keeping an eye in on the time ’cause I can talk a lot.

0:06:40.4 Liz Rohr: One of the pitfalls is that sometimes clinicians will only counsel cisgendered women, so women who have a uterus and ovaries, and that is the only population that they focus on, and I wanna really encourage you to think about contraceptives as family planning for all patients, cisgender, transgender, non-binary male, female, all the patients, right? The other pitfall, which I make myself still sometimes, is making assumptions about desire for pregnancy or contraception, so typically what happens is that people will start a visit, I myself would start a visit and say, “Are you using any contraceptives? Would you like to talk about that?” I’m gonna tell you a little bit of a different approach that is a little bit more inclusive. The third pitfall, especially if you were a newer clinician, is overwhelming your patients with a huge list of options like a huge laundry list like a cheesecake factory style, like huge menu versus a tailored list specific to their needs. And so I’ll talk about a method of how to get there, but these are some pitfalls to watch out for.

0:07:51.2 Liz Rohr: The other thing that I unfortunately do see is coercion, and that’s pushing patients toward an option that the clinician thinks they should do, and like Latrina said, it’s always about the patient’s preference, we’re centering the patient in these conversations, we’re going to give them information and counsel them appropriately, but it is always their choice. Now the other kind of last pitfall is not including a conversation about sexual history and sexual health practices, as well as genders of partners and the risk factors that they have. So a lot of times, we’ll see a cisgendered woman and ask them what contraceptive they want, when in fact we should really expand that conversation a little bit more, because we never know what genders of partners these patients have that we’re talking to. And sexual health history is like another talk in of itself, but just doing your best to ask those questions. So when I talk about some history questions, this is like the history when it comes to that contraceptive counseling visit. Actually, does anybody have any questions before I keep going?

0:09:03.2 Professor Walden: While they’re deciding whether or not they’re gonna type, just you ask for some suggestions on birth control for ages 30-plus for better cycles, and that already popped up, I don’t know if I put the question on the screen, I don’t know if you can see that.

0:09:22.2 Liz Rohr: I can’t see it.

0:09:23.5 Professor Walden: That’s okay.

0:09:24.5 Liz Rohr: Yeah, all I can see is my full screen. Ooh, boy that’s a little…(Laughter)

0:09:28.7 Professor Walden: Okay, I’ll pop in here, no problem.

0:09:32.6 Liz Rohr: I have my phone. I’m gonna write some stuff down. So contraceptive options for 30-plus for cycle management.

0:09:38.2 Professor Walden: To regulate their cycles better.

0:09:40.9 Liz Rohr: Cool, cool, awesome. Yeah, so depending on time, I just don’t wanna overload information, we can definitely get to oral contraceptives, ’cause that’s like the third most common kind of option. So these are some really grounding history questions that can guide these visits, and this is based on the framework from Patty Cason, who is a sexual health educator, a nurse practitioner. She actually came to UCLA, I felt that was super cool. So the first question, again, instead of opening with what kind of contraceptives do you wanna use, it might feel like an uncomfortable conversation or uncomfortable question, but it’s a really inclusive one, “Do you plan on having children,” which is a very simple yes or no, or I’m not sure.

0:10:22.7 Liz Rohr: It’s a pretty straightforward question. So the follow-up question is, do you have any idea when you’d like to do so? Because then that gives you a context of you’re starting to triage what options would be best for them to present to them in that menu, a little customized menu. And then the third thing is, how important is it for you to wait until that time, so you might get a whole range of answers. “Do you plan on having children? I’m not sure.

0:10:50.0 Liz Rohr: Do you have an idea of when you’d like to? No. How important is it to you to wait until then… Oh, it doesn’t matter, if it happens, it happens.” That’s a very different conversation than somebody who’s like, “Yes, I definitely want children, but not for… Until I’m… After done with grad school.” So, yeah, that gives you a branch point of, “Do we talk about pre-conception counseling like healthy behaviors and activities we can do for that patient before they start their family versus what contraceptive methods might they benefit from?” So those are the three kind of core questions. Patty Cason also has additional ones, but I feel like it’s just really simple to have those three. The next part though is assessing health conditions, so that’s the main next triage-based approach. Here are the options in your mind of what you can offer them based on the answers to those questions, followed by what is actually medically contraindicated, that’s our main job is to say, “This is contraindicated for you, this is safe for you.” And then a great resource is that CDC medical eligibility criteria, if you haven’t used that already, I definitely recommend it. It’s a table, that’s a PDF that you could print out.

0:12:07.0 Liz Rohr: I really love the app, it’s called Contraception by CDC, and it’s free, and when you download it, you can enter the patient’s information in so that it’s their age, do they smoke, what are their medical conditions, etcetera, etcetera, and the results are levels one through four. So level one, good to go, number two, typically also good to go, three and four are heading towards contraindicated. Some other questions that you can kind of fill out after you’ve gotten those initial triage points, what’s important to you about your contraception? And I really advocate giving options for patients, because sometimes when we ask a question, they’re not really sure what you’re looking for for an answer, so I give them options. So here are a couple of options. Do you care if you have a period or not?

0:13:05.5 Liz Rohr: And again, this ties into sexual health history, but do you feel safe at home? What are their partner’s situation? Do they have to worry about their parents? Are they adolescents? Do they feel like they need to conceal their contraceptives, right? So IUD Nexplanon might be better for that. And then here are some other options. A lot of times, patients will tell you these things voluntarily and have it in the front of their minds. However, you can give them these options. How important is it that it’s really effective, right? Do they care if they have a device in their body? Do they worry about needing to take it every day or not? Are they worried about return to fertility? Are they thinking about hormones or not? Can they stop it themselves? And actually, if you want these slides, I can give you a copy of them to keep. But these are kind of like muscle memory type of things that will naturally happen when you have these types of visits, but then also these can be helpful reminders. But a lot of times, like I said, patients will volunteer that information too. So the recommended approach is a top-down approach where you’re counseling based on their answers, you’re recommending them the options that are the most effective, that are also safe for them from top to bottom.

0:14:26.5 Liz Rohr: So the options. The most effective options are long-acting reversible contraceptives. Like I said, those LARCs, and that’s IUDs and Nexplanon. The next kind of like run-down in terms of efficacy is oral contraceptive pills as well as those vaginal rings. The NuvaRing is a brand name, but there are a couple of brand names, so sorry about that I probably should have just put vaginal ring. And then the next tiers down are those progestin-only pills and DMPA, which is that Depo-Provera injection. There are other options. This is the majority of what I’ve covered in this presentation and then the most popular options. The last one that is also an option… Again, there are other ones, but these are the most common ones. I don’t want you to forget that permanent contraception is an option. I think that a lot of times providers, and myself included, sometimes will forget that permanent contraception is a very great choice for a number of patients. And so just don’t keep that off the table. So I guess a couple of important notes I wanted to add, so… Well, first actually, I wanna pause. Any questions? How are we doing? Questions or suggestions or requests?

0:15:45.9 Professor Walden: As they are deciding whether or not to chat, they are just… The app. So they’re already calling for the app that you mentioned.

0:15:55.8 Liz Rohr: Yeah.

0:15:55.9 Professor Walden: I really love that app as well, so.

0:15:57.3 Liz Rohr: Yeah, it’s a great… It’s a great app, that’s really helpful. I’m all about these kind of like hacks to allow my brain to have more space. And so as long as I remember that there is an app to help me with that, we’ll start there. And I have to assess contraindications, right?

0:16:11.0 Professor Walden: Right, (chuckle) right, but no questions yet.

0:16:13.4 Liz Rohr: Okay, so a couple of important notes is that I just wanted to add a few things about two kind of like general important notes. There’s so many things I could say, but for adolescents, there, I think, has been some touchiness for people and discomfort about giving contraceptives to adolescents and what kinds are appropriate or not. But according to guidelines, ACOG and otherwise, any contraceptive is appropriate for adolescents, whether it’s an IUD, Nexplanon, oral contraceptives, all of that stuff. There isn’t really evidence that says… There used to be this thought of like, “We shouldn’t give hormones to adolescents early in or close to menarche, close to their first menstrual cycle.” But no, it’s any contraceptive, just based on their assessment risk and their preferences, same as adults. And the other thing is about body mass index. So patients who have a body mass index of greater than 30 have not been widely studied for all methods in terms of efficacy, etcetera. So when you have the hormonal options, they potentially may be less effective for patients. I think that IUD… And again I apologize, this is off the top of my head, but I believe the IUD, the copper and the Mirena are more effective than oral contraceptives or the NuvaRing. Just something to keep in mind in that conversation with your patients which is unfortunate, we don’t have more research.

0:17:41.3 Liz Rohr: So I’m gonna jump in to IUDs. I’m obsessed, so I’ll just… Let me know if this is too fast or if you have questions. But I’m first… I’m gonna give you an overview of IUDs in general, and then I’ll get into the hormonal kinds and then non-hormonal kinds. Okay, so there’s two types of IUDs. There’s hormonal and non-hormonal copper-based. I’m gonna give you… There’s a whole long list of them. There they are, big long list. There’s four main ones, Mirena, these are brand names, Liletta, Kyleena, and Skyla. They are all levonorgestrel, which is a type of progesterone-only. The only difference between them is the device size, like physical size, and how much estrogen they… I’m sorry, how much progesterone they have, and how long they’re effective for. So I have them in descending order. Mirena and Liletta are exactly the same, different manufacturers, and they have slightly different FDA approvals for how long to have them. It used to be five years, but now it’s six years and then seven years, Liletta, Mirena respectively. Kyleena is five years, slightly lower dose on the levonorgestrel progesterone. And Skyla, the lowest amount of progesterone, smallest size device, shortest amount of time. One thing I wanna stress about IUDs in general, patients commonly think that they have to commit to seven full years with this IUD. However, they don’t have to.

0:19:13.0 Liz Rohr: In terms of cost effectiveness, it’s typically recommended to have it between nine months and maybe a year and a half for cost-effectiveness only. But there’s no restrictions about that, and I’ll talk about how these work. So non-hormonal, there’s only one, which is the ParaGard, and it’s the only brand name, and it’s copper. It’s a plastic device wrapped in copper wire, and that is FDA approved for 10-12 years. It’s been studied, and kind of like “Expert opinion recommended” to be longer than that, but FDA approval is that length of time. Okay, so how do these work? And I think this… For me, when I understand how something works, it’s easier to remember than straight memorization.

0:19:57.0 Liz Rohr: So the mechanism of action for both kinds, hormonal and non-hormonal is, they’re multiple. However, they both in common have a sterile inflammatory response that is toxic to both sperm and ova, which also prevents implantation. So there’s an inflammatory response that’s not an infection, and it’s toxic for the sperm and the ova. So it doesn’t… There’s no fertilization possible. And actually I’ve had patients ask, are there chemical pregnancies that are happening. Meaning, is their sperm and ova that are combining, that are just not implanting. These are not abortive, and all of the evidence we have is based on research, right? And so, all of the research studies looking at inside the fallopian tubes, inside the uterus, have not found any embryos, right?

0:20:47.6 Liz Rohr: So, all the studies we found do not… And the CRM or the environment do not detect pregnancy hormone HCG so, they’re not suspected. I’ve had many patients ask about that so it’s why I say that. The key take home points about both of these options, they’re greater than 99% effective. They’re rapidly reversible, They’re concealable. The cost at first might be high. Oh, two years. I misquoted myself there. The initial costs might be high but over time, the cost is reduced, so usually about two years. I found actually very conflicting sources, but I guess two years is the consensus. One other thing to keep in mind, none of the methods that I’m gonna be talking about tonight protect against STI. So that’s something that you wanna think about, counseling with patients whenever you’re talking about contraceptives.

0:21:40.0 Liz Rohr: Also, there are slightly higher rates of ectopic pregnancy than other methods. But yeah, it’s great if they can remove it any time and there’s immediate return to fertility. There’s no delay in fertility for either method. So a couple of contraindications. Again, consulting that app, beautiful. Severe distortion of the uterine cavity, acute pelvic infections, unknown or suspected pregnancy or really importantly, unexplained uterine bleeding. We always wanna investigate if somebody has unexpected menstruation of any reason. Investigate that first. Don’t treat it for anything without investigating, right? Key take home there. So a couple of complications with IUDs. The expulsion rate typically happens in the first month where the IUD comes out on its own.

0:22:34.1 Liz Rohr: It’s about 3-6%. Pelvic inflammatory disease is about 0.5-1% failure. Meaning pregnancy is like 0.1-0.6%, and perforation, meaning breaking through the uterine wall during insertion is very low, 0.01. However, in terms of side effects, that’s not really a… Well, it’s I guess potentially a complication but malposition can happen unfortunately in up to 10% of people, and a lot of people can have pain and irregular bleeding, and those are the main reasons for removal. I think that’s around 10% as well. If you have an IUD, whether you insert it yourself or you have somebody who has recently had one inserted, if there’s any ongoing heavy bleeding or cramping, those patients need to be evaluated for that malposition expulsion pregnancy or any cervical dysplasia, right? So just, the take home there is that there’s excessive ongoing heavy bleeding that’s painful after insertion, just investigate that. Any questions before I jump into the progesterone IUDs?

0:23:52.5 Professor Walden: None yet.

0:24:02.8 Liz Rohr: None yet. Perfect. Okay. Trying not to overwhelm. I think my last presentation was a little too intense. Okay. I’m gonna talk about the Levonorgestrel IUDs, so that was that list of four of them. So these additionally, in addition to that sterile inflammatory state, it also has a local effect of the hormones. Most progestins thickens cervical mucus which also impairs implantation, and it also may inhibit the binding of the sperm and the egg together. It does not necessarily inhibit ovulation. However, it can lead to amenorrhea for some patients. So some side effects to keep in mind that patients might not like as an option is that you can have… The patients can have unscheduled bleeding. Meaning, they can have their regular menses as expected or it could be spotting, light bleeding here and there irregularly. However, bleeding changes generally improve the longer you have the IUD. And that amenorrhea like I said is about 20-40% of people with the highest dose hormonal IUD, so, Liletta and Mirena, they’re the same, just different brands. Depends on your insurance. But yeah, so… And the thing I want you to… If you can… I know that contraceptive options can feel overwhelming ’cause there’s so many things to remember. One of the wonderful things is that progestin works the same way regardless of the method, right?

0:25:29.6 Liz Rohr: So progestin is in a bunch of different hormonal methods. Thicken cervical mucus, impairs implantation, may inhibit binding, doesn’t necessarily have ovulation. It might, might not, right? That’s the same, regardless of OCPs or progestin only pills or Depo-Provera, that stuff. So a couple of pros of practice, super fun, is that it reduces the risk of cervical, endometrial and ovarian cancers. Unclear reason. Maybe alternating response. And as of February 2021, there was 52 milligram that the Liletta and Mirena can be used as emergency contraception, and that was in a non-inferiority trial and Levonorgestrel medicine. So, why would you choose one over other? Based on the patient’s preference, cost, availability and insurance. So again, just as a reminder, Mirena is seven years, Liletta is six years, Kyleena is five years, Skyla is three. I have to say…

0:26:31.1 Liz Rohr: The majority of my patients go for the highest doses, Mirena, Liletta, they have the lowest regular bleeding risk and the highest chance of amenorrhea, which people seem to like again, based on your preferences of your conversation, do you care if you have a period, do you need to see it every month, some people want that. Some people don’t want that. The other thing to keep in mind is Skyla has the lowest dose, shortest duration, it has the smallest device size, it is slightly smaller, so if you have an adolescent, for example, who’s never had a child a cis female or patient with a uterus rather, they might want a Skyla, it might be less uncomfortable, unclear, but again, all options can be used in adolescence or annular patients, so meaning they haven’t had a child before, they haven’t given birth before. So yeah, so moving on to Copper. So again, sterile inflammatory state that’s toxic to sperm and Ova prevents implantation, ’cause it’s not a good place, not cushy place to land, but also it enhances that effect and reduces that sperm motility, so it works in a lot of different ways, mean side effect for the copper, so a lot of people don’t want a hormonal IUD because of acne or they’re very sensitive to hormones in general, like they’re worried about waking, they’re worried about acne, statistically, it may or may not have those big effects, it’s kind of like a smaller percentage, but any hormones can potentially contribute to that… Right.

0:28:06.6 Liz Rohr: Luckily, with the hormonal IUD is, it’s largely a local effect, but I have in terms of the hormone is locally acting, but I have had some patients who have severe acne when they’ve gotten an IUD, their acne is not getting any better. It’s kinda getting worse. Anyway, but the main thing for copper IUD is that their periods tend to get heavier and longer and can be more crampy. This is especially true in the first three months, however, by six months plus research supports that it tends to get better and better, and so the symptoms at that six-month Merck in research studies have shown that they are similar to that levonorgestrel IUD side effect profile, so you might not wanna recommend this to somebody who has heavy bleeding to start, very crampy bleeding to start. Who might have fibroids, those are the kind of things to keep in mind when you’re choosing one over the other, ’cause I frequently… I frequently have patients who come for their IUD appointment and they don’t know which one they’re getting, so even if you don’t wanna do IUDs, if you could just maybe talk about that just a little bit, that would be nice, but duration of use again, 10-12 years, 12 plus off-label. Couple points of practice, again, this one can also be used as emergency contraception up to about five days after one episode of unprotected intercourse for that. So before I jump into Next one, I just wanna check in. How we’re doing, and if you have any questions?

0:29:38.8 Professor Walden: Yes. Okay, so we just wanted to confirm, can you use ultrasound to confirm placement with an IUD? Correct?

0:29:47.8 Liz Rohr: It depends actually. So standard practice does not require that if you have an issue with mal-position or excessive pain or bleeding, then definitely get an ultrasound, but I do not… It’s not routine practice. You don’t have to do that. The OBGYN offices that have in office ultrasound, sometimes will do it ’cause it’s there and it’s nice, but like primary care, you don’t have to.

0:30:10.3 Professor Walden: Perfect, that was the question. Thank you.

0:30:14.0 Liz Rohr: Sweet. Okay, so sorry, this was supposed to animate, this one didn’t animate well, like line by line, but… Okay, we already did that. So NEXPLANON, this one did not animate. I love NEXPLANON. I also don’t love NEXPLANON, it’s wonderful and it’s got some side effects, so for the most part, people love it, but the people who don’t love it really don’t love it. So again, this is a progesterone-based option, same mechanism of action, thicken cervical mucus. Makes it less favorable to implantation, and this particular option has a very high dose of progestin, so it can potentially inhibit ovulation more so in the beginning, but tends to wean off over time, but again, not the main mechanism of action. Might happen, right? This is the most effective, there are actually less failure rates than tube elongation, which is a permanent contraceptive option, and then the FDA has approved three years of use. However data suggest up to four to five years. That’s lovely. That keeps working. So why would you not use NEXPLANON. Patients who have active or suspected breast cancer, liver disease, again, known or suspected pregnancy, undiagnosed abnormal uterine bleeding This is gonna be a theme. Never prescribe anything until you’ve diagnosed it, and then allergies to any of the components. There’s one tiny note here about patients with a history of thromboembolysm.

0:31:48.0 Liz Rohr: It’s listed as a contraindication because I don’t actually understand this why, but it’s based off of studies of oral contraceptives that have this type of progesterone. But then NEXPLANON the people who teach you how to do it the manufacturers is only one, it’s Merck. Have said it’s not something to worry about, it hasn’t come up that often, honestly, but just a little note there, as you can see, NEXPLANON has quite a few side effects. The main one I want you to remember, you can take a look at this and again, you can have a copy, the main thing I want to to keep in mind is bleeding, even if you’re not inserting these, if you can have a conversation with your patients, the main side effect is bleeding…

0:32:26.7 Liz Rohr: This is literally what I say to patients. You have a couple of options, and we won’t know until you get the device, you can have the same periods as usual, your periods can go away entirely, you can have random bleeding here and there, might be light, might be the amount of a period might just be like one time anyway, the last option, and this is very uncommon, but I do see it, people will get their periods as soon as they get the device and it never goes away until we take it out in three months. I warn patients that that can happen and they get to choose, we’re never gonna push them into something, it’s a really great option for adolescents, ’cause most of the time…

0:33:10.9 Liz Rohr: It’s concealable and they either don’t care about the spotting or it doesn’t affect them as much, I don’t know, there’s not great research for that, but my adolescents really do love it. But anyway, I do warn patients that those are the main side effects. The other ones to keep in mind are headaches, mood, and acne. Those are like the main ones that people worry about. And again, those are all for progesterone options. So some people can have amenorrhea, about 20%, slightly less than that IUD, the highest dosed IUD. Some people can have weight gain, about three kilograms over three years versus one kilogram for the IUD, so that’s like it may or may not be statistically significant. Acne, headache, again, these are pretty low percentages though, 20% is a little bit on the higher side, but those are the main ones to keep in mind because right then and there, if they cannot accept that risk of the bleeding, it’s not even worth getting into the other side effects. If they’re fine with that, then we move to the next tier.

0:34:08.3 Liz Rohr: Again, those like hacks of what do I need to remember with Nexplanon? Bleeding. Four options, right? There we go. Okay, take home counseling points, it is the most effective. It’s very private, it might lighten bleeding, it might also cause unscheduled bleeding. Most bleeding patterns, whatever they have in the first three months, will probably continue… I usually recommend patients that they give it a try for about three months to see how their body adapts, to see if the bleeding improves, if they’re okay with accepting that risk in the first place, right. About 50% of people who have unpleasant bleeding profiles at three months, will get better, most of them don’t… Or it’s 50/50. But whatever they have in the first three months, if it’s bleeding non-stop, then, yeah. There are things you can do about it, and I can answer some of those if you have questions about managing complications depending on time. But this is the main comparison slide that I wanna talk about, because this comes up so often.

0:35:05.8 Liz Rohr: Why would you choose IUD versus Nexplanon? IUD has less unscheduled bleeding, fewer hormonal side effects, again because they will primarily it is a locally acting in the uterus and ovaries, that general area, not in the serum and the whole body, longer duration of action as well as… Oh, I said, Yeah, localized action of hormones. Nexplanon, great option we cannot use IUDs because of structural changes, right, they’re more effective than the short-acting reversible methods, OCPs, vaginal ring, transdermal patch, etcetera. And again, amenorrhea, if they are like, I really don’t wanna have a period anymore. 20-40% of the highest dose IUD, Mirena and Liletta versus 20% of Nexplanon users. It’s a real gamble with Nexplanon depending on your bleeding profile, what you’re willing to accept. And it’s a little bit more predictable with the IUDs anecdotally and research-based. So any questions about IUD or Nexplanon before I move on to oral contraceptives?

0:36:10.6 Professor Walden: The one thing with back to the IUD.

0:36:14.0 Liz Rohr: Yeah.

0:36:14.0 Professor Walden: So that conversation about how do you evaluate placement, once you place it then if an ultrasound isn’t there? And we do know, like you said, some of them said you feel for the strength, but I’m just for clarity’s sake for her, I just wanted to make sure…

0:36:29.9 Liz Rohr: Yeah, so the way that the IUDs are placed is there is a uterine sound, and so you place a… Basically like a stick, it’s not the right word, but it’s a medical device and it has measurements, and you do a bimanual exam to start… You place the sound to the fundus, and then you measure how far it is, and then when you place the IUD, you match up the insertion depth based on that sound. And it’s a lot of clinician practice, the way that it feels to have a properly placed IUD. The reasons you would suspect to get an ultrasound is if they were having, again, that excessive pain or bleeding and/or those strings seemed like excessively long, it seemed like it was long or it got longer when you saw them again. But there’s no standard ACOG says you have to re-check the placement, it’s just based on their symptoms and the procedures. So yeah.

0:37:30.9 Professor Walden: Fantastic.

0:37:31.3 Liz Rohr: Thank you.

0:37:31.3 Professor Walden: A question, just with Nexplanon… Do you see weight gain?

0:37:37.0 Liz Rohr: Yeah, so I can go back. So there is some weight gain. Oops. It’s about 12-14%, so it’s not renowned for weight gain, but it does have progesterone in it and progesterone, like plus minus can contribute to appetite changes. I don’t know if it’s necessarily the progesterone itself, but if someone’s really concerned about weight gain, I just tell them our percentages. I’m like 12% of people, 12-14% of people can gain some weight, and the statistics that say that it’s usually about six pounds over three years for Nexplanon, versus, what is one kilogram, two pounds for the copper IUD. So there’s some weight gain for a non-hormonal IUD and some weight gain for Nexplanon, and so it’s not… Putting that in context, I just explain that to patients as like, do you wanna accept that risk? And then they say yes or no. It’s up to them, but it’s not statistically, it’s not like a lot compared to Depo, I think is a lot higher, I can’t remember what the kilograms are for that, but…

0:38:41.8 Professor Walden: Much higher. And then another question.

0:38:44.1 Liz Rohr: Yeah.

0:38:44.1 Professor Walden: So with the IUDs, just curious, do most NPs or providers, primary care providers place IUDs, or is this something that is usually punted in your opinion?

0:38:58.4 Liz Rohr: It depends on the clinician preference, honestly. So I like procedures. The training that you have to do, I believe, so for Nexplanon, specifically, you have to do the Merck training, ’cause they’re the only manufacturer for IUDs when I was in school. I did an IUD training with Mirena, whatever the company is that makes Mirena… However, the on-the-job training was supervision, I placed 10-20 of them with supervision and assistance and then I was cleared to… I was signed off to do it on my own. So it really depends on the clinic and the clinician of preference… There’s no rules about it, but I find that in most of the FQHC settings that I’ve practiced in and been familiar with, there’s usually a primary care provider that does them. I love them. I think it’s super fun. It’s a nice skill builder too.

0:39:47.8 Professor Walden: Fantastic, thank you.

0:39:52.3 Liz Rohr: Yeah. Cool. So I’m gonna jump into OCPs, ’cause I think we still have some time. What time are we going till? Are we going till 8:00?

0:39:57.9 Professor Walden: Yes, and you can finish up your lecture, so…

0:40:00.7 Liz Rohr: Okay, cool, so I’ll go through OCPs and then we’ll kind of pause there and then see what other questions, ’cause I don’t wanna like rush through stuff, if people have other specific questions, but, this is a super long slide, but basically the moral of the story is that, it suppresses ovulation through kind of like taking over the hormonal cycle. I love this stuff, I won’t get too much into it, but basically, there is an estrogen surge that triggers a whole series of events, which leads to ovulation. So when you take oral contraceptive pills, the estrogen remains the same or decreases depending on if you have monophasic, meaning the same dose for the whole month, or multiphasic, meaning different doses throughout the month.

0:40:46.4 Liz Rohr: And so it suppresses ovulation by inhibiting those LH surges that contributes to ovulation and again, progesterone is the same thing it’s always done, right? It’s less favorable to implantation, thickens cervical mucus, all that stuff. We’ve said it a bunch of times, just for a like repetition remembering, but basically just remember the estrogen suppresses ovulation, it just takes over that cycle. So failure rate with perfect use is 0.3%, but user error, typically use is about 7% failure rate. As of compared to the LARCs or tubal ligation permanent contraception, it is higher, right? So 1% for those and then 7% for typical use.

0:41:28.8 Liz Rohr: And duration of use, I’ve gotten a lot of questions about this where how long can people take OCPs for? And these are estrogen and progesterone combined oral contraceptive pills and you take them every day, depending on the formulation that you have, which I can get into if you’d like, but you can take those up through menopause, until menopause for patients who do not smoke, have a BMI less than 25 and are generally healthy. There was a thought before that you had to stop at 35 because of the risk of venous thromboembolism, that is still a risk factor, but the risk of getting pregnant confers much higher thromboembolism risk. So if they don’t have risk factors, it’s safe to continue them, ’cause that’s the main side effect, that’s the main thing to be concerned about when it comes to estrogen specifically. Your risk increases with age, smoking and a higher BMI for venous thromboembolism. Okay, so this is a big old side too. Moral of this story? Look at that app, (chuckle) there are absolute and relative contraindications, right? So that CDC Medical Eligibility Criteria, you can literally just plug that stuff in and it will tell you, you know, one, two, three, four.

0:42:44.0 Liz Rohr: And a general, general thing to keep in mind is smoking, general health conditions, just like as a quick thing in your mind, like heart disease, hypertension, diabetes, especially elevated out of the goal range, breast cancer, liver problems, migraine with aura. Right? If you don’t remember any of those things, just think about heart, right? (chuckle) Hypertension, migraine with aura, breast cancer and smoking. Just think about those things, but again, always, always consult your app and you can just make sure, or that list and then you can feel comfortable with that, but again, just the main thing to keep in mind with oral contraceptives is that risk for venous thromboembolism. Okay, I’m sorry, this was supposed to animate the series, but it’s overwhelming when it’s like all this in one, but basically, why would you choose one oral contraceptive over another? So there are a lot of options.

0:43:37.8 Liz Rohr: Like I said, there’s monophasic and multiphasic, meaning like same dose the whole time, different doses throughout the month, cyclic versus extended cycle, versus continuous use. Like do you take the three weeks out of the month, have a period the last week? Do you take it three months at a time and then have menstruation? Or do you use it non-stop? Those… That’s what that means. And then the other choices have to do with the estrogen and progesterone. I wanna make it really simple, the way that I choose them is based on the easiest one for the patient. I like to choose monophasic, less confusing, less doses to worry about, if you miss a pill it’s the same dose. I start with like kind of a run-of-the-mill, kind of like the lowest dose possible option, see how they do, change it if we need to.

0:44:32.2 Liz Rohr: There’s a lot of people who want to pick and maybe this is just a philosophy or practice difference, but the evidence does not support that one type of estrogen, or one progesterone is better than the other for acne versus cycle regulation versus whatever, right? It’s really… There’s no real evidence to support that, ’cause I know a lot of people are like, “Oh, this is the best for acne.” It’s like, “No, not really.” They all have the same options, right? But basically with estrogen, there’s low dose to high dose, really what you should do is choose 20, 30 or 35 mcg, 10 mcg is really low, that’s low, low estrogen, that’s the absolute lowest, which you could do, but it might lead to more breakthrough bleeding.

0:45:16.9 Liz Rohr: And then 50 is the other highest option, but that’s really only used in specific indications. So usually I just pick 20, what has 20 and I just remember the options that have 20 in them and I start there and titrate from there. You can get fancy with the progesterone types, right? If you wanna really dig into those little tiny pieces of like, what type of progesterone is good for what? And is it first generation, second generation? All that stuff. So for example, Drospirenone is a spirono… I’m not gonna say that right. Spironolactone analog, which might be better for patients with hirsutism, maybe, ’cause it’s kind of like a hormone blocker, but they all kind of do. There isn’t one necessarily that’s more effective than the other at treating those hyperandrogenetics, hyper-andro. I’m not gonna say that right. Acne and hirsutism, right? There’s not one more than the other, so that’s my like quick and dirty approach to OCPs.

0:46:13.1 Liz Rohr: And some side effects. Again, some unscheduled bleeding more common in the lower estrogen dose, more common with the continuous use of OCPs. However, similar to any of the hormonal options, those side effects tend to get better after three months. That’s usually why I say take about three months. Breast tenderness, nausea, bloating, that can, again, resolve with time. If it doesn’t, then maybe consider some of the dose adjustments and then think about counseling on that increased risk of venous thromboembolism. The absolute risk of Hypertension, stroke, heart attack is relatively low. And then just a couple of pros of practice to throw in there. It can regulate bleeding. So somebody had asked about… And I just wrote that question down. I just wanna make sure I’m answering it correctly, but the question of cycle regulation after 30, any option. And again, as long as we’ve investigated the underlying cause for unscheduled bleeding or abnormal uterine bleeding, as long as we’ve diagnosed that, then we can move to treatment because it could be a whole bunch of other things and stuff. I have another talk on that if you wanna hear about that. But yeah, any of the options because it’s just about starting something and seeing how they do.

0:47:27.6 Liz Rohr: And it can also help with pelvic pain disorders, ovarian cysts, like I said, Hypoandrogenism, that hair loss, hirsutism, acne. It has a rapid return to fertility and then there’s also a reduced risk of ovarian and endometrial cancers. So that’s a nice little bonus. And then just a couple of counseling points just to keep in mind is that the patients, generally speaking, should take their pill at the same time every day. It’s not as crucial with the progesterone-only pills to take it at the same exact time, however around the same time. It doesn’t matter where in the cycle you start. You don’t have to wait for the first day of the menstrual cycle. You don’t have to… You can do a quick start that same day. You can wait for Sunday because the pills are starting with Sunday. Doesn’t matter as long as you have a backup, secondary method for seven days, the first seven days.

0:48:17.5 Liz Rohr: We always wanna do a medical screening and blood pressure screening to start. Thinking about medical contraindications on your app and don’t have… If you don’t have it memorized, it’s okay. And then just what other meds do they take and would that interfere. The main ones are anti-seizure meds, Rifampin, which is not very common. Antifungals, again not very common. Antiretrovirals might be common. Saint-John’s-wort, just ask them about supplements, over the counter. And then again about missed pills, if they take… If they miss one pill, you can take two the next day, no backup required. Two or more pills, you can take them, use a backup method. If it’s more than three, then we recommend stopping, having the menstruation, then restarting that pack. So that’s all I have for through oral contraceptives. I don’t wanna get too crazy with getting into all the other stuff. So do we wanna pause here? Or are there any other questions that people have?

0:49:13.3 Professor Walden: Just I’m not sure if you touched and maybe I missed this, but just the best kind of for those over 30, that one question that we had.

0:49:24.4 Liz Rohr: Yeah, so that’s what I was saying about… So anybody over 30, it really just depends on what their underlying problem is. So have we diagnosed the cause of the abnormal uterine bleeding? If it’s irregular, has this been their whole life? Is it just starting now, because we really need to investigate that. But if we know the reason, as long as they do not smoke, their BMI is under 30, under 25, ideally, and they don’t have health conditions, you can do oral contraceptives. You can also, depending on the underlying reason for their abnormal menstruation, consider IUD. That would be the one that I would go to because that has the highest chance of amenorrhea, if that’s what we’re trying to do for the patient.

0:50:09.2 Liz Rohr: Because if we choose ParaGard, the next one on is like, “Who knows?” You could have amenorrhea that’s only 20% versus 40%. And then the ParaGard is gonna make the periods heavier and it’s gonna go on their own hormonal cycle. But if you’re worried about using estrogen… Again, that’s the main risk factor for patients over the age of 35 with increased risk of thromboembolism, especially with those other factors. Then you can choose a progestin-only option, if you want. But again, progestin-only pills, same mechanism of action, thickens cervical mucus and makes it an unfavorable to implantation but does not necessarily help with the cycle management. It doesn’t help with ovulation. That’s estrogen.

0:50:54.3 Professor Walden: Right. I actually just read an article the other day and it said… You keep talking about uterine bleeding. And so you guys notice, remember when you were taking your exams or if you are preparing for your exams, remember the question was always, “Was an older woman bleeding? What about the uterine bleeding?” Not necessarily about the disease process that’s happening. What is that underlying? So the uterine bleeding is we get that was abnormal, but basically, the article said that IUDs basically were the best treatment.

0:51:29.6 Liz Rohr: Sweet.

0:51:29.7 Professor Walden: That we have here in America, that we have for uterine bleeding. I don’t know if you wanna do some further investigation.

0:51:37.3 Liz Rohr: Totally.

0:51:37.9 Professor Walden: Or screening, figure out what’s going on. But if it seems pretty benign and there’s nothing serious going on, the research is telling us that our best treatment for women sans sterilization… You know what I mean? Is an IUD. So that is what the recommendation is specifically for uterine bleeding.

0:52:01.5 Liz Rohr: Cool.

0:52:02.1 Professor Walden: Yeah. So another question.

0:52:06.1 Liz Rohr: Sweet.

0:52:07.6 Professor Walden: Is the under 25 BMA a hard stop?

0:52:10.9 Liz Rohr: For what?

0:52:12.6 Professor Walden: I think.

0:52:13.6 Liz Rohr: For oral contraceptives over 35?

0:52:17.8 Professor Walden: I think so.

0:52:18.5 Liz Rohr: That’s usually a risk-benefit conversation with the patient. But again, I can’t remember the percentage risk that it confers for the estrogen. But pregnancy is a four times higher risk than baseline of thromboembolism. So unintentional pregnancy is a much higher risk for venous thromboembolism and can include a whole host of other issues if that’s not what they want. So it’s not necessarily a hard stop, but it’s definitely… We have a… It’s not a consent form, but it’s like an informal… It might be a consent form, actually, where they… We’ve talked about it and then we review the signs, those ACHES signs. It’s one of the acronyms for the signs of a thromboembolism. So, yeah, I just have a conversation with them, but the higher they’re getting… If that’s the only thing, then that’s a little bit softer than if somebody also smokes. That makes me really uncomfortable. (chuckle) In terms of safety for them.

0:53:08.0 Professor Walden: No, for sure, for sure. I actually had a roommate, not a roommate, she was actually my neighbor in college, healthy, young, we were young and we were healthy. She smoked on occasion, not even socially, and got a clot and high blood pressure. So, I mean, birth control medication, I think… Who was it that asked that question? I think Christina, like you said, that BMI she says, most of our patients are above a 25 BMI, and again, that is that conversation that you had because let’s just be honest, there’s not a lot of us, Americans, is what I’m saying, that are out in there who have a BMI 25… You know what I mean?

0:53:54.6 Liz Rohr: I know.

0:53:55.1 Professor Walden: This is where we’re at, as a country, right now. So you definitely have to have that conversation because as that goes up, like listen and as it increases it’s like, what are you willing to take on? (laughter)

0:54:09.7 Liz Rohr: Yeah and I just, I do worry about the efficacy above 30, and so I tend to go for IUD more than the other methods, but…

0:54:20.3 Professor Walden: Yeah, what I have found is the idea of no cycle is very exciting. (laughter)

0:54:26.1 Liz Rohr: Yeah.

0:54:26.1 Professor Walden: Patients, who… Will go with an IUD first. Here’s another question.

0:54:32.1 Liz Rohr: Yeah, totally.

0:54:32.3 Professor Walden: So if a patient requests oral contraceptives, she’s a huge fan of Triphasic.

0:54:38.7 Liz Rohr: Yeah.

0:54:39.2 Professor Walden: For mono versus tri, is there any specific reason?

0:54:43.2 Liz Rohr: No, so if the patient’s already taking something and they love it, I’m gonna continue that. The only reason I choose Monophasic is because… So the origin of Triphasic was that they were trying to more closely monitor the body’s cycles, however, it didn’t pan out with research. It didn’t pan out that it was more effective in reducing side effects or that it helped manage unscheduled bleeding, maybe slightly more. But there is, I think just for ease of dosing, so for example, if somebody misses three pills and then they need to stop that pack, have their period and then restart, that’s a lot more complicated to get into the middle of a Triphasic pack than it is to do a Monophasic, and then also emergency contraceptives. An alternative method is that patients can take multiple oral contraceptives depending on what they take, and if they have Monophasic, they can take for example, five of those. I think it depends on the dose that you have in your pack, but that’s just a little bit simpler.

0:55:46.3 Liz Rohr: So that’s the main reason that I start with that, but if they already love it, then I’m not gonna make any changes, there’s no reason to change. But it was… It was almost like a pharmaceutical company marketing thing, actually, is one of the things that I was reading, so… It was just like they were trying to be fancy, and it’s like, this isn’t really helpful.

0:56:04.5 Professor Walden: Yeah, it’s not really working. You know, how a lot of our drugs come about.

0:56:08.5 Liz Rohr: Yeah, totally. (Chuckle)

0:56:09.9 Professor Walden: Okay, another question, a patient is already taking oral contraceptives and is over 35.

0:56:16.2 Liz Rohr: Yeah.

0:56:16.3 Professor Walden: And is found to have elevated blood pressure. Would you advise stopping or just stopping while getting the blood pressure under control?

0:56:26.2 Liz Rohr: That’s a great question. Yeah, so most of time, I think it’s a relative contraindication, I would definitely pull it up on the CDC Medical Eligibility Criteria. Most of the time the patients that I have with hypertension are not on oral contraceptives. I would have a conversation about it, I’d say that I’m pretty concerned about it, but if they love it, it’s worked for them for years, it’s only slightly elevated blood pressure, okay probably. It’s probably a two, maybe a three, in terms of that one to four scale. So if it’s a two… Let’s see what we can do. I think the other thing to keep in mind that is, just a curl of practice at hypertension is ACE inhibitors can be teratogenic. A lot of them can be teratogenic, actually. So it can cause birth-defects, if their contraceptive option fails, so just keeping that in mind when you’re, when you’re helping somebody with, in their 30s with Hypertension. But yeah, I’m pretty easy in terms of patients, patient-centred care, as long as it’s not an absolute contraindication.

0:57:30.8 Professor Walden: Absolutely, I think it’s more of a… That’s a great question.

0:57:34.4 Liz Rohr: Yeah.

0:57:34.6 Professor Walden: And also more of a, “What is your patient like?”

0:57:39.9 Liz Rohr: Yeah.

0:57:40.7 Professor Walden: You have to know your patient because how uncontrolled is uncontrolled, and how high is that BP?

0:57:46.3 Liz Rohr: Yeah, and are they monitoring at home and are they aware of the symptoms and is this a brand new initiation of OCPs that started their hypertension? I’ve had that happen a number of times, and then the patients can only tolerate progesterone options, so.

0:58:00.7 Professor Walden: Right, right.

0:58:01.0 Liz Rohr: It just depends.

0:58:02.3 Professor Walden: This is a great question as well. Is there any recommendations for prescribing contraception for minors without parental consent?

0:58:09.9 Liz Rohr: Yeah, so this is state-based, and unfortunately, I’m really only familiar with Massachusetts, but there are laws that, I think it’s 12 and up or 13 and up. There’s no consent required for anything sexual health-related. Luckily, in the state of Massachusetts, it’s really state-dependent, so I would just look at your state and see what the rules are there, and then the policy of your clinic, if you don’t have that option. And then a lot of the times, yeah, I think it depends on the state. But yeah, it’s tricky.

0:58:37.7 Professor Walden: Yeah, definitely, it definitely it gets tricky. This is one of those situations where I don’t go at this one alone, so there’s one of those, you have collaborating physicians.

0:58:47.7 Liz Rohr: Yeah.

0:58:48.3 Professor Walden: You have like your medical director may be there, get guidance, document that you’ve got in guidance because just in case we always have to cover us. You know what I mean?

0:59:00.7 Liz Rohr: Yeah and also if you can find out those state rules that you have, I let patients know, adolescents know, again, being in Massachusetts, just so you know, any time you can come and tell all of your friends. You don’t have a parent with you for any of these problems. I’m just like, it’s so important ’cause they don’t know, and if they have that power, definitely empower them to do that.

0:59:21.0 Professor Walden: Absolutely, absolutely. No, that was great. So these were great questions. I don’t think we have any more, but I’m sure if I have anymore, I’ll message you.

0:59:29.5 Liz Rohr: Totally, totally. (Laughter)

0:59:33.3 Professor Walden: It would be like, I don’t know this one, help me out.

0:59:35.0 Liz Rohr: Yeah, and there are many other options. It’s just it’s so much to talk about. It’s so much.

0:59:39.9 Professor Walden: It is. It is, and this was a good overview, just kind of introduction.

0:59:44.9 Liz Rohr: Intro, yeah.

0:59:46.0 Professor Walden: Of kind of what to say and what to give. Exciting things, guys. What I will let you know is the document that she mentioned is going to be dropped in your portal. The CDC contraceptive, that’s gonna be dropped in your portals along with some other helpful guidelines as well, just to kind of sum up everything that she’s kind of said and give you something to reference while you are in clinic. ‘Cause again, we love apps, we love paper, we love things that we can flip through and look at. We’re gonna make sure you have those things so that again, you’re a strong practicing clinician. That’s the whole goal of this situation.

1:00:27.0 Professor Walden: This was great conversation and super excited that Liz, you were able to be here. I’m excited about that. But with that being said, I am going to… Let Liz go, and then we’ll kind of wrap up. Hang out with me for a second, Liz (laughter) All right. I’m glad you guys liked it. I’m laughing because homework is what I’m seeing. The comment homework… Guys, I am going to give you things, but it is never work-work for you. It is more to kind of reinforce the things that Liz has said, and just so that you are aware and building your knowledge base. ‘Cause y’all know that’s how I am. It’s like, we gotta build a knowledge base so that we know what we’re talking about. But yes, so you guys are going to have several documents dropped to you in the next coming weeks. So just kind of be on the look out for that. If you missed the beginning as always, it is going to be in your portal, so don’t worry.

1:01:32.6 Professor Walden: You’ll be able to watch the whole thing, which was really, really great conversation. Good, good lecture with Liz, and we can’t wait to have her back. What I do want to know though, is there any kinds of conversations that potentially Liz could give, that you would be interested in? I’m gonna post that. And you don’t have to answer right now. I’m gonna post that in our group. And just things that you are interested in, that you would like to have more information on. And that’s going to be the question. You can post that. For example, I’ve had some request on hormone replacement therapy, ortho. Anything that you would like to have, so we can just kinda get that conversation started. But I’m super excited. There’s a lot of information coming but a lot of clarity for you. I’m excited and I’m glad that you all enjoyed it. And we are right over our time. And you know what, I will figure out how we get that Merck training, and I will let you know. I will give you some pointers about how you can go about doing that. How about that? Okay, alright. With that being said, anything else y’all let me know on the group. And we’re gonna go ahead and be respectful of your time and of Liz’s time. And I appreciate you guys for showing up, and we’ll talk soon. Alright, if you have any more questions, I’ll see you in the group. Alright, talk to you guys soon. Bye.