Stem-cell treatments; inflammatory bowel diseases; IUD overview: Upstate Medical University's HealthLink on Air for Sunday, Jan. 12, 2025

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a hematologist-oncologist explains how stem-cell transplants and therapies can help people with certain cancers and rheumatologic diseases.

Frank Zhou, MD: ... The whole process takes about two weeks to three weeks inside a hospital. And when the stem cell grows out, people are ready to be discharged home. ...

Host Amber Smith: A gastroenterologist discusses Crohn's disease and ulcerative colitis.

Idan Goren, MD: ... Crohn's can basically affect any part of the digestive tract. And ulcerative colitis affects only the colon, or the large intestine ...

Renee Mestad, MD: And a gynecologist tells why the intrauterine device is becoming more popular. ... They're what we kind of refer to as "no-brainer" birth control. You don't have to remember it every day. You don't have to refill it every month. It's expensive to start, but once it's in the uterus, the woman owns it; it's hers. ...

Host Amber Smith: All that, plus a visit from The Healing Muse, after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll learn about inflammatory bowel diseases and treatments. Then, what's important to know about the IUD. But first, stem-cell transplants and therapies are options for more patients with cancers and rheumatologic diseases.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Treatment options for certain cancer therapies and rheumatologic diseases may broaden through the use of stem-cell transplants or therapies. Today, I'll talk with Dr. Frank Zhou about this potential. He's the director of the stem-cell transplants and cell therapies program at Upstate.

Welcome to "HealthLink on Air," Dr. Zhou.

Frank Zhou, MD: It's a pleasure.

Host Amber Smith: Can you describe what a stem-cell transplant is and who it can help?

Frank Zhou, MD: So, as the name implies, we use stem cells, either from the patient themself or from a healthy donor, to use them to treat for different types of blood cancers. That's what we do.

Host Amber Smith: Let me ask you, if I can, what is a stem cell? How does it differ from other cells in our body?

Frank Zhou, MD: It's a very general term when we refer to stem cells. What we use here, for cancer treatment, in stem-cell transplants, are hematopoietic stem cells, which means the stem cells that will differentiate into our blood cells in the bloodstream, eventually.

It's different from the stem cell in the general sense that people use this for tissue generations, but we only use hematopoietic stem cells.

Host Amber Smith: And what are the stem-cell transplants used to treat?

Frank Zhou, MD: Primarily for different types of blood cancers, including lymphoma, myeloma and leukemia.

Host Amber Smith: And can you tell us how they're done? I know you said it can be with a donor blood or from the actual patient, right?

Frank Zhou, MD: Depending on the disease. For lymphoma and multiple myeloma, we oftentimes use patients' -- their own -- stem cells, once they were treated adequately from the beginning. When they're ready for stem-cell transplants, we will collect their blood stem cells and reinfuse back to them after the transplantation.

Host Amber Smith: And this sounds like a specialized technique.

Frank Zhou, MD: It is. It may sound difficult by itself, but the steps are pretty simplified. When people had adequate treatment from the beginning, they're ready for the stem-cell transplant. We will collect their stem cells first through a dialysis-machine type of machine.

While we collect enough of those cells, we can freeze them down. When the time comes, they're ready for transplant, they will be admitted to the hospital. At that point, we will get something called conditioning chemotherapy, which is a high-dose chemotherapy to eliminate all the disease in their marrows and elsewhere in their bodies, before they're ready to get the stem cells reinfused back to them.

So the whole process takes about two weeks to three weeks inside a hospital. And when the stem cell grows out, people are ready to be discharged home.

Host Amber Smith: So what is done to the stem cells, once they're extracted, before you give them back to the patient?

Frank Zhou, MD: They can be frozen down in the liquid nitrogen tank, and it can be kept for months to years, until the patients are ready to receive them back.

Host Amber Smith: And when they receive them back, does this hopefully take the place of cancerous cells?

Frank Zhou, MD: Correct. So the chemotherapy we give to them, (which) we call the conditioning chemotherapy or preparative chemotherapy, is to wipe clean their diseased (bone) marrow to allow the healthy stem cells to be reinfused back.

In the case of leukemia, because the primary disease is in the bone marrow, we would not use their own stem cells for the transplant, but rather a healthy donor, matched donor cells, for the stem-cell transplant.

Host Amber Smith: Are treatments like this generally covered by insurance?

Frank Zhou, MD: Correct. They're covered.

Host Amber Smith: And how long do the effects of a stem-cell transplant last?

Frank Zhou, MD: If it's successful, it lasts lifelong. You gain your health back, and the disease is in remission. People can live as long as the stem cells are going to support them.

Host Amber Smith: How hard is it for you to find a match, someone who has stem cells that can be donated?

Frank Zhou, MD: If you need healthy donor cells, there are relatives who could be a potential genetic match to you. Or it could be healthy donors who volunteer themselves across the globe. There is an international donor database that allows us to find healthy donors for the patient.

Host Amber Smith: Are blood relatives always a match or not necessarily?

Frank Zhou, MD: Not necessarily. Statistically speaking, if you have the same parents, every one out of four siblings will be genetically identical to you, so they could be so-called matched sibling donors.

Then, across the donor registry, there are genetically comparable donors we could find, depending on ethnicity. For Caucasian/white people, the chance of finding a healthy donor from the registry is around 70%. For other ethnicity people, the percentage varies. It is not because of less healthy donors from African Americans or Asians, it is because their genetic background is more admixed.

Host Amber Smith: So it's more of a challenge to find a match.

Frank Zhou, MD: There is a new technique being developed using "haploidentical" donors, meaning half-matched donors. So if older parents were diseased, having leukemia or other blood cancers, their children, by definition half-matched, now we have a technique to have their children to donate for them, or their sibling who is a half-match. So this is a significant advancement in the transplant world over the past 10 years.

Host Amber Smith: Do the recipients of stem cells, do they have to take anti-rejection medicine, like with organ donors and recipients?

Frank Zhou, MD: Correct. Obviously for autologous, meaning that (you) use your own stem cells, you don't need any immunosuppression medication because they're part of their own (body). For the allogeneic (from a donor) stem-cell transplant, after the transplant, when those stem cells grow out, you do need immunosuppression medication this time -- we call it graft-versus-host disease -- to prevent it. This is the opposite of the organ transplant, in which case you reject an organ. But in the stem-cell transplant, actually the bone marrow you receive is going to reject you, so that's what we are suppressing.

Host Amber Smith: If it's successful, the stem-cell transplant, are the stem cells immune from developing cancer?

Frank Zhou, MD: So the stem cell that you receive from a healthy donor will keep you under check for those remaining cancer cells. They will seek out and kill them. Obviously, this goes hand in hand with graft-versus-host disease; we call it graft-versus-leukemia or -lymphoma effect.

That's a potential cure.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with assistant professor Dr. Frank Zhou from Upstate, where he directs the stem-cell transplants and cell therapies program.

Can you walk us through the cell therapies that may be used to treat cancers or rheumatologic diseases?

Frank Zhou, MD: Yes. This is another exciting area, as we see a lot of development and advancement. Right now we have something called chimeric antigen receptor T cells. Those were bioengineered T cells from the patient we collect. And then those cells were manipulated in the laboratory to have them recognize the cancer cells and engage them through the receptor expression on the cell surface.

When you infuse those cells back to the patient, those particular T cells can seek out their cancer cells, engage them and kill them.

Host Amber Smith: Is that also the one that's called CAR-T cell?

Frank Zhou, MD: Correct. C-A-R dash T (which stands for) chimeric antigen receptor T cells.

Host Amber Smith: Did I read recently that they're looking at that for lupus as well?

Frank Zhou, MD: This is another interesting area to see more development and usage of this treatment modality. It originated from treatment for cancers. Now the CAR-T can also manipulate the immune system of the patients who suffer from autoimmune disease, such as lupus or rheumatoid arthritis.

Host Amber Smith: Now, what about adoptive transfer of regulatory T cells? What is that?

Frank Zhou, MD: It's very similar to the chimeric antigen T cells therapy. In which case, those regulatory T cells can regulate your immune system by interacting with the rest of your immune cells in the body just to restore a homeostasis, a balance in your immune system to treat or to prevent autoimmune disease.

Host Amber Smith: In general, how effective are these therapies and how long do they last?

Frank Zhou, MD: So when CAR-T therapies are used for blood cancers, they are also a potential cure for that, theoretically, as long as those T cells can last inside the body a long period of time and also kill any cancer cells that have resurfaced.

In the matter of years, the median survival currently for CAR-T therapy in lymphoma and leukemia patients, we see median survival more than two years, that was revealed from the study. In the real world, we also see longer remission, more than two years.

Host Amber Smith: Interesting. Are these useful in children?

Frank Zhou, MD: It is, although I'm an adult cancer doctor, but I heard my colleagues in the children's hospital also exploring the CAR-T therapy approach, as well as the allogeneic transplant approach for the past few decades, for children's blood cancers.

Host Amber Smith: What other therapies do you see on the horizon?

Frank Zhou, MD: So there are a lot of improvements of the CAR-T cell itself, by how you construct the cells, how you bioengineer the cells, how you make them more potent, how you reduce side effects from them. So there are a lot of things that can be done and more work to do.

Host Amber Smith: When you got started in medicine and scientific research, did you think or anticipate that there could be such development with stem cells?

Frank Zhou, MD: It's certainly a surprising, pleasant surprise. When I was a fellow (receiving specialized training) ) almost 10 years ago, the CAR-T therapy was not there. Look at right now what we have, and I'm looking forward. That's exciting for us, as a cancer doctor, and also it's a blessing to our cancer patients.

Host Amber Smith: I don't often get to interview people that use the word "cure." So that's encouraging.

Frank Zhou, MD: Yes. That's the goal we are shooting for, although not everyone is cured, but theoretically, those approaches can offer a cure to our cancer patients.

Host Amber Smith: Well, Dr. Zhou, I appreciate you making time for this interview. Thank you.

Frank Zhou, MD: Thank you. It's my pleasure.

Host Amber Smith: My guest has been Dr. Frank Zhou. He's the director of Upstate's stem-cell transplants and cell therapies program. I'm Amber Smith for Upstate's "HealthLink on Air."

A look at inflammatory bowel diseases -- next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Today, I am talking about inflammatory bowel disease with Dr. Idan Goren, who's an assistant professor of medicine specializing in gastroenterology at Upstate. He's an expert in managing inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis.

Welcome to "HealthLink on Air," Dr. Goren.

Idan Goren, MD: Thank you. Thank you so much for having me. I'm excited to be here.

Host Amber Smith: Well, let's start with a description of what inflammatory bowel disease is.

Idan Goren, MD: So inflammatory bowel disease is an umbrella term that includes two chronic conditions, both Crohn's disease and ulcerative colitis.

Both of them can affect the digestive system, but they can affect different parts of the intestines. So Crohn's can basically affect any part of the digestive tract. And ulcerative colitis affects only the colon, or the large intestine.

Host Amber Smith: Well, we'll get into this a little more, but are the symptoms the same?

Idan Goren, MD: First of all, I would like to state that this is pretty common nowadays. We have more than 3 million Americans living with these two conditions. And the most common symptoms for patients with IBD include abdominal pain, diarrhea, sometimes it can be even bloody diarrhea, fatigue, weight loss. In some cases fever is also one of the symptoms initially during a flare or first presentation of the disease.

Patient can also experience symptoms which are not inside their GI tract, but systemic symptoms such as joint pain, different skin problems and eye inflammation.

There are certain differences between the presentation of these, of both diseases. Usually ulcerative colitis is associated with a bloody diarrhea, whereas in Crohn's disease, this is not really common.

Host Amber Smith: I see. Do we know what causes Crohn's and ulcerative colitis?

Idan Goren, MD: Yeah, so this is like the $1 million question, I would say, because we don't really fully understand what the exact cause is. But we do know that there are several risk factors that seem to play a role. And genetics is definitely one of them because we know that IBD can run in families, so if a parent or a sibling has it, you are at a high risk to develop it, too. We also know that the environment plays a role.

We know that there are certain lifestyle factors such as high-fat diet, living in urban areas, exposure to antibiotics, especially during the first year of life, put the patient at higher risk for developing inflammatory bowel diseases. Breastfeeding during the first year is considered one of the protective factors.

And then geography also plays a role. People in more developed countries, or people who live in cities are, more likely to develop inflammatory bowel disease. And this is potentially related to the dietary pattern or lifestyle.

Host Amber Smith: So if someone realizes that they're at high risk -- maybe they have family members that have had this -- is there anything they can do, actively, to help prevent the development of this?

Idan Goren, MD: So I would say, first of all, eat well. So if you eat, your diet is rich in fiber, fruits, vegetables, that might be beneficial not only for inflammatory bowel disease prevention, generally, but we do know that healthier diet and higher in fibers is one of the potentially protective factors. Avoid smoking. So cigarette smoking is one of the major risk factors for Crohn's disease, and patients with Crohn's disease who continue smoking, they're at high risk to lose response to the therapy. So it, it is both risk factor to develop the disease, but it is also associated with a poor prognosis or worse outcomes in patients with preexisting diagnosis of Crohn's disease.

Host Amber Smith: One general thing that I like to discuss with my patients: It's reducing stress. So chronic stress can worsen the symptoms and can also indirectly or directly cause a flare. These are conditions that flare up. So it's not always constant that you're having the symptoms. It comes and goes. Is that right?

Idan Goren, MD: That's the case. So this is very unpredictable, and most patients experience periods of active inflammation and periods of remission. That's correct.

Host Amber Smith: How is this treated, in general?

Idan Goren, MD: So we have different ways to treat the inflammation. And the key here is medication.

So as I mentioned before, people that are dealing with inflammatory bowel disease have these flareups when the symptoms, like pain, diarrhea, fatigue, becomes really severe. And this is very unpredictable. So we do use different medication to treat the inflammation. And by doing so, we can put the disease into remission and help our patient feel better.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with gastroenterologist Dr. Idan Goren from Upstate.

Can you tell us about the new IBD service that you've launched for Central and Upstate New Yorkers?

Idan Goren, MD: Sure. So our new IBD service is focused on providing a more comprehensive care for people with inflammatory bowel disease.

I was privileged to do some of my training at the Cleveland Clinic, where I trained in advanced IBD care. And my goal here is to fill a gap in this community by offering both medical, surgical treatments for inflammatory bowel disease. And I do work closely with other specialties. So I have a very good collaboration here with the surgeons, with rheumatology department, psychiatry and also dermatology, to make sure that we can cover all the aspects of inflammatory bowel disease management.

And hopefully in the future we'll also offer some support for diet to make sure that our patients have the care they need for their whole well-being, not just focusing on their inflammation, but treating them as a whole.

Host Amber Smith: You mentioned psychiatry, rheumatology, dermatology. How do those specialties benefit patients with IBD?

Idan Goren, MD: The main message here is that IBD is not just inflammation of the gut. It has many, many manifestations, both inside the gut and outside the gut. And this is basically a systemic inflammatory disease. Because it affects different parts of the body, it is important to have a team that can help with all the symptoms and all the manifestations, not just the digestive one. And unfortunately, over time, patients with Crohn's disease may develop bowel strictures and structural damage to their gut that may require surgery. So we do work very closely with our surgical colleagues. And in cases of poorly controlled colitis, we also may end up using surgery as a treatment for the disease. So being followed in an academic center is a big advantage.

Host Amber Smith: Does having an inflammatory bowel disease raise a person's risk for developing a colorectal cancer?

Idan Goren, MD: Yes. So people with long-term inflammatory bowel disease, especially when the affected area is an extensive part of their colon, or their large bowel, they are at high risk for colorectal cancer. And that's why we do need to screen them regularly. When I say screen, I mean doing more frequent colonoscopies on those patients.

Host Amber Smith: OK. And is that the best way for them to reduce their risk? Or are there other things that they need to be doing actively?

Idan Goren, MD: There are three waysto reduce the risk for colorectal cancer in patients with inflammatory bowel disease. The first is by treating the inflammation. The better we can treat the inflammation over time, we can prevent or reduce the risk for colorectal cancer in our patients.

Second is by doing surveillance. So surveillance colonoscopies starting at eight to 10 years after the IBD diagnosis is the way that we can identify earlier and treat earlier any lesions that may eventually end up developing into colorectal cancer. So the ideal cases that we can detect earlyany lesion, and then we do repeat more frequently the screening colonoscopies, meaning that after eight to 10 years, we tend to do more colonoscopies, usually every one to three years on average.

And the third thing is like any other person, just lifestyle. So don't smoke. Stay active. These are always beneficial to reduce the risk for colorectal cancer.

Host Amber Smith: So what does natural aging do? If someone has inflammatory bowel disease in their 30s, what is it like in their 50s or 70s? Does it naturally get better or worse?

Idan Goren, MD: That's a great question. So since this is a very unpredictable disease, I would say that in some patients, we do see decline in the inflammatory activity over the years, and when they get older, the disease become more.... I like to call it, like, "burned out" disease, or less active. But we do see that in certain individuals, the age does not really play a significant role. And we have patients in their 70s and now even 80s, showing up with very, very severe active disease, sometimes after years of remission. So I would say that this is really variable and unpredictable.

Host Amber Smith: So it's a lifetime disease. There's not a treatment that cures it, then?

Idan Goren, MD: So unfortunately we cannot cure it, but we can definitely treat it.

Host Amber Smith: OK. Well, let me ask you about some of the latest advances in IBD treatment or what you see on the horizon.

Idan Goren, MD: There have been some really exciting advances in the treatment of IBD in recent years, and I think that one of the most important developments is the advanced therapies.

And we do offer many, many new therapies, both biologic therapies, which are usually given in injections, but we also have some new oral small molecules, which are pills, that does not require going into infusion clinic anymore and really improve our patient satisfaction.

These are really game changers, these medications, because many of our patients did not really respond to the older medications or the traditional treatments. And now we can help them getting into remission and improve their quality of life.

I think that one of the key advantages of the way we treat IBD now is that we don't really wait too long until putting the patient on a good and effective treatment. So, in the early days of inflammatory bowel disease, there was a perception that delaying the care and keeping the best medication down the road when everything else failed is the right way to go. Now we know that this is the other way around. We should use our best tools upfront as soon as possible, and then we can prevent some of the damage or some of the irreversible damage of this lifelong disease.

Host Amber Smith: I didn't ask you before, but how does a person become diagnosed with an inflammatory bowel disease?

Idan Goren, MD: So as I mentioned, there are certain symptoms which are really typical for inflammatory bowel disease, and they include both abdominal pain, diarrhea with and without blood, fatigue, weight loss, fever, and any of the extraintestinal manifestations such as joint pain, low back pain, new skin rashes or eye inflammation. Usually the combination of them.

Once the patient has these symptoms, they should get referred to IBD center or any GI provider who can further assess them. And there is not a single test to diagnose a patient with inflammatory bowel disease. There's a combination of endoscopy, which means colonoscopy and upper endoscopy, as well as some cross-sectional imaging like a CT scan or MRI. And then when we do scope the patient, we take biopsies from areas that look inflamed and check them under the microscope to look for specific signs of chronic inflammation. And this combination altogether helps us to diagnose a patient with inflammatory bowel disease.

Host Amber Smith: Now, can you tell me the difference between inflammatory bowel disease and something I've heard of, irritable bowel disease? They're not the same thing, right?

Idan Goren, MD: Correct. So, irritable bowel disease is way more common than inflammatory bowel disease, thankfully. As opposed to inflammatory bowel diseases, which involves inflammation in your colon or any other area of your GI (gastrointestinal tract), irritable bowel disease is a diagnosis of exclusion. It means that the patient does not have any inflammation or any disease that can be found in their system, but they still have a lot of symptoms such as abdominal pain, diarrhea, constipation or the combination of them.

And one of the key features is abdominal pain. As opposed to inflammatory bowel disease, irritable bowel disease is a functional disorder. So our approach to the therapy of irritable bowel disease is completely different. When we treat patients with irritable bowel disease, the goal is to treat their symptoms. Whereas when we treat patients with inflammatory bowel disease, we should treat both the inflammation as well as their symptoms.

Host Amber Smith: I see. Well, Dr. Goren, I want to thank you so much for making time for this interview.

Idan Goren, MD: Thank you for having me.

Host Amber Smith: My guest has been gastroenterologist Dr. Idan Goren, an assistant professor of medicine at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air" -- what to know about the IUD for birth control. From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

The intrauterine device is one of the most popular forms of contraception in America. And today we'll learn about why with Dr. Renee Mestad. She's director of the complex family planning section of the obstetrics and gynecology department at Upstate.

Welcome back to "HealthLink on Air," Dr. Mestad.

Renee Mestad, MD: Thank you.

Host Amber Smith: What is the intrauterine device, or the IUD?

Renee Mestad, MD: In the United States, the IUD is a small device that has a T shape, and it fits inside the uterine cavity.

While there, it provides what we call LARC, or long-acting reversible contraception, that is as effective as being sterilized without actually being sterilized, so that, depending on the device, it provides contraception from anywhere from three years to 12 years but can be removed at any point in time if the patient wants to become pregnant.

Host Amber Smith: You said in the United States. Are IUDs different in other parts of the world?

Renee Mestad, MD: Yes. There are a wide variety of different types of IUDs throughout the world, but in the United States, the only ones that are approved by the FDA (Food and Drug Administration) are the two T-shaped IUDs.

Host Amber Smith: Now, have you seen that its popularity is on the increase in America?

Renee Mestad, MD: Yes. When I started in complex family planning, way back in 2008, the utilization was roughly about 1%. And at this time, we are up to about 14%, with the highest group being about 16%, being young women aged about 18 to 25.

Host Amber Smith: So why do you think this is becoming more popular with that segment?

Renee Mestad, MD: Part of the unpopularity was due to the Dalkon Shield scandals from the '70s that resulted in a lot of physicians not wanting to provide intrauterine devices, or IUDs, for women who had never had children, due to a concern that they might cause pelvic inflammatory disease or scarring of the Fallopian tubes, which would cause infertility to these women.

And as a result, all of the IUDs were basically taken off the market. The companies that made them determined that it wasn't profitable to provide these methods of contraception.

When people interested in contraception went through the data that had been accumulated, stratified out the different IUD types, they found there was only one kind of IUD that caused the pelvic inflammatory disease. The rest of the IUDs did not increase a woman's chance of developing pelvic inflammatory disease any more than any woman who was sexually active. Period.

So, starting in the late '90s and early 2000s, two companies were willing to start making IUDs again. And the people in the family planning world began publishing a lot more data about the safety around IUDs, the efficacy around IUDs. And new physicians became very interested in IUDs. They're very popular because they are as effective as they are. And because they're what we kind of refer to as "no-brainer" birth control. You don't have to remember it every day. You don't have to refill it every month.

It's expensive to start, but once it's in the uterus, the woman owns it; it's hers. If she loses her insurance, she doesn't lose access to her IUD. If she gets into a car accident and has to pay a huge deductible to repair her car and therefore doesn't have any money to pay for her copays for anything else, she still has her IUD. So they've become very popular for these reasons. And for female trainees in obstetrics and gynecology, it's the No. 1 form of birth control.

Host Amber Smith: What's the difference between hormonal IUDs and copper IUDs?

Renee Mestad, MD: The copper IUD: In the United States, we have one available, and its contraceptive effect comes from the copper ions that come from the very thin copper wire that's wrapped around the frame of the IUD -- the frame is basically of plastic -- and copper ions are very toxic to sperm. They prevent the sperm's ability to fertilize. And these ions actually act up into the Fallopian tubes, which is why this is a very good method of emergency contraception for up to five days after unprotected sex, because those ions are able to get to that sperm that's already made it into the uterus and even made up into the Fallopian tubes, and therefore it's unable to fertilize the egg that is released with ovulation.

The progestin IUDs have only one hormone, which is a synthetic version of progesterone. Progesterone helps to decrease the amount of blood that the uterine lining creates, but its primary mechanism of action is that it thickens cervical mucus, so the sperm cannot penetrate the cervix and therefore cannot get into the uterus and ever meet up with an egg to fertilize it.

The added benefit by thinning the lining of the uterus is that it can also help with women who have heavy periods. It can help with women who have problems with abnormal bleeding, women who have things like polycystic ovarian syndrome, or PCOS, where they bleed only every few months, because it can help, therefore, to prevent endometrial hyperplasia, or development of precancer cells. And it can definitely help with preventing endometrial cancer for women who are at high risk of that.

Host Amber Smith: And it's pretty effective at preventing pregnancy?

Renee Mestad, MD: Yes. The risk of pregnancy for both the hormonal and the copper IUDs is less than 1%.

Host Amber Smith: What about sexually transmitted infections?

Does it guard against any of those?

Renee Mestad, MD: Not officially. It, first of all, does not increase the risk of sexually transmitted infections. The progestin, by thickening cervical mucus, can make it more difficult for bacteria to also work its way up into the uterus. So observational studies have demonstrated that any kind of progestational (preceding pregnancy) contraceptive can decrease the chance of developing pelvic inflammatory disease. It will not prevent a woman from getting gonorrhea or chlamydia of the cervix. It will not prevent HIV (human immunodeficiency virus). It will not prevent herpes. It will not prevent HPV (human papillomavirus), but it can possibly help decrease the risk of pelvic inflammatory disease.

Because these are just observational studies, we don't promote this as a benefit of utilizing the methods. If sexually transmitted infections are a concern, then condoms need to be used.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking with Dr. Renee Mestad from Upstate's division of obstetrics and gynecology about the intrauterine device, or IUD.

Now, let's talk about who is a good candidate for this. I know the younger women seem to be interested in this, but is it for any age woman?

Renee Mestad, MD: It is for any age woman who can tolerate having a pelvic exam. It requires the provider to place a speculum so that they can see the cervix, so that they can insert the device through the cervix.

So if a patient can tolerate a pelvic exam, and the whole process is usually about five minutes, then it's a good method, good option, for this woman.

Host Amber Smith: What if the woman has never had a vaginal birth before getting the IUD? Does that matter?

Renee Mestad, MD: It does not. Once upon a time, that was a reason to not be able to get an IUD, because it can be a little bit harder to insert the IUD through the cervix, because the cervix has never been stretched open, but it is not a hard and fast rule of why a woman cannot receive an IUD.

Host Amber Smith: Are there any medical conditions that would prevent, assuming that you can undergo a pelvic exam, are there any things other than that, that would disqualify?

Renee Mestad, MD: For the copper IUD, if a woman has something called Wilson's disease, or basically an allergy to copper, she clearly should not. Women who have heavy periods, where they bleed for many days and have developed anemia as a result, should probably not get the copper IUD, theoretically. And there have been complaints that it causes more bleeding, but it's more a matter of it won't really help the bleeding at all.

Any abnormal bleeding should be worked up before either IUD is provided. Cancer often will bleed in advance of being diagnosed. It's not usually the reason a woman, particularly a young woman, has abnormal bleeding, but it needs to be ruled out first.

And then, anybody with a current pelvic inflammatory disease infection should not get an IUD. It needs to be treated first, and then they can get an IUD. Women who have fibroids or scarring of the inside of the uterus or have something that we call didelphic or bicornuate uterus, uteruses that are not the normal light-bulb shape but are actually like two horns. They're not a hard and fast rule, but it could be much more difficult to place or keep the IUD. It may wind up being ejected by the uterus if the shape of the uterus is not standard.

Host Amber Smith: So are these inserted in an office procedure?

Renee Mestad, MD: The vast majority of the time, yes.

Host Amber Smith: And does it hurt?

Renee Mestad, MD: Yes. And it varies woman to woman. I'll have some patients who I go through the process, and I place the IUD, and the response is, "Oh, you started?" And I have other patients who just ... it's just excruciating.

And I can't speak to why it varies. It can be the same person inserting the exact same device or from the same company, and the response is just different. But it does merit that providers be honest with the patients that yes, this is definitely going to be uncomfortable, it might be painful, that the patient makes sure that she takes some ibuprofen before she comes in. It won't necessarily help with the immediate pain of the insertion, but it can help with the cramping that's going to happen afterwards, so it's important that the provider not brush off the potential for pain or significant discomfort by saying, "Oh, it's just a couple little cramps."

I mean, for some women it is, but for some women, it is very significant.

Host Amber Smith: So once it's in place, can the woman feel it?

Renee Mestad, MD: She will have an awareness of her uterus, which is how I describe it. Most of us go through the month without really thinking about most of our organs, until you bruise your arm, and now, every time you wave it, it hurts a little bit.

But when it comes time for our periods every month, then we're very aware of our uteruses, down there in our pelvis. So there might be some cramping; well, there will be some cramping upon insertion and the rest of the day. It should ease up, and it could be a couple of hours up to a couple of weeks and even maybe a month or two, before a woman stops being aware of her uterus.

But like I said, it's just kind of an awareness. It might be a dull ache, or it might just be, "I have a uterus," and you know it's there. And eventually, though, that goes away.

There are strings that hang down from the IUD through the cervix and into the vagina. They should not hang out outside of the vagina like a tampon string. But a lot of times women can feel that. Occasionally a male partner might complain about IUD strings, so we usually try to tuck them behind the cervix if that becomes an issue.

Host Amber Smith: How hard is this to remove?

Renee Mestad, MD: Most of the time, not very.

It's often easier coming out than it was going in because we just grab the strings and pull. sometimes it can get flipped around in the uterus. I don't know how that happens, but it does, so it may be difficult getting it unflipped.

Rarely, but not impossibly, one of the arms can wind up kind of embedding in the muscle of the uterus itself, which can make it difficult to get out. And we've had a few cases where an "L" of the IUD comes out with one of the arms breaking off and being stuck inside the uterus, whether it's in the uterus itself or in the muscle of the uterus.

And very rarely, like, at this point, about less than one in a thousand times, you can get an IUD that goes all the way through the uterus and into the woman's abdomen, into her belly. In that case, then, she would need a laparoscopic surgery through her belly button to find and remove that IUD.

Host Amber Smith: So those, I assume, are some of the risks of using an IUD.

Renee Mestad, MD: Yes.

Host Amber Smith: But for most women, that doesn't happen.

Renee Mestad, MD: Correct. It's generally pretty straightforward.

Host Amber Smith: Will use of an IUD make it difficult to become pregnant when they're ready to start a family?

Renee Mestad, MD: Return to fertility is pretty immediate. The copper IUD does not affect the function of the ovaries, so a woman continues to ovulate every month. So basically whenever she would ovulate next would be the next time she'd be able to get pregnant.

The progestin IUD, or hormonal IUD, sometimes might affect ovulation, but it's really not reliable in that respect. So once it's removed and that progestin is removed, then the ovaries should start ovulating again, and her fertility comes back fairly quickly.

The thinning of the lining of the uterus, that recovers fairly quickly once the progestin is removed, as well.

Now, the thing to keep in mind is because these are long-acting devices, say that the woman gets one that lasts for eight years, so she has it placed at 24 years of age. She has it removed at 32 years of age. She will have a more difficult time getting pregnant, not because she uses contraception for a long period of time, but because she's now 32 years old. Eight years have passed. Her ovaries are eight years older. Pregnancy after the age of 30 does become more difficult, so that is the only reason why getting pregnant after removal might be more difficult. You simply aged.

Host Amber Smith: Now, we talk about the hormonal IUDs. Do they have the same sort of emotional effects that the pill might have, the hormonal pill?

Renee Mestad, MD: Intuitively, they should not. The amount of hormone in the progestin IUDs is very, very low. It's not zero, as far as getting into the bloodstream and affecting the brain and the emotion centers. But it is significantly lower than that of systemic hormones like birth control pills or the shot, the patch or the ring.

They don't stop ovulation. So if a woman is ... say her PMS (premenstrual syndrome) is well managed with systemic hormones like the patch or the ring or the pills, that might stop, and she may find that she has more significant PMS or mood swings again. All that said, we have had women who have had mood disturbances after having an IUD placed.

Like I said, intuitively, it doesn't make sense, but it happens, and we just don't necessarily know why at this point, but it has the potential to happen.

Host Amber Smith: Do IUDs affect a woman's cancer risk for uterine or ovarian cancers or breast cancers?

Renee Mestad, MD: The progestin IUDs definitively decrease the risk of what we call endometrial cancers, which are the most common uterine cancers.

So if a patient is at risk of developing something like that, then it can definitely decrease her chances of getting endometrial cancer. The copper IUD may or may not decrease the chances of endometrial cancer, due to the inflammatory process that happens within the uterus. It doesn't increase, but it may actually help to decrease the chance.

Neither will have any effect on ovarian cancer, as far as we know at this point in time.

Breast cancer, the copper IUD will not affect breast cancer risk. The progestin IUD, if a woman has an estrogen or receptor positive breast cancer, she really should not use a progestin IUD.

Will it increase the risk?

I just looked at a study last week, and they did find a small increased risk of breast cancer. But you're looking at about eight per 10,000 women higher. Interestingly, pregnancy also increases your risk of breast cancer in the first few years after delivery.

And then, as time goes on, that risk goes back down to what your normal risk would've been. And the risk of developing breast cancer after being pregnant, for a few years afterwards, is actually higher than of using this IUD. So if your biggest, absolute biggest fear in life is getting breast cancer, maybe it might not be your best choice.

The likelihood that you're going to get breast cancer, though, like I said, the absolute numbers are like eight per 10,000 women. So your risk really is not that much higher than the average woman's. And again, the risks of pregnancy across the board in all causes, mortality, morbidity (deaths, illnesses) is significantly higher, particularly in the United States, than the risk of developing breast cancer using an IUD.

So what providers and women need to keep in mind is, when you're comparing the risks of using an IUD or any method of contraception, if they're sexually active, then they need to compare the risk with the contraceptive against her risks of becoming pregnant. If this is a woman who is not having sex, will never have sex and is not at risk of ever becoming pregnant, then her comparison is different. But women and providers need to remember that the risk of pregnancy is not "none." And it's actually fairly significant, particularly in the United States.

Host Amber Smith: What are the other birth control methods you counsel women to consider if they're just not sure about whether the IUD is a good option for them?

Renee Mestad, MD: We run the gamut. It starts with what the patient's goals are. So if this is a patient who has no desire to get pregnant in the next four or five years, then we lean towards either the IUDs or the Nexplanon, which is the only subdural contraceptive implant that's available in the United States. That is a device that fits in the upper arm, just under the skin, and that is effective officially for three years, but post-marketing research outside of the pharmaceutical company has found it to be effective for four and five years.

So those two methods, again, once they're in the body, they're owned by the patient, and they're both extremely effective in preventing pregnancy for many years.

Now if this patient is interested, she just got engaged, and they're getting married, and a few months after they get married, so in about six months, they're thinking they want to try and get pregnant, I'm not going to recommend an IUD or a Nexplanon. They're both very expensive devices. And to place them and then remove them in five or six months is, unnecessary expense and it's unnecessary anything for the woman to go through for insertion. So in those cases, I would lean towards birth control pills or the patch or the ring, or, if they're really good at using their condoms or their spermicide gels, then I recommend in that direction.

The shot, the birth control shot, which in the States is Depo-Provera, that's very effective, and it's good for three months at a time, but the return to fertility can be anywhere from the week after you missed your dose to 18 months. So I'm not particularly fond of recommending that for women who are of an age, in their 20s and early 30s, where when they decide they want to get pregnant, they want to get pregnant right now, they don't want to wait up to 18 months before they can get pregnant.

So it's good for teenagers who are definitely not getting pregnant anytime in the next six or seven or eight years. And it's good for women who are done with childbearing, and they're just kind of waiting for menopause. But for women of that age group where when they decide they want to get pregnant, they want to get pregnant right now, I don't recommend Depo for them.

Host Amber Smith: Well, Dr. Mestad, thank you so much for making time for this interview. I appreciate it.

Renee Mestad, MD: Thank you.

Host Amber Smith: My guest has been Dr. Renee Mestad. She's the director of the complex family planning section of the obstetrics and gynecology department at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Anne Rankin gave us a beautiful but difficult poem that analyzes Vincent Van Gogh's "Starry Night" and finds in it an unsettling similarity with her own speaker. Here's her poem "Broken."

Staring again at Van Gogh's Starry Night,

I've a fervor all my own. Before me the sky

a sea of waves, the swirling almost holy.

But I can't pray here, can't turn away

from the weight of the cypress, the glaring

eyes of the stars. The moon

looks unwell but there's nothing I can do.

Subdued, the little boxes of the village stand

opposed to the curves of the swirls.

(Right angles never fix anything.)

There's so much pain here, I can almost hear

the canvas calling.

Most are dazzled by the strange

brushstrokes: the swell of his yellows,

the depths of his blues.

But it's too hard for me to watch.

Sickness, painted boldly.

They're never going to get

all the ways he's broken.

He had told Theo, Just as we take the train ...

we take death to reach a star.

He'd reached before, was reaching still.

But there's a black hole

in every galaxy, dark matter in every life.

I'm never going to fix

all the ways I'm broken.

There's nothing romantic about the mind

succumbing to its own black hole.

There is only the ear, calling, and the gravity

of the blade. In the end,

a small voice -- deep as the universe --

convinced that nothing will mend me.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," a look at toxic positivity. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

This is your host, Amber Smith, thanking you for listening.