Restorative Reproductive Medicine Explained (Episode 497)

Full Transcript: Episode 497

Lisa: If you have wondered why doctors aren’t as knowledgeable in fertility awareness based methods as we would like them to be, or if you’ve wondered why they may not be able to look at your charts and base your treatment on what they see or what changes or be able to really interpret those charts, you will really appreciate today’s episode with Dr. Marguerite Duane. We really get into this concept of restorative medicine and where fertility awareness cycle charting can fit into the equation. We also get into why most classically trained physicians are not able to utilize the skillset, why it’s not something that is taught at medical school, and we also talk about how to find medical professionals who may be more knowledgeable in this skillset.

Lisa: Before we jump in, let me tell you a little bit about Dr. Marguerite Duane. Dr. Duane, a board-certified family physician, is co-founder and executive director of FACTS about Fertility, a non-profit organization dedicated to educating medical professionals and students about the scientific evidence supporting fertility awareness-based methods and restorative reproductive medicine. She also serves as an adjunct associate professor at Georgetown and the University of Utah. Dr. Duane also cares for patients via a direct primary care house calls based practice, MD for Life. Dr. Duane trained as a Creighton, FEMM and NeoFertility medical consultant and a TeenSTAR educator, giving her an in-depth understanding of multiple fertility awareness-based methods. So without further ado, let’s go ahead and jump into today’s episode.

Lisa: I’m really excited to be here once again with Dr. Marguerite Duane. It’s always a treat to have her on the show. Welcome to the show.

Dr. Marguerite Duane: Thanks, Lisa. I’m delighted to be here again.

Lisa: It’s been a minute since we chatted. We had a lovely pre-chat. We were able to catch up. I’m excited to get into our topic of the day. The topic that you shared with me to talk about today is restorative reproductive medicine. For anybody who’s listening and may not be familiar with your work, who may not have heard one of our previous episodes, of course I’ll link our previous episodes for anyone who wants to learn a little bit more. Maybe share with us the high-level overview of what prompted you to start FACTS, what it is, and what you do.

Dr. Marguerite Duane: First and foremost, I’m a family physician board-certified, care for patients from cradle to grave, or as I like to say, from lust to dust, since I really focus on before birth. I trained in Lancaster General Hospital in Lancaster, Pennsylvania, and that’s actually where I first heard about fertility awareness and female cycle charting when I was a first year in my residency training, having never learned about it in medical school.

Dr. Marguerite Duane: When I discovered these methods and how they really can help address women’s health and be used to help couples with family planning, I was blown away. I wanted to learn more. I was also angry that I’d never heard about this, angry that when I had my own cycle-related issues in college and was offered birth control as the solution, which caused more side effects than helped address issues. I was frustrated.

Dr. Marguerite Duane: A decade after first learning about these methods myself, when I was on faculty at Georgetown where I’ve served as an adjunct associate professor, I had an opportunity to teach a small group of medical students about these methods. The response was overwhelmingly positive. The students were like, “Why isn’t this something we all learn?” I thought, “You’re right. This is something we should all learn.”

Dr. Marguerite Duane: That led me to start FACTS. At the time it was the Fertility Appreciation Collaborative to Teach the Science. Now we officially became our own nonprofit and are officially FACTS about Fertility. Our mission is to educate current and future medical professionals about the science of female cycle charting using fertility awareness-based methods, the evidence behind these methods, both from a family planning perspective to help couples achieve pregnancy or prevent pregnancy, as well as how the female cycle can serve as the fifth vital sign. It’s also the title of one of our webinars that we offer for the medical professional community, and it lays the foundation for the restorative reproductive medical approach.

Lisa: I love it. I love that you’re in the world. I love that we had a chance to meet in person. I hope we have that chance to meet again in the near future. I also enjoy it when I have clients or practitioners who are saying, “Why don’t the doctors know this? What can be done? How do we teach the doctors?” I’m like, “I know the perfect person who’s already teaching the doctors.”

Dr. Marguerite Duane: I don’t know if I shared with you. When I taught this elective, it was officially approved. We would have a couple students every month. With the pandemic, Georgetown sent an email saying they’re shutting down all their electives and I responded, “But my elective is entirely online.” Our elective exploded. In the last five years, we’ve trained nearly 1,000 medical students, not only from all over the United States, but Canada, and all over the world.

Dr. Marguerite Duane: In March 2023, I had the opportunity to present about our FACTS elective at the International Institute for Restorative and Reproductive Medicine Conference in Lisbon, Portugal. I had doctors from Croatia and Hungary and Chile and the Ukraine and Mexico say, “How can we bring this course to our medical students?” I was shocked to think the elective that we offer through FACTS about Fertility is the only one of its kind, not only in the United States, but in the world.

Dr. Marguerite Duane: We are actively working not only to reach more medical students, but we’ve put together a nursing committee so we can begin to translate and adapt this content for nursing schools. We developed a continuing medical education course because there are so many physicians, midwives, nurse practitioners, other health professionals in practice that didn’t have the opportunity to learn while they were in training and are interested now. We’re trying to reach them through all of these avenues, as well as through our conferences. It’s been encouraging to see the interest in the medical community.

Dr. Marguerite Duane: It’s amazing to think of what happens when you start something, start somewhere. It also speaks to how much work goes into it and how slow change really happens. Thousands of doctors now have been informed to a much greater degree, but we still have a long ways to go.

Lisa: From your experience as a physician and now as an educator who’s worked with so many different physicians, how are physicians trained to respond to medical issues? I hear this from almost every single client. It’s always the same story: I have this problem with my menstrual cycle, and then they told me to do the pill, this or this other medication. Share your insights on this from both sides.

Dr. Marguerite Duane: From a patient perspective, when I was in college dealing with painful periods, the answer was, “Let’s put you on the birth control pill.” I thought, “But I don’t need birth control.” They were like, “No, but this will treat your symptoms.” I was like, “But I only have painful cramps for one or two days out of the cycle. Do I need to take a pill every day?” They were like, “Yes, this will be good for you.” I didn’t question it because I wasn’t a doctor then and I didn’t know much better, so I followed their advice.

Dr. Marguerite Duane: I went on birth control and was taking it for about six months, having some side effects, but brushed them off, was told, “Give it some time.” I did until I started to experience serious cosmetic effects. I was having major hair loss resulting in a bald spot. I was like, “This isn’t good.” The doctors were like, “We’ll switch you to another type of the pill.” I was like, “Seriously, there’s got to be something better.” I’m like, “What am I supposed to do about the bald spot?” They’re like, “We’ll send you to dermatology and you can have injections.” I was like, “No.” I went off and didn’t know what else I could do, and like a lot of women, I sucked it up and dealt with the symptoms.

Dr. Marguerite Duane: A few years later, I went to medical school. There’s a lot to learn in medicine, even more today. The focus is very much disease-focused and treatment-focused in a lot of ways: What’s the best drug, device, surgery that we can do to treat the problem? There’s not a lot of emphasis on what are things that you as a patient can do, the lifestyle changes, the dietary changes, the other factors that you have control over that you can employ to improve your health.

Dr. Marguerite Duane: Nutrition is a perfect example. I think nutrition is critical to good health, but when I was in medical school, I had a six-week nutrition class that met every Friday afternoon for an hour. Six hours is not enough to learn all the nutrition that we as doctors need to learn. My pharmacology class lasted for three months for two hours twice a week. We learn a lot about medication, but not necessarily alternative holistic approaches to healthcare.

Dr. Marguerite Duane: The way our healthcare system is set up, at least in the United States, doctors often have very little time with patients. They may have a 10, 15, 20-minute visit. That’s not enough time to get a root cause and come up with a concrete, comprehensive plan to address the underlying issues.

Dr. Marguerite Duane: If a woman comes in with painful periods or irregular cycles or abnormal bleeding, it’s much easier to say, “Let me prescribe this hormonal pill to treat your symptoms.” That’s the way I was trained. When a woman came in with anything cycle-related, it was, “We’ll put her on the pill.”

Dr. Marguerite Duane: The pill will often treat the symptoms. Painful periods: it will reduce the pain. Irregular periods: it’s not giving her a regular period. The period marks the end of the ovulatory cycle, but with hormonal birth control it suppresses the cycle and gives women a withdrawal bleed. It gives the impression that she’s having a regular cycle when she’s really having a regular withdrawal bleed. It doesn’t address why she was having irregular cycles.

Dr. Marguerite Duane: Now, as a physician who’s trained in fertility awareness-based methods, I can look at the chart of a woman who has 40 to 50-day cycles, which we know is abnormal. Normal is between 21 to 35 days. I can look at that chart and tell you if it’s more likely that she has polycystic ovarian syndrome, or if she’s more likely to have functional hypothalamic amenorrhea. Visually they appear different, and the approaches to treatment are different. Traditional medicine trains us to put all of them on birth control. It gives them a regular bleed, but it doesn’t treat the underlying issues.

Dr. Marguerite Duane: We never learn in medicine that ovulation is a sign of health. It’s a sign of health because it reflects the normal fluctuation in female hormones that are critical. Estradiol and progesterone are not simply reproductive hormones. They are critical for brain development in adolescence. They’re critical for mental health in women of reproductive age. They’re not something we can just shut down and not experience adverse effects. This is why it’s important that women from a young age learn to chart their cycle and use their cycle chart as a daily diary to understand what’s happening with their hormones.

Lisa: One of the things you said that stood out to me was women deserve real healthcare. Share a little bit about that comment.

Dr. Marguerite Duane: Women are not smaller versions of men. We are biologically different. Once women go through puberty, their hormones function on a cyclical basis over weeks. Men, their cycle is a 24-hour cycle. There are different times in our cycle when our energy levels are different. It’s not just about reproduction. It’s about our overall health and how our hormones affect our overall health.

Dr. Marguerite Duane: It’s important that women learn to understand and observe their biomarkers that reflect these internal hormonal changes, because that’s what allows us to identify underlying abnormalities. Pain is not normal. So many women suffer for years with period pain and are told, “That’s normal,” only to find out it’s not.

Dr. Marguerite Duane: I saw a woman who described debilitating periods in high school and college that left her doubled over for two days, sometimes vomiting. She would take ibuprofen around the clock. A doctor recommended hormonal birth control. Her mom asked if there were other options and was told, “No, keep taking the ibuprofen.” Years later, when she was trying to get pregnant and struggling, she was seen by a NaPro-trained doctor, had surgery, and was found to have stage four endometriosis.

Dr. Marguerite Duane: In the United States, it still takes on average about 10 to 12 years from the onset of symptoms to the diagnosis of endometriosis. Women often have their symptoms treated by suppressing their cycle without treating the underlying cause. When I have young people charting their cycle, if I see spotting two, three, four days before the period, that can be an indicator of endometriosis.

Dr. Marguerite Duane: With endometriosis, women are commonly put on birth control because it will suppress the pain, but the disease process will continue. The appropriate way to treat it is surgically. We need to be able to refer to surgeons trained to remove all aspects of the endometriosis contributing to pain, inflammation, and possible infertility. Bottom line: women deserve real reproductive healthcare, which in many instances requires us as physicians to diagnose the underlying causes and restore the reproductive system to the way it’s designed to function.

Lisa: For anyone who’s not familiar with NaProTechnology, could you briefly explain what that is?

Dr. Marguerite Duane: Within fertility awareness-based methods, there are a number of methods available for women to learn to chart their cycles. There are ovulation or cervical mucus only methods, including the Billings ovulation method and the Creighton model. The Creighton model was developed by an obstetrician gynecologist, Dr. Thomas Hilgers. Dr. Hilgers also developed the first real medical model of natural family planning or fertility awareness and restorative reproductive medicine.

Dr. Marguerite Duane: He developed what we refer to as NaProTechnology. It stands for natural procreative technology. He started his work in the 70s and over the last few decades has continued to develop and refine this approach to using the Creighton chart as a diagnostic tool to identify potential underlying causes, to target laboratory testing based on the cycle, and to tailor treatment to get at the root cause.

Dr. Marguerite Duane: Since the development of the Creighton model and NaProTechnology, there are other fertility awareness-based methods, including symptothermal and symptohormonal methods like the Marquette model. There have since been two new medical approaches developed: FEMM, which stands for Fertility Education and Medical Management, and NeoFertility. NaPro, FEMM, and NeoFertility are the three medical approaches that can be used to offer women restorative reproductive medicine, designed to restore the reproductive system to the way it’s designed to function.

Dr. Marguerite Duane: By way of disclosure, I am trained as a NaPro medical consultant, as a FEMM medical consultant, and as a NeoFertility medical consultant. Each approach has strengths and shortcomings. As a physician, I feel fortunate to have had the time and energy to invest in learning each of these approaches because it allows me to provide more comprehensive care to the patients that I see in my practice.

Lisa: The way that you’re using the term restorative reproductive medicine, it seems to be the combination of fertility awareness charting and using a medical approach alongside the woman’s chart to restore from that medical standpoint. Did I get it right?

Dr. Marguerite Duane: Yes. I often get the question, why don’t doctors learn about fertility awareness-based methods? Part of it is that women don’t need doctors to be able to use a fertility awareness-based method. Women are smart. They need to learn from trained educators who can teach them the biomarkers to observe—cervical fluid, basal body temperature, urinary hormones. You can learn this from a trained instructor.

Dr. Marguerite Duane: Where physicians play a critical role is when we take that female cycle chart and use it for what the American College of Obstetricians and Gynecologists pointed out in a statement in 2015: the female cycle serves as the fifth vital sign. We use the chart as a historical document to help identify potential underlying abnormalities. For physicians and other medical professionals trained in NaProTechnology, FEMM, or NeoFertility, we use that training in conjunction with the female cycle chart to engage in a shared partnership with our patients to diagnose and treat underlying issues.

Dr. Marguerite Duane: We can take the chart that the woman documents as a daily diary to guide laboratory testing and then implement treatments to restore hormonal balance, cyclical balance, and normal biologic anatomy, with the goal of restoring the reproductive system so that it functions in a normal, healthy way.

Lisa: When you think of it that way it seems obvious. If a leg is broken, we set it. But from an outsider’s perspective, it feels like both approaches take place in medicine: set the leg and also give medication. It seems like traditional allopathic medical care is less equipped to treat certain chronic conditions.

Dr. Marguerite Duane: That’s true. Sometimes it’s easier to give the quick fix. Sometimes it’s necessary. If a woman comes in hemorrhaging from heavy menstrual bleeding, we need to stop the bleeding. Then we need to figure out why she’s bleeding like this and fix the underlying problem. In the emergency room with a broken leg, you’re going to give pain medication first, then fix the underlying problem. It’s the same thing with women’s reproductive health.

Dr. Marguerite Duane: If a woman is having debilitating heavy bleeding, we may need medication to stop the bleeding, but then we need a diagnosis and treatment of the underlying cause. If a woman has debilitatingly painful periods, you want to treat the pain, but you also want to diagnose why she’s having painful periods. It’s not enough to give birth control around the clock or pain meds every month. Let’s figure out: is it endometriosis, adenomyosis, other causes, adhesions, and then identify, diagnose, and treat the underlying issues.

Lisa: From my perspective, women need to be warned that’s not how medicine works most of the time when it comes to women’s health issues. Often we’re given pain medication while the leg is broken and no one’s offering to set it. You mentioned NaProTechnology, FEMM, and NeoFertility, and those modalities are not taught in med school. The doctors who practice these approaches had to take an interest and study separately. Talk about that and how physicians find their way to these trainings.

Dr. Marguerite Duane: I encourage women to be patient with their doctor. I was one of those doctors. All I knew was how to write the prescription for birth control or refer for an IUD placement because I wasn’t trained any differently. For me, I happened to have a senior resident who was trained in the Creighton model when I was on OB call one night and she shared about it with me. It was transformative.

Dr. Marguerite Duane: Doctors don’t learn about this. FACTS published a research study last year on our website looking at what is taught in medical schools when it comes to reproductive health and family planning. Fertility awareness-based methods are mentioned less than 4% of the time. There are some schools that don’t mention these methods at all. Most of the methods by name, like Creighton, aren’t talked about.

Dr. Marguerite Duane: For many doctors, it’s a personal experience, a friend or family member, a patient. My co-founder, Dr. Bob Moulder, was in practice for about 20 years before he learned about these methods. He had a medical student rotating with him who challenged him. He had no idea.

Dr. Marguerite Duane: We published a basic research article in 2022—Fertility Awareness-Based Methods for Women’s Health and Family Planning—that is a detailed summary of the research from the last few decades. It’s available for free on our website. Download it, print it out, share it with your doctor, and encourage them that this is rooted in science and there is good evidence.

Dr. Marguerite Duane: FACTS focuses on students, but we recognize we need to support physicians and medical professionals in practice. We offer continuing medical education courses. We have a virtual conference coming up called the Continuum of Women’s Health Care—how we can use the female cycle chart to address women’s health issues from adolescence through menopause. Every woman of reproductive age deserves doctors who take an interest, look for the root cause, make the diagnosis, and employ a treatment strategy that will restore the reproductive system to the way it’s designed to function.

Lisa: I love that. Never underestimate the power of your words. The doctor may not respond with enthusiasm, but you may be planting a seed.

Dr. Marguerite Duane: Exactly. Our motto at FACTS is “share the facts.” Communicate with your colleagues, classmates, friends, family. Refer them back to factsaboutfertility.org for more information so that we can expand the number of medical professionals trained to treat women’s health issues.

Lisa: Sometimes the doctor who’s the most dismissive ends up being the biggest advocate. You never know how the seeds you plant will grow.

Dr. Marguerite Duane: You never know. This is one of the reasons why I love your podcast. People have come to me and said they heard me on the Fertility Friday Podcast, or heard you mention the FACTS website. There is an OBGYN in Ohio, Dr. Summer Holmes Mason. Summer graduated from medical school, did her OBGYN residency, never learned anything about fertility awareness-based methods, but was seeing more and more women who weren’t getting better with synthetic hormones and were dealing with side effects. She wanted more. She listened to a podcast that you and I did years ago. It opened her eyes. She came to our first in-person conference in Cleveland, Ohio in 2019, got trained, and now sits on the board of directors for factsaboutfertility.org.

Lisa: There’s a lack of knowledge. If people had this information, it would change their practice and approach to fertility. We have to keep going and keep talking about it.

Dr. Marguerite Duane: It’s time consuming. I had a patient with primary infertility. She got connected with a symptothermal teacher and referred to a surgeon. She had surgery, was found to have PCOS, and was able to get pregnant shortly thereafter. Then she had secondary infertility, multiple miscarriages, and came to me. We discovered a gluten intolerance, then diagnosed autoimmune thyroiditis, and treated that. Even though we restored as much as we could, she still had PCOS affecting fertility. I referred her to a NaPro surgery colleague. She had an ovarian wedge resection, which went out of favor once IVF came on the scene, but it’s still a very effective treatment. Within a month after surgery, she conceived without additional medical support.

Lisa: Most listeners have never heard of ovarian wedge resection. Explain what it is.

Dr. Marguerite Duane: With polycystic ovarian syndrome, you have many small follicles producing estradiol, throwing off the hormone balance. A wedge resection is like taking out a little piece of the ovary where you have many hormonally active follicles. It can reset the hormones so that her hormones go back into a normal balance. It’s a laparoscopic surgery. The doctor takes out a small piece of the ovary and that can reset the hormones. In this patient’s case, she had surgery in September, a normal period in October, conceived in November, carried to term, and after weaning that baby got pregnant again within a month or two.

Lisa: It’s fascinating. It had fallen out of favor. It makes you wonder why it’s not explored more in certain situations. Many doctors won’t go that route and will refer to IVF and IUI.

Dr. Marguerite Duane: Most traditionally trained OBs are not trained to do it. When it was being done regularly in the 60s and 70s, it was an open operation with more adhesions and complications. Now it’s laparoscopic and safer. Because IVF and IUI exist, many doctors won’t go that route. I feel strongly that with conditions like PCOS and endometriosis—the two leading causes of female infertility—we need to treat the underlying issues. Ovarian wedge resection can effectively treat infertility in patients with PCOS, but you need to find surgeons who are open and able to do that. Many NaPro surgeons are.

Dr. Marguerite Duane: On our website we have a directory—a physician, clinician, educator directory—that we’re building. We encourage fertility educators or clinicians who are trained and want to be listed. It’s free. We want to increase accessibility to these services to more people.

Lisa: As we wrap up, what suggestions do you have for listeners who are fired up about finding physicians trained in this way? What questions can patients ask? How do we find doctors who will support us?

Dr. Marguerite Duane: We have our directory, but it is limited. There are resources through the Creighton website and the FEMM Health website. NeoFertility still has very few physicians trained. It’s a fair question to ask your doctor if they are familiar with charting, using the female cycle as a fifth vital sign. Print out our review article on fertility awareness-based methods for women’s health and family planning and give it to your doctor and ask if they are familiar with the methods and the science behind them and how they’re used to support restorative reproductive women’s healthcare.

Dr. Marguerite Duane: Many doctors may not be familiar and may be dismissive, but don’t despair. Encourage them to learn more. If you’re struggling, reach out to FACTS at [email protected]. We’re trying to train more medical students and residents, not only in the United States, but in Canada and across the world. Recognize that the numbers are limited—probably less than 1% of the physician population. It’s like finding a needle in a haystack, but we are working to change that. Anything you can do to spread the word, share the facts, support the work—invite your physician, midwife, nurse, pharmacist to check out the website and resources.

Lisa: We’ll say it again: factsaboutfertility.org. It’s always a pleasure chatting with you.

Dr. Marguerite Duane: Likewise. I’m a huge fan of your work.

Lisa: For the listener who loved this conversation, do you have any last words you’d like to leave her with?

Dr. Marguerite Duane: I want to express a caveat. The term natural family planning was coined by the National Institutes for Health in 1974. In the 1970s, the groups that primarily promoted natural family planning were faith-based groups. Still today, the majority of people that promote these methods promote them from a faith-based perspective. You may encounter teachers or doctors that come at it from that perspective. The reality is that this is rooted in science and basic biology of how the female and male reproductive systems work.

Dr. Marguerite Duane: At FACTS, we focus on the science. We believe in respecting all people regardless of belief system. If you find someone where their teaching or approach doesn’t resonate with you, there are people trained in that method or other methods where you may be able to find what you’re looking for. Women deserve high quality healthcare that’s designed to restore the reproductive system and hormonal system so it functions in balance.

Lisa: Thank you so much for being here, Marguerite. It’s been such a pleasure.

Dr. Marguerite Duane: It always is. Thank you so much for having me.

Lisa: Thank you for listening. If you enjoyed today’s show, please share it with a friend. You’ll find the show notes page for today’s episode over at fertilityfriday.com/497. I hope that you enjoyed today’s episode with Dr. Duane. It’s always a treat to chat with her and to jump into the topic today of restorative medicine and where the menstrual cycle fits into that. For many of you who may have started to lose hope in the medical profession’s ability to fully support women based on understanding their natural cycle and rhythms, this episode gives you a boost and shows you that there are medical doctors out there working to get this knowledge into the hands of many, but it will take some time before this knowledge is truly mainstream. I hope you have a wonderful week or weekend whenever you’re tuning into the show. Until next time, be well and happy charting.