Why Doctors Don’t Learn Fertility Awareness (Episode 362)

Full Transcript: Episode 362

Lisa: This is the Fertility Friday podcast, episode number 362.

Welcome to the Fertility Friday podcast, your source for information about the Fertility Awareness Method and all things fertility. I’m your host, Lisa Hendrickson-Jack. I’m the author of the fifth vital sign and the Fertility Awareness Mastery charting journal. I’m a certified fertility awareness educator and holistic reproductive health practitioner with nearly 20 years of experience teaching women to connect to their fifth vital sign through menstrual cycle charting, balancing hormonal health, and optimizing the menstrual cycle without hormones. I’m outspoken about hormonal birth control and its impact on fertility and overall health because you have the right to know how your body works and how artificial hormones disrupt that natural process. I host live coaching programs to help you achieve optimal fertility and health because it’s important to have healthy menstrual cycles regardless of whether or not you want to have babies. I’m also a wife and mother of two beautiful boys. I know, I know, I’m a busy girl, but I managed to fit it all in. This podcast is designed to empower you to take full control of your cycles, your fertility, and your overall health. And I’m so excited that you’re here with us today.

Today I’m excited to welcome back Dr. Marguerite Duane to the podcast. If you’ve been a longtime listener, you may have already heard one of the two previous occasions that I had her on the show back in episode 123 and episode 194, and I’ll make sure to link those two episodes to the show notes page of today’s podcast episode. But for those of you who don’t know, Dr. Marguerite Duane is a board certified family physician and adjunct associate professor at Georgetown University. She is co-founder and executive director of FACTS, the Fertility Awareness Collaborative to Teach the Science. She is trained as a Creighton Model, FEMM, and NeoFertility medical consultant as well as a TeenSTAR educator, and she works with Modern Mobile Medicine, which is a direct primary care house calls based medical practice that serves patients of all ages in the DC area.

And so in other words, Dr. Marguerite Duane is not only an MD, but she’s also certified in a number of fertility awareness-based methods. And one of my favorite things that Dr. Marguerite Duane does is she trains medical professionals and other professionals to be more knowledgeable in fertility awareness-based methods through FACTS, through the Fertility Awareness Collaborative to Teach the Science. And in today’s episode we are going to delve into fertility awareness-based methods and talk about the science, talk about the efficacy, and you know, why it is that so many medical professionals are really not too keen or not very inclined to encourage their patients to utilize fertility awareness-based methods. So we get into that and more in today’s episode. Without further ado, let’s go ahead and jump right in.

Lisa: And I’m excited to be here once again with Dr. Marguerite Duane. Welcome to the show.

Dr. Duane: Thanks, I’m delighted to be back, Lisa. Thank you for having me.

Lisa: Well, it’s always a pleasure to have you. And of course this year you are joining us for a teaching session in the FAM class. So I’m really excited to have you as part of the guest teacher series in the class of 2021.

Dr. Duane: I think it’s a fantastic program that you’re offering and I’m delighted to be a part of it.

Lisa: Well, thanks so much. And I mean, I’ve had you on the show at least two other times and we’ve talked about a lot, I think, in those episodes, so I’ll certainly link those for anyone who hasn’t heard them before. So as a medical doctor with a background in fertility awareness, founder of FACTS — I think of it as, this is the way the world should be — you teach medical students who are going to be doctors about fertility awareness. So everyone who is a long-time member of the Fertility Friday community is like, yes, this is exactly what we need, thank you so much for existing.

Dr. Duane: And to be clear, we go beyond just medical doctors. I mean, our goal is to teach medical students and nurse midwifery students and nurse practitioner students, any health professional student that is interested in really expanding options for women’s health care and their understanding of fertility awareness. We welcome them to participate in our elective and our conferences and all our educational offerings because the entire medical community needs to be better informed about these methods.

Lisa: Well, yeah, so we’ll link to all of the different opportunities because you do offer educational opportunities, continuing education credits for medical health professionals and all those things. So we will certainly link to all of those opportunities. I’m getting a lot more questions about continuing education opportunities for professionals, so absolutely. So with that said, I think maybe just to get our feet wet today — we went through your story, so I think the listeners can go back, but just briefly share with us why you are just — it seems to me that you are just as passionate about fertility awareness today as you may have been when you first discovered it. I feel you and I are very similar in that respect. So what keeps you jazzed? I mean, you’ve been at this for a long time.

Dr. Duane: Yeah, I would say in many ways I’m actually more passionate now. You know, when I first learned about these methods as a first-year resident at Lancaster General Hospital, I think my initial reaction was one of anger. I wasn’t so much passionate, but I was like, why didn’t I ever learn about these? And it took a decade before I actually became trained in any of the methods, and then in 2010 I co-founded FACTS because I wanted to educate my medical colleagues and the students at Georgetown about these methods. But what motivates me today and what makes me so excited about using these methods are the actual women and men and patients that I care for that benefit from the use of these methods. And so to me, that’s what motivates me — when I look at the people’s lives that I’m impacting in a positive way, whether it’s the 23-year-old with severe PMS symptoms who is struggling with going to work a couple days every month, to the woman who had secondary infertility and had tried to conceive multiple times after having recurrent miscarriages. I mean, the lives of the people that I’m impacting is what it’s really what motivates me today. And it’s exciting because I have two outlets for my work. Obviously my work at FACTS, the Fertility Appreciation Collaborative to Teach the Science, is all about educating current and future healthcare professionals about the science of fertility awareness-based methods, all of the methods that are out there, so that they can be more informed and offer these methods to patients, or at the very least support women who choose to use these methods. But then through my direct primary care practice, I serve women and care for them and couples and help them achieve their family planning goals, as well as more importantly their health goals, so they can truly live their best lives.

Lisa: Well, one of kind of another preliminary question before we get into today’s topic — I remember talking to you, I’m sure, on one of the previous occasions, and you sharing your experience as an MD and the difference between what you learned about birth control, and how I cited you in the Fifth Vital Sign, I think, from this conversation, because you shared the difference between what you had learned, or quote not learned, about hormonal contraceptives versus what you did learn when you discovered fertility awareness, and fertility awareness being one of the only birth control methods with no side effects. So maybe just share your thoughts on that.

Dr. Duane: Sure. Yeah, I mean, as a medical student you learn about the female cycle and reproductive physiology, but really at a very superficial level. And when I learned about fertility awareness-based methods, I really developed a much deeper understanding. You know, the cycle is an intricate orchestration of the female hormones that, if everything is working properly, results in ovulation, and ovulation is a sign of health. And the amazing thing that fertility awareness-based methods teach you is that women can learn to make external observations of her signs, like her cervical mucus secretions or her basal body temperature or urinary hormone measurements, to identify where she is on her cycle. And these biomarkers actually reflect these internal hormonal changes, and women can learn to monitor this and use this, as you point out so eloquently in your book, as a fifth vital sign. So it’s incredibly empowering for women. But what we learn in medical school is so much more superficial. We don’t really learn that there are different types of cervical mucus, and that there are healthy types of cervical mucus, and we learn about the myriad of medical conditions that may affect women, from PMS symptoms to irregular cycles or painful periods. But what we learn about those, and how to treat those, is that the pill is the panacea for all that ails women. So she has irregular cycles, put her on the pill and it will quote unquote regulate her period. Well, you and I both know it doesn’t regulate her period, it suppresses her cycle and gives her a withdrawal bleed once a month, but it doesn’t actually treat her irregular cycles. Same thing with her painful periods. I mean, no doubt the birth control pill is very effective at reducing the symptom of a severe painful period, but it doesn’t get at what is the root cause, what is the underlying condition that is causing painful periods. And for the women that are listening, let me be very clear, and certainly for the medical professionals, it is not normal at all to ever have debilitating menstrual cramps that lay you out for even a day. If your period pain is that severe, then there is an underlying issue, perhaps it is endometriosis, perhaps it is something else, but the pill is actually not going to treat the underlying cause, it simply serves as a band-aid to temporarily suppress the symptoms, when what you really need is a more thorough evaluation and investigation to treat those symptoms.

Lisa: So I think one of the questions that I was thinking about asking you — I think you did share just a little bit about even the philosophy of allopathic medicine and why the pill is basically the panacea, because I think for a lot of women who discover fertility awareness, they then go into their doctor’s office with their charts and become quite frustrated because the doctor either doesn’t want to look at them, can’t really help them interpret it. And I tend to be on the sidelines saying that you can’t really expect your doctor to know that because that’s not how they’re trained. So maybe you could just share a little bit about how doctors are trained and what a patient can expect when they go and see their typical physician.

Dr. Duane: Sure, sure. And I think that we have talked about this before — through FACTS we have actually done research where we have surveyed what is being taught in medical schools about fertility awareness-based methods. And through one of our studies we discovered that when we look at all of the various reproductive health terms and how frequently they are mentioned, fertility awareness-based methods are mentioned only two to four percent of the time in medical schools. And most often they’re not even learning about modern methods, they may hear about the rhythm method, which was developed a century ago in the late 1920s and early 1930s. So medical students are not learning about this. In fact, through FACTS we offer an online elective to medical students and nursing students, and we surveyed them at the beginning — have you learned about these topics before in medical school — and over half have said they’ve not learned anything at all about modern fertility awareness-based methods. But to your point about the way the current healthcare system exists and functions, and our training, we are really trained to look for the quick fix solution. I mean, the reality is that at least in the United States in the conventional healthcare system, family physicians or obstetrician gynecologists may have 10 or 15 minute visits for follow-ups. That’s not nearly enough time to sit down and go over a woman’s chart with her and explain to her, if you’re going to do a targeted hormonal assessment, timing your laboratory testing where she’s in her cycle — there is not enough time. If a woman comes in with irregular cycles, it is much easier, much faster for a doctor to write the prescription for the birth control pill rather than talk with her about her diet. Perhaps she is suffering from polycystic ovarian syndrome, and medical journals will say the first line treatment is birth control pills, but the reality is, in polycystic ovarian syndrome, the first line treatment really needs to be a significant change in the woman’s diet and lifestyle. And as a medical student, I remember having six weeks of a nutrition class on Friday afternoons at two o’clock in the afternoon, that’s not enough time to really accurately learn about all this information. So writing prescriptions for pills, doing procedures, are certainly easier and more profitable and less time-consuming than taking the time, first of all, for physicians and medical professionals to learn about fertility awareness-based methods, because you need to do it as an elective or outside your usual training because it’s not a part of the routine training, and then implement that into practice. Personally, I am able to implement fertility awareness-based methods into my practice because I have a direct primary care practice, which basically means I work directly for my patients, so my patients pay me a low monthly fee, and I tell my patients a new patient visit is 60 to 90 minutes, follow-ups are typically 30 to 60 minutes, and that’s what gives me the time to really go through their chart and walk through and make the recommendations. So our current healthcare system is not really set up well to support the active integration of fertility awareness-based methods into practice, because medical professionals overwhelmingly are not trained in or knowledgeable about these methods, nor do they have the time needed to really effectively interpret the women’s charts and use it as a diagnostic tool, which is unfortunate because it is an incredibly valuable diagnostic tool.

Lisa: Thank you for going through that with us. I think it’s really important because I’ve had clients who will say to me, like, I haven’t seen a doctor in years and kind of like happy about that, and I always say, well, we all need doctors, so this is not about making everybody hostile to their doctor. I don’t want to send angry women to their doctors. That’s not the goal for me, because I feel that it’s more important for us to understand, let’s have everyone put their pitchforks down so that we can understand each other where we’re coming from. You can’t go to your medical doctor and expect that he or she knows everything under the sun about every specialization, that’s why we have specialized practitioners. And so I think that your explanation provides a bit of that foundational basis, and I think this leads us into our kind of main topic of the day, which is effectiveness of fertility awareness-based methods. So kind of recently I did this post on Instagram and it went a little crazy, but basically I asked a bunch of questions about women’s experiences with their doctors related to fertility awareness, and I mean it was unfortunate how many of the responses were that they were literally laughed at by their doctors. The fortunate thing, the tragic results were that there was a pretty significant number of women who actually did have some success, meaning that their doctor knew about it, was encouraging it and supportive, and I really do feel like that’s progress, because I feel like, you know, it’s 15-20 years ago — yes, but the overwhelming majority, as you know, were either not very supportive, it’s not effective, it’s not going to work, let’s get you on a prenatal because you’re going to be pregnant in two months. So let’s talk about the effectiveness of fertility awareness-based methods, so I’ll just kind of let you take that one, how you will.

Dr. Duane: Sure, no, absolutely, and it’s unfortunate, and I really feel for women. I mean FACTS also, we actually did a research study where we surveyed women about their experiences in discussing their use of fertility awareness-based methods with their medical professional, whether it was their physician or their nurse midwife, and we found similar results. At least a third of the women reported that they had a doctor or nurse midwife laugh at them or mock them for their choice of using a fertility awareness-based method, which I find so upsetting, because we may not always agree with all of the choices that our patients make, but it’s never healthy or supportive of a therapeutic relationship to make fun of a patient or mock them for their choice. You may not understand it, and so rather than laugh at them, take this as an opportunity to learn from them — what method are you using, what do you mean your chart, I be humble and say I’ve never seen a symptothermal chart, can you explain to me what does this line mean — to my colleagues I would encourage you to take this opportunity to learn, and I would encourage you to learn about the different evidence-based methods. Now we’ve talked about the fact, Lisa, that there are many methods out there. When we have surveyed physicians about their knowledge of fertility awareness-based methods and the modern evidence-based methods, again the overwhelming majority of physicians do not even know that these exist. The method they’re most familiar with is the rhythm method, which again at its time, a century ago, was a major scientific advance, but since the 1960s newer methods have been developed and studied and evaluated in high quality research studies to demonstrate their effectiveness in pregnancy prevention. When we discuss these methods, we like to break them down into the different types. So there are cervical mucus-only methods, in which women learn to observe their cervical mucus or cervical secretions. These include the Billings Ovulation Method and the Creighton Model, which both allow women to identify their potential fertile window, and it also includes the Two-Day Method, which is a much simpler, more straightforward method. It does not actually teach you to identify when you may be fertile, but it can still be used very effectively. Then there are cross-check methods, methods like the symptothermal method, where women look at cervical secretions and cross-check that observation with their basal body temperature. People are probably most familiar with the symptothermal method because it was popularized by books like Toni Weschler’s Taking Charge of Your Fertility, and it’s been popularized by apps such as Kindara. There’s also basal body temperature-only methods, which actually have not been very popular, but they’re making a resurgence because the Natural Cycles app, which is one of the few apps that’s approved by the FDA in the United States for family planning, is actually a basal body temperature-only method, and with this women use basal body temperature and an algorithm to identify when they may be fertile and when they’re not. Another cross-check method is the Marquette Model, which uses again cervical mucus secretions as well as urinary hormone measurements to identify when women are fertile and when they are not. And then there is actually a modern calendar method, the Standard Days Method, which uses the length of the female cycle in women with very regular cycles to identify a fertile window or not. So all of these methods, the Billings Ovulation Method, the Creighton Model, and the Two-Day Method, which are cervical mucus-only methods, have solid scientific evidence to support their effectiveness. The same goes for the cross-check methods, the symptothermal method and the Marquette Model, as well as the Standard Days Method, when people may also be familiar with CycleBeads. So that’s just an overview of the methods, I’ll pause here to see if you have any comments before I get into the effectiveness rates.

Lisa: I think the overview is really helpful, because we often get into — especially if you’re relatively new to fertility awareness method — that you think there’s such a thing as the fertility awareness method, and that there’s only one, and everyone’s doing the same thing, and it also applies to practitioners who are wanting to figure this out in their own practices, because again there is not one fertility awareness method that everyone agrees on and everyone practices. So it’s good to know the different ways that this can be done, and it also speaks to the fact that because there are so many different methods, there’s a lot of different ways that people can go about doing this. For example, a lot of women, probably the overwhelming majority, discover fertility awareness through Toni Weschler’s Taking Charge of Your Fertility, which is the symptothermal method, but there are plenty of other women who may discover other organizations that are teaching the Billings or mucus-only methods or different things like that. So maybe share with us then the effectiveness, just as a concept — I know that it’s different for different methods — but for the woman who’s listening who wants to use fertility awareness, has been kind of listening to the podcast for a while, the major concern for women who are not trying to get pregnant, who potentially are on the pill and wanting to transition off, obviously is, is this going to work, can I really do this without hormones, am I going to get pregnant, right, and that’s a very valid concern, especially when they have been told for so long that fertility awareness-based methods may not be effective and they do need to rely on drugs or devices.

Dr. Duane: I truly believe that women are smart and they’re capable and they can learn to observe their observations, but when it comes to effectiveness, it’s important to recognize there are a number of factors that play into effectiveness of a method. The methods that I described, as I said, have all been evaluated in high quality studies to demonstrate their effectiveness, and I’ll talk about the rates, but it’s important to know in those studies women actually learn how to use the method from trained instructors. So I tell people that’s really the first thing you need in order to use a method effectively, you really do need to learn from a trained instructor. I think Toni Weschler’s book has been great in terms of increasing awareness and the conversation, but it’s never been studied from a perspective of can I just read a book, or in today’s day and age can I just learn from an app. Again, the studies for effectiveness, other than the Natural Cycles app and the Dot app which have been shown to be effective, they’ve been done when women learn from trained instructors, and so it’s important to look at that when we talk about effectiveness rates too. It’s also important to think about what are we talking about, because they may hear well the perfect use rate or the correct use rate versus typical use rate. So as a reminder, perfect or correct use is the number of pregnancies that occur when the methods are used correctly according to the rules for that method. Now that means if you’re using the symptothermal method that you’re checking your mucus observations throughout the day, you’re checking your basal body temperature every day at the same time. Interestingly, in almost all of the studies they found the percentage of women that actually use the method perfectly, meaning check observation every single time, check temperature every single day, is exceedingly small, right, because something happens, you know, we wake up early, we run to the bathroom, or the baby’s crying and we get up and we forget to take our temperature, we forget to do things. So perfect use rates tell you the best you can expect under ideal conditions, and with perfect use rates what is interesting to note is that methods like the Billings Ovulation Method and the Creighton Model and the symptothermal method all have correct use effectiveness rates of greater than 99%, meaning the unintended pregnancy rate is less than one percent with perfect use. Again, the reality is none of us are perfect, we live normal lives, things happen, we don’t ever do everything exactly as we’re told. And as parents, I know you and I can both appreciate sometimes we wish some people did do everything they were told, but typical use rate is actually the more accurate predictor, I would say, and that is the number of pregnancies that occur during actual use, when people use the method correctly and incorrectly. Meaning, you know, with for example the Billings Ovulation Method, they teach you if you have any sensation you need to consider that fertile. Well some women, on their first day of sensation, may think, well I don’t notice any mucus and it’s only day eight of my cycle, it’s probably fine. That’s typical use, and pregnancies can happen on such days. And so typical use effectiveness rates I think are better predictors. And again, I can share some of these slides, we have a great handout, What Are FABMs, which lists both the perfect and typical use rates that I’ll quote. But with typical use rate, for example, with the Billings Ovulation Method, the unintended pregnancy rate is about 10 per 100, so it’s got about a 90% effectiveness rate. The symptothermal method is a little bit better, they found in two large studies that the typical use unintended pregnancy rate is actually only two unintended pregnancies per 100 women years, so it’s about 98% effective. The Marquette Model, again which uses cervical mucus secretions plus urinary hormone measurements, there have been studies that demonstrate typical use effectiveness rates, or I should say unintended pregnancy rates, range from 7 to 14 per 100 women years. So there is variation, but with modern fertility awareness-based methods, unintended pregnancy rates can be as low as 2 to 14 pregnancies per 100 women years, or to say it a different way, these methods are 86 to 98% effective.

Dr. Duane: Now that’s all well and good to say something is 98% effective, but the truth of the matter is for an individual woman it doesn’t matter whether or not a method is 98% effective, because you’re not going to be 98% pregnant, you are either going to be 100% pregnant or you’re not going to be pregnant. And again, for the individual woman who is trying to make the decision, is this the best method for me, she needs to consider, did she learn from a trained instructor, does she have the support of her partner. The reality is, with fertility awareness-based methods, having a partner that’s supportive is really important because these methods really rely on the behaviors you’re choosing to engage in when you’re fertile and when you’re not, and if you have a partner that may not be supportive and may not want to avoid sexual relations for a certain period of time, it may certainly make it more difficult. The other thing to take into consideration with effectiveness rates is your motivation. We oftentimes think of a person’s desire to get pregnant as a black and white question — either I absolutely want to get pregnant or I absolutely don’t want to get pregnant. It’s not a simple yes or no question, it actually, I think the desire to get pregnant or not really lies on a scale from zero to ten, where zero is I absolutely do not want to get pregnant, I will do everything in my power at all costs to prevent possible pregnancy, whereas ten is I absolutely do want to get pregnant, I’m going to do everything I can in my power to try and get pregnant. I would argue most people live in the mushy middle of like three to seven. Depending on how motivated you are will affect it. I have had patients who have had very, very serious medical reasons for why they could not get pregnant, like literally a pregnancy would be a threat to the woman’s life, and I could still confidently recommend that they use these methods. I would work with them very closely to help them pick a method that they could use effectively, that they could learn from a trained instructor, and more importantly I would counsel them about when the likelihood of an unintended pregnancy is most likely to happen. You know, and I know, Lisa, that once ovulation occurs, once that egg has been released, within 12 to 24 hours, if that egg has not been fertilized, that egg will begin to disintegrate, and there will not be another egg throughout the remainder of that cycle. So if a woman can confirm with certainty that ovulation has occurred and passed, she can be confident in using the method in the second half of her cycle to effectively avoid pregnancy. Now a lot of couples don’t want to limit sex to just the second half of the month, so that’s where learning the rules effectively and being able to apply them in the first half of the cycle becomes really important, in terms of being able to identify your potential fertility and avoiding sexual relations on those days when you may potentially be fertile.

Lisa: And I think your explanation is really, really thorough, and one of the questions that I was thinking about is just related to — because you’re right, it does come down to motivation, but then there’s a part of me, of course, as a FAM instructor, that says the motivation can will, does, obviously affect the effectiveness of the method, but really it comes down to the rules never change though, so the way I think about it and the way I talk about it in my programs, I just address this issue head-on, where I just call it out and say this is why the method fails, right, because you’re like, ah, just a little bit of mucus, oh I never ovulate this early, I just call it all out, because you can have motivation anywhere on the spectrum but still use the method correctly. I think this is where, as you mentioned, working with a trained instructor is helpful, so that you can get to the point where it’s black and white, it’s never gray. So in order for fertility awareness to be effective for you it can never be gray, and what I would argue, because I know one of the things that you said as well, which is true, is that life does happen and sometimes you do have to jump out of bed and you didn’t take your temperature, but as an instructor I advise my clients, when in doubt, consider yourself fertile plus a buffer, and so what that means is that you don’t have to be perfect for the method to still work. So I’m just curious about your thoughts on some of those challenges for women who are concerned about the effectiveness.

Dr. Duane: Great commenting and question, with regards to the gray areas, and I think you make an excellent point about the rules. I mean each of these methods have developed rules that have been studied, and if you follow the rules, and if you follow them perfectly, again you can expect very, very high effectiveness rates. Where it becomes an issue is when people begin to blur the rules or bend the rules. As I used the example earlier, with a woman who may be using the Billings Ovulation, the Billings is very clear, it’s not about seeing mucus, it’s about sensing mucus, so as soon as you sense wetness, moisture, or lubrication, you consider yourself fertile. I remember working with a woman who had an unexpected pregnancy because she had sensed mucus on day seven of her cycle, and she’s like, I never ovulate this early. Each cycle is unique, right, do not go back and say well for the last 12 cycles XYZ, no, each cycle is unique, and news flash to women, as you get older your follicular phase gets shorter, so it’s not uncommon for you to begin to ovulate earlier in your cycle as you get older. But this woman had sensed some mucus sensation on day seven, and she was actually combining methods, so she was doing Billings but she was also paying attention to the Standard Days rule, and with Standard Days, women who have very regular cycles between 26 to 32 days, they consider themselves fertile day 8 to 19. So she, in her mind, rationalized, well I didn’t see any mucus and according to Standard Days it’s not until day eight, so she took a chance, and she ended up getting pregnant. It wasn’t the end of the world because she was open to having another child, but she was like, I don’t know how this happened, we had sex on day seven and then we didn’t have sex again until day 18, and I’m pretty sure I ovulated or I’d peaked at mucus on day 12. The rules are the rules for a reason, but she was willing to bend those rules a little bit. Another thing I wanted to highlight is the idea of combining methods. At FACTS we truly believe that the best fertility awareness-based method is the one that’s going to work best for that woman or that couple, and that is going to vary from woman to woman, and it’s actually going to vary for a given woman depending on where she is in her reproductive life. I never tell a woman, well you’ve signed up for Creighton, you’re a Creighton person for life, no, you might use Creighton for like six months and decide this is not for me, I want to switch to something else, but what I recommend is if you’re going to learn to use a method, use the method for at least three months, and if it’s not working, then switch. I discourage people from trying to take what they like from different methods and piece them together, because then you’re not using an actual method. There are some methods, like the Marquette Model, that combine mucus plus urinary hormones, but they’ve actually studied the combination of those two signs in research studies, so if you like to observe more than one sign, that’s great, there are methods out there that do that, but try not to combine different methods within one cycle, that’s where you can run into rules, because in your mind you might rationalize, like this woman did, well according to Standard Days I wouldn’t be fertile until tomorrow anyway, even though she had done Billings, and Billings was very explicit, as soon as you noticed sensation consider yourself fertile, she hedged her bets, and she’s very happy in the end, but it’s an interesting perspective.

Lisa: Well, I mean because I’ve — you and I have both been around this field for a really long time, so that also means that you and I have heard a lot of stories, and I think that’s a benefit also to clients to actually hear actual stories of, this is why it didn’t work for her, because I think that’s how we learn as well. So especially if you are looking to avoid pregnancy, one of the questions that I wanted to ask you about the effectiveness is, you defined perfect use and or correct use, and what I find to be interesting — so if I ever jump on Planned Parenthood and they list all the different methods and they’ll talk about correct use, it’s really interesting, so I’ll use condoms as an example, because when I was growing up I was taught that condoms were 98% effective, and it’s not that hard to use them correctly, like if you understand how to use them correctly. Now I totally get that people do things differently, but I guess the question out of this is that there’s almost this underlying assumption that using a method perfectly or correctly is difficult. So one of the things that I always argue about this is that no one ever forced anyone to chart their cycles, there’s no woman alive who’s using fertility awareness because someone forced them to. The women who are choosing to kind of go all anti-establishment and not use hormones, they’re pretty motivated, this is not something that you just take and then never have to do anything, you have to read a book, you have to actually take your temperature, put it in your app, track it, you often have to take a class or work with an instructor for a little bit, and so this is, I feel like, not your typical situation. So what are your thoughts on that, correct use, because I think that if you learn to use the method, like for me, even to this day I am no longer like a zero or ten when I was 18, it was like all zero all day, right, so my husband and I are not trying to have a baby right now, but I personally am like out of four, we don’t have accidents in my house, I’m almost at the point like it would be kind of nice, but like literally I know too much and he knows too much, but my point is that when I was using the method in my twenties, there were no options of not using it correctly, and so I guess my bias is that you can use it correctly.

Dr. Duane: So you absolutely can, yeah, no, you absolutely can. You make an excellent point about women who use these methods are motivated, and when it comes down to effectiveness, again from the medical professional community perspective, the number one recommended form of birth control that is routinely recommended to women are long-acting reversible contraceptives, and the reason that long-acting reversible contraceptives are recommended is because they have typical use effectiveness rates that are comparable to correct use effectiveness rates, because the woman doesn’t actually have to do anything to use it, right, and actually it’s kind of a misnomer to refer to it as birth control because she’s actually not in control, once a woman has an IUD placed, she’s really dependent on a medical professional to remove that IUD if she changes her mind. But to your point, condoms are 98% effective with correct use, but with typical use it’s actually much less, it’s anywhere from, depending on the studies, 80 to 85 percent, which is lower than modern fertility awareness-based methods. And the interesting thing is the studies of the effectiveness of condoms were done when condoms are used throughout the cycle. Well, news flash, if you’re using condoms during the luteal phase, it’s not effective because the condom is protecting you, it works because the woman isn’t fertile. And that brings up another point, because I get this question a lot, well can women use condoms when they’re fertile, is that an option — I’m like, anything is an option, but it’s important to know if a woman is using a condom when she knows she’s in her fertile window, then we refer to it as a fertility awareness combined approach, she’s using her knowledge of fertility awareness and combining it with the barrier method, and when she’s using that barrier method when she’s fertile, she needs to expect the potential effectiveness rate of the barrier, right, and if she gets pregnant it’s not that the FABM didn’t work, it’s that the barrier, the condom, didn’t work. And so I just caution women, because there’s this sense of like, oh, artificial birth control is perfect, it’s not, and if a condom is going to fail, it’s going to fail when the woman is fertile. Back to your original question about motivation and the need to be able to use these methods effectively, and can women use these correctly or with near correct use, I would say absolutely. Learning to use a fertility awareness-based method is a behavioral change, right, you develop a new habit, it’s a skill, and in the beginning, like any new habit, is hard. When you’re learning a fertility awareness-based method, you have to work with an instructor, learn the rules, get accustomed to making those observations, but once you get into the habit of it, it is exactly that, it is a habit. I tell people making cervical mucus observations is not rocket science, and it’s not difficult to remember, can you remember to wipe when you go to the bathroom — if you can do that, just wipe before you go to the bathroom, pay attention, it really is about becoming more mindful about the way that our body works. So if you can get into the habit of checking for cervical secretions every time you go to the bathroom, get into the habit when you turn off your alarm first thing in the morning, pick up that thermometer and put it in your mouth, you develop the habit, and once you develop those habits it becomes much, much easier. And again, I will oftentimes with my medical colleagues use the example, you know, we don’t tell people who are overweight and need to lose weight, you know what, dieting is hard, that’s too tough, we’re just going to send you for gastric bypass surgery because that’ll be quick and easier, no, better yet, here’s a diet pill, just take this every day, don’t worry about changing your diet, that’s too difficult, no, we work with them, and sometimes we’ll refer them to a nutritionist, or we’ll advise them to work with a personal trainer, somebody that, if they don’t know how to use the equipment in the gym, they may need to learn, and so you work with somebody who’s skilled and trained in using that fitness equipment, and they work with you to show you how to do it, and they encourage you along the way, maybe you get a fitness buddy, an accountability partner that’s going to say, did you go to the gym today — that might be for the woman that’s using a fertility awareness-based method, may be her sexual partner saying, hey, did you remember to check your mucus, you know, I know you’re away for the day, but what was your temperature this morning, so I can write it down. So if they have that connection, that support, it becomes much, much easier to use, and the research shows that most women can effectively learn to observe and differentiate between their fertile mucus and their non-fertile mucus within about two to three months of learning the method. So in the beginning it can be challenging, in the beginning it can become scary, that is why many of these methods, for example Billings and Creighton, advise women for that first month when you’re learning, they advise you to not have sex at all that month one, just take that stress off the table, if you’re not worried about that. Two, the other reason why they recommend avoiding any sexual relations during that first month, especially with any of the mucus methods, it becomes then much easier for you to know, this is what my mucus looks like, because once you add semen into the equation or into the observation, you need to then learn to differentiate that from your normal mucus, so it can be challenging. But we see this all the time, again, we talked about the effectiveness of the Billings Ovulation Method having a typical use effectiveness rate of 90, or 10 unintended pregnancies per 100 women years, that was done in a study in rural India with very poor people, the overwhelming majority, nearly ninety percent, had less than a fifth grade education, right, these were not women that were college graduates with engineering degrees, I mean these are women who live very simple lives, but can learn to make these observations very effectively, with the appropriate instruction from a trained educator and support throughout the process. So I believe any woman can learn to do this, and I encourage them to consider, and if you need more support, certainly work with your trained instructor, involve your partner in it, so you don’t feel like you’re bearing the burden of all of this on your own.

Lisa: I love those points, and one of the things that came to mind as well is that there’s a method for every personality, it’s, you know, what method do you need. So if you are really, really, for lack of a nicer term, like a spaz — and I’m a spaz, so I’m saying this with love — but if you’re terrified of getting pregnant and you’re totally just anal, and you want to have a method that allows you to be completely on top of everything, I teach a method like that, but there is a method for you, right, regardless of your level, just your personality. Some women obviously are a little bit, maybe they’re not on the either end of the spectrum like you mentioned, and for them a method that isn’t necessarily as stringent in terms of observations and things like that might work a little bit better, but for other women it’s like, nope, I want to do the most, I want to be on top of it, and that’s how I am, I think I attract a lot of type clients for that reason, but there’s a method for you, right. So I think the kind of summary, correct me if I’m wrong, that we’ve talked about so far is essentially that, first of all, there are multiple fertility awareness-based methods, there are plenty of methods that have had peer-reviewed science, so modern fertility awareness-based methods have obviously been tested, so we are not doing voodoo in the woods.

Dr. Duane: Exactly, exactly, and the effectiveness is high.

Lisa: Yes, so the effectiveness is high, it’s comparable to hormonal methods, and if you take the time that you need to really choose the method that’s going to work for you, take the time to learn and apply it accurately, which is possible, it is not complicated, within about two to three cycles most women are fully capable of understanding all the rules and using the method correctly.

Dr. Duane: You can do it, right, absolutely. A couple of thoughts came to mind when I love how you describe yourself as type A, wanting to cross your t’s and dot your i’s. Just a little bit of personal information about me, when I first started learning how to use these methods, like the first method I learned to use was basically the Sympto-Hormonal method which has not been studied per se in studies, but I was learning as a single woman just to better understand what was happening in my body, and it worked really well, but then when I was getting married I wanted to make sure that I wasn’t going to have a honeymoon baby, so I was like I need to use something that’s really certain, and so I used symptothermal and it worked really, really well until I had kids, and I’m like there’s no way — well I should step back, the symptothermal method worked well except I kept forgetting to take my temperature because I’m not a morning person, and my husband kept getting tired, he just started taking my temperature for me because he wanted to know that this is working, he wanted to have lots of days available, and so it actually worked really well from sharing the responsibility, and it made me feel much better that I did not bear the burden, but once we had kids I was not sleeping throughout the night, and I was waking up and I couldn’t do it effectively, so I ended up switching, and the ironic thing is I first got trained as a Creighton medical consultant because at the time that was the only program available for medical professionals. I personally have used every method at different points in my life except for the Creighton Model, because I feel like you really need to be very detail-oriented to use that one, but yes, there is a method out there. One other thing I want to talk about in terms of effectiveness, because you talked about the comparability with hormonal birth control and using a fertility awareness-based method, is, with a behavioral method like taking a birth control pill every day, one of the key differences between using fertility awareness-based methods and using conventional forms of birth control is women that use fertility awareness-based methods truly understand that if you have sex it could result in pregnancy, and they learn this, and there’s true purposes of sex, it leads to babies and it leads to bonding, that’s the whole point, and women who use fertility awareness-based methods, it’s very rare that I work with a woman who’s using a fertility awareness-based method that has a surprise pregnancy, she’s like, oh yeah, I remember, because they expect, well if I’m having sex, pregnancy can happen. When women are using birth control, we have convinced women that birth control is so good that they’ll never get pregnant, and then when they do, there’s this how could this possibly happen, and I’ve seen so many women beat themselves up over it, like what did I do wrong, and I’m like, sometimes it’s just the method doesn’t always work, and I encourage women, this is not about self-blame, sometimes the hormones don’t work as effectively as we like to think that they do, or sometimes you take antibiotics for an unrelated issue and it reduces the effectiveness of the birth control, no one told you that happened.

Lisa: Well, you know what, I’m so glad that you mentioned that, because we just discussed this during one of my class discussions today, and one of the medical students said ACOG has actually updated their recommendations and says that antibiotics no longer interfere with the effectiveness of birth control pills.

Dr. Duane: Which that was a news flash to me, did somebody just wave a magic wand on that, I don’t know, I haven’t had a chance to look into the literature on that.

Lisa: Well I don’t know, I would be curious, I literally had a conversation with several clients but one recently who literally that was her experience, was the opposite of what you just said.

Dr. Duane: As I said, I literally just learned about this today from one of my students, so I always want to know what is the latest science, I’m definitely going to research that, because for women that are struggling to get pregnant who may have very limited cervical mucus, we actually will use antibiotics to help improve cervical mucus production to improve fertility, so I think the question is still out there and I’m going to do a little bit more research into that. But one other thing I want to make sure to talk about, if we’re doing an entire podcast on the effectiveness of fertility awareness-based methods, because I think we would be remiss not to talk about this, is what is most commonly quoted when it comes to fertility awareness-based methods. So Lisa, what do women tell you, or what do you hear most commonly in terms of how effective these methods are?

Lisa: Well, I mean, I’m not the general garden variety audience, so I literally hear 99.4 most often because I say that all the time on the podcast, based on the Frank Hermann study, the 2007 study, right, so my audience is quite well-versed, but absolutely, I mean when I was doing research to list the effectiveness, it’s like anywhere from 60 to 98 and wildly different depending on the study, and often — you’re going to talk about this in detail, right — so but I mean anything goes with a lot of these studies, if a woman just checks a box that she checks her mucus sometimes or whatever, she’ll be included in an efficacy study.

Dr. Duane: Right, right, great point. So until very recently in the United States, the Centers for Disease Control, which a lot of other medical organizations then reference, until very recently they quoted that fertility awareness-based methods have a failure rate of 24%, meaning one in four women who use these methods will get pregnant, but this is incorrect, and they have recently updated it to say it ranges from 2 to 22, but it’s important to know where this figure comes from. It’s commonly cited in women’s health textbooks, but it reflects only one effectiveness rate for all FABMs, and it’s based on retrospective surveys from 1995 and 2002, we’re talking 20 years ago, where women were asked to recall what form of family planning they were using when they became pregnant. Then what they did is they combined the effectiveness rates for all of the natural methods that women reported, and of note, fully 86% of those women said they were using some sort of calendar calculation method, they were not using symptothermal or Marquette, and we don’t even know if they were actually using the actual rhythm method versus their own homegrown version of when they might be fertile. But the issue with that is that you’re combining multiple methods, which is not accurate, because we’ve discussed the methods work differently, they have different rules, they have different observations, so combining effectiveness rates for all FABMs and reporting one rate is misleading, because they have different guidelines for use. It would be like quoting one effectiveness rate for the Mirena IUD and the Depo shot and the progestin mini pill because they all contain progesterone — well sure they all contain progesterone, but they’re different. So as I said, fortunately the CDC has recently updated its website and there is a range of effectiveness rates for fertility awareness-based methods. And that being said, I also often caution women, don’t simply compare methods and say, well symptothermal method has a 98% effectiveness rate and Billings has a 90, so symptothermal must be better. Well the Frank Hermann studies that you quoted were done in Germany in college educated women, versus the Billings study was done in rural India with mostly illiterate women, so you’re looking at two very different populations. So while that might help guide your initial choice, if you’re somebody like me, you’re never going to remember to take your temperature every morning, then symptothermal is probably not going to be very effective for you, Marquette might be a little bit easier because you have a six hour window in the morning when you need to check your urinary hormones. So effectiveness rate is important, you know, unfortunately in medicine we almost place all importance on that effectiveness rate, and effectiveness is important, it’s certainly a consideration, but one of the other advantages to fertility awareness-based methods is that it’s side-effect-free, right, I mean the IUD may be way more effective, but there are a whole lot more side effects associated with it, and again the World Health Organization recognizes modern fertility awareness-based methods as the only form of family planning that have no medical side effects. So when women are considering it, yes, you absolutely need to consider effectiveness, and for my medical colleagues I would encourage you, yes, effectiveness is important, but if a woman’s not going to continue taking birth control pills, then it’s not going to work very effectively, and you need to be aware of and able to offer a wider variety of options to your patients.

Lisa: Well, I mean, I could honestly talk to you all day, obviously, but at some point we’ll have to go to our respective rest of our days, but Marguerite, I just want to thank you so much for coming on the show today and sharing your wisdom. I love talking to you, I mean ultimately FACTS is the Fertility Awareness Collaborative to Teach the Science, and so you always have evidence-based information to share with us, which of course my audience really appreciates, and I think it is important to break down the kind of truth about fertility awareness, like no one’s standing up saying that there is not a failure rate or that it’s 100% effective, and I love one of the things that you said was that women who use fertility awareness-based methods, they understand that sex is connected to pregnancy.

Dr. Duane: Yep.

Lisa: And I’ve said certain things like that in different ways over the years, because everyone who’s having sex with another human should know that the sex could result in pregnancy, and I recently released an episode where a woman, it was in the Pill Reality Series, and she was using the IUD and she became pregnant on it, like five years in, I think it was, if I’m remembering correctly, and literally she couldn’t wrap her head around it, it was a bad situation, it was like an ectopic pregnancy, but legitimately not even in the window of possibility in her mind. So the connection between sex and babies was completely gone by that point, right, and it shouldn’t be, regardless of your method. So without going on any more tangents, if you have any last words for everything that we’ve talked about today, if there’s anything that you want to share with the listeners, and also let us know about your upcoming courses, options for medical care providers, all the things.

Dr. Duane: Excellent, yes, well, like I said, I will definitely share our What Are FABMs handout with you that you can make available to your listeners, because it gives a nice overview of the different methods and the effectiveness rates. We are having an upcoming virtual conference, so anybody from anywhere can attend, on May 14th and 15th, the focus is really on fertility awareness, expanding care for women’s health, so we’re going to talk about how these methods can be used to address things like dysmenorrhea, acne in adolescence, miscarriage and recurrent miscarriage, so a wide variety of topics related to the use of fertility awareness for women’s health. We have ongoing monthly webinars where we do an introduction of fertility awareness-based methods and its role in family planning, and our other one is the female cycle as the fifth vital sign, and we’re always excited to share how the chart can be used as a diagnostic tool to address a range of women’s health issues. So we have those ongoing webinars, and then coming later this year we are super excited to release an online continuing medical education course for medical professionals, to earn up to 60 continuing medical education credits, to learn about all of the different evidence-based methods and how they work, and the effectiveness behind their use, the role of fertility awareness-based methods in family planning, whether it’s to prevent pregnancy and in many cases to achieve pregnancy by addressing infertility, we’ll talk about the psychosocial aspects of addressing infertility, we’ll also have a class on using these methods at different stages in life, both in the adolescent population, the postpartum population, and the perimenopausal population, we have a presentation on apps included in this course, and then again we’ll have an entire section devoted to fertility awareness-based methods for women’s health, whether it’s to address polycystic ovarian syndrome and ovulation, endometriosis and more. So we have that online CME course coming soon, and again our FACTS virtual conference is Friday May 14th and Saturday May 15th, and we welcome any and everyone to attend. While our courses are mainly geared towards medical professionals and students, we certainly welcome fertility educators and women who simply want to educate themselves more and become more empowered to better manage and monitor their health, we welcome everyone.

Lisa: Awesome, that is amazing, and yes, on behalf of the Fertility Friday community, we are thankful that you are in the world educating doctors, there’s so many women’s lives who you’ve saved because of the work that you do, so honestly, I’m kind of joking but I’m really not joking at all.

Dr. Duane: Well thank you, it’s a pleasure to work with wonderful people like you, Lisa, to help do this important work on behalf of all women.

Lisa: Yes, well, in the pre-chat we were having this conversation of like, I think both of us have had different times in our life where it’s like, well if I don’t do it, who, right, why not now. And I know that there’s a lot of women listening, we can only imagine what the future holds, but I do think that we’ve come a long way, even though it doesn’t necessarily feel like it, but I think the next 15, 20, 30 years is going to be incredible for women’s health, because we just lit a fire under thousands, tens of thousands of women, like, what do you mean there’s this whole other area of my body and reproductive health that no one ever talked to me about, that no one ever taught me.

Dr. Duane: Yeah, no, you have done absolutely amazing work through your podcast, and I think it’s incredible, and yeah, we are here to obviously educate the medical professionals but to support women. I should also note we finally have released our new fertility awareness-based method physician, clinician, and educator directory, to help women find teachers and doctors, not only throughout the country, we have people from all over the world. So if you’re looking for somebody that is trained and knowledgeable, visit the FACTSaboutfertility.org website, and if you still can’t find someone, email me at [email protected], because we want you to get the resources that you need to truly be empowered to care for your health, fertility literate doctors.

Lisa: So the only question left is when do you sleep, but I’ll let you answer that at another time. Marguerite, thank you so much for being here, it’s always a pleasure.

Dr. Duane: Thank you, it’s been wonderful, thanks.

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/362. I hope that you enjoyed today’s episode with Dr. Marguerite Duane. I really appreciate her approach, I love that she’s out there in the world educating doctors and other health professionals about fertility awareness-based methods, and really diving into the science of it so that there’s kind of no excuse, when you’re looking at peer-reviewed published research studies that are really examining the nitty-gritty details, how the methods are different, how they work. I also think it’s important that FACTS highlights the differences between fertility awareness-based methods, so users can really understand that it’s not just there’s an umbrella of fertility awareness and it’s not just one singular thing. I think especially when you first start out and you hear about the fertility awareness method, it’s good to know that there is no fertility awareness method per se that everybody agrees on, there are multiple different fertility awareness-based methods under that umbrella, and I mean it’s a good thing because it means that even within the category of fertility awareness-based methods there are multiple options, so you can really dive in and learn about different options, whether it’s mucus-only methods, the symptothermal method which combines mucus with temperature, there are temperature-only methods, there are calendar methods, there are modern day rhythm methods, it is a thing, I like the Standard Days Method, and there are symptohormonal methods, because as many of you know there are a lot of different tools such as ovulation predictor strips and hormone testing devices that can be used in conjunction with your charting protocols. So there are a number of different methods for different times. I’ve talked a lot about the Marquette Method, which is a symptohormonal method, and its applications during the postpartum phase, if mucus is not something you can rely on primarily, depending on the woman and the circumstance. And so I think it’s really helpful when you start to learn about fertility awareness to really educate yourself about the different options that are available, so that you can know if there are different types of methods, different approaches that might help you at different points in your life, similarly to how I talk about contraception in general, how there typically is not one method of birth control that someone’s going to use their entire life in the exact same way, often we make different choices when we’re in our late teens and early twenties for birth control than we would when we’re in our early thirties planning for pregnancy, than we would when we’re approaching menopause, and just at different stages of our life, it makes perfect sense that there might be different options that we might utilize at different times. So with that said, I hope that you have a wonderful week, weekend, whenever you’re tuning into this show. If you can think of someone who could really benefit from hearing this episode today, the link once again is fertilityfriday.com/362. And of course, as always, until next time, be well and happy charting.