Duke’s Department of Obstetrics and Gynecology has several specialists with advanced expertise in treating menopause as certified by the Menopause Society. They can offer novel treatment options as well as in-depth counseling to patients with complex histories and needs.
 
These specialists welcome referrals of patients who have complicating conditions such as cardiovascular risk factors (including hypertension or a history of blood clots or stroke), chronic pain, osteoporosis, anxiety, advanced age, or a history of breast cancer. They also welcome patients who might benefit from hormone therapy but are reluctant to try it. 
 
Practitioners earn the credential by passing an exam administered by the Menopause Society (formerly known as the North American Menopause Society) and fulfilling yearly educational requirements, according to MargEva Cole, MD, an obstetrician-gynecologist at Duke. 
 
“The certification reflects the extra knowledge and expertise that come from continual learning through formal reading, education, and attending conferences, as well as many years of learning on the job that every woman has a different set of symptoms and concerns,” Cole says. She finds great value in an annual day-long update seminar at the Menopause Society meeting that reviews the latest findings in menopausal endocrinology, impact of co-morbidities, treatment options, and more. 

The great changes in the perception of hormone therapy highlight the need for this kind of study, according to Jennifer Howell, MD, another certified obstetrician-gynecologist. A menopause specialist can help both patients and primary-care doctors who are confused by evolving and apparently conflicting recommendations. 
 
“In the 1990s, we kind of considered hormone therapy the fountain of youth and prescribed it to everyone,” Howell says. “When the Women’s Health Initiative study came out in the early 2000s, it seemed to have more risks than benefits. I have continued to follow the data and to prescribe it to certain patients based on a nuanced understanding of each individual’s situation.”
 
“A lot of what we do is counseling on ways to approach your menopausal symptoms and laying out the options,” Cole says. “Sometimes the patient has a long list of questions, and it can be  difficult to untangle how much their symptoms relate to menopause rather than a different concern. We have more time than another provider might to lay out the options and let patients feel empowered to make their choices.” 
 
An example of this kind of patient might be a woman with menopausal symptoms as well as chronic pain or fibromyalgia. Cole says that such a patient might benefit from a neurologic medication like gabapentin, which can help them with hot flashes, sleep, and chronic pain. 
 
Or a patient with a history of hormonally sensitive breast cancer who has hot flashes, palpitations, and difficulty sleeping because of anxiety about their breast cancer diagnosis could benefit from a low dose of a medication also used for anxiety or depression, such as an SSRI or SNRI. “Sometimes we can kill two birds with one stone,” Cole says.
 
Howell adds: “I keep up to date on new products that your average OB-GYN might not have heard of.” She is open to prescribing off-label drugs like testosterone or new alternatives, such as Veozah (fezolinetant), a nonhormonal treatment of moderate-to-severe vasomotor symptoms.

To enhance the expertise and patient care options for children and adolescents, Duke Health’s gynecology team recently welcomed Tara Streich-Tilles, MD, MPH. Streich-Tilles brings specialized training in the medical and surgical care of children, adolescents, and young adults with gynecologic concerns, and brings comprehensive, inclusive, and impactful care to the community. 
 
“The health of this patient population is important and Duke is committed to growing its presence in this area,” says Streich-Tilles. “I’ve appreciated the warmth I’ve received, as well as the integrity and innovativeness of the Duke community.”

Untreated gynecologic concerns can negatively impact health and development, and Streich-Tilles says some patients feel apprehensive to seek expert care in this area. In this specialty, it’s particularly important for patients to have the information they need to make healthy decisions, and involve parents and caregivers in the education process.  
 
“I start each visit by getting to know the patient — what they enjoy doing, who is a part of their family, and what they are passionate about. This helps us build comfort and trust.” 
 
Streich-Tilles serves patients from birth to young adulthood and offers high-efficacy therapies for a wide range of gynecologic conditions and reproductive health concerns specific to children and adolescents, including:

• Abnormal pubertal development
• Vulvar dermatoses
• Adnexal masses
• Menstrual disorders
• Dysmenorrhea
• Chronic pelvic pain
• Endometriosis
• Complex contraception
• Müllerian anomalies
• Differences of sex development
• Ovarian insufficiency
• Reproductive care for children, adolescents, and young adults with cancer, and cancer survivors

Streich-Tilles collaborates with community providers, specialists, and subspecialists within and outside Duke, including pediatrics, family medicine, gastroenterology, urology, urogynecology, hematology, endocrinology, oncology, surgery, and more.
 
“I have great respect for my colleagues who help patients manage their reproductive health, and I can serve as a supportive team member for second opinions or for patients with more complex needs,” says Streich-Tilles.
 
Within Duke, Streich-Tilles is collaborating with various subspecialties and programs to integrate a higher level of gynecologic care, including fertility preservation, into the treatment and disease management of many conditions, such as cancer, urogenital conditions and anorectal malformations, endocrine disorders, and others.

In a recent study published in BJOG: An International Journal of Obstetrics & Gynaecology, gynecologic surgeon Arleen H. Song, MD, MPH, OB/GYN resident Jenny Wu, MD, and their colleagues uncovered how women perceive the current state of endometriosis care by taking a closer look at TikTok.
 
“Women find communities online where they can share their diagnosis and the way their symptoms have impacted their lives. This connectivity is important because endometriosis is underdiagnosed and often stigmatized,” says Wu.
 
Wu and fellow researchers found that endometriosis was a high-traffic topic on TikTok, with around 1.4 billion views. “We wanted to know why so many people were interested in this topic, what they were saying, and why they were turning to TikTok instead of a healthcare professional,” Wu adds.

Researchers analyzed the top 100 TikTok videos that discussed endometriosis, 75% of which highlighted a personal experience with the disease, finding:

• Of videos discussing endometriosis symptoms, 50% focused on dysmenorrhea, with many emphasizing the fact that painful periods are not normal.
• Around one-quarter of the videos signaled a distrust in healthcare. A common complaint was a perceived delay in diagnosis by providers.
• In videos discussing treatments, surgery had a much more favorable response than hormonal treatments, and around 12% of videos highlighted alternative treatments, such as dietary changes and supplements.
• Infertility was the key topic in 24% of videos, with many of those videos focused on in vitro fertilization.

“Healthcare providers can use these findings to develop better trust and rapport with patients,” says Song.

The study findings have influenced the way Duke specialists care for women with endometriosis in the following ways:

Starting a conversation

Wu says many patients with endometriosis have some ideas about their condition and treatment before they see a physician. “Focusing on what patients have seen online is something that I have made part of my routine practice because I think patients feel validated. Asking what they know, what they’ve found helpful, what their goals are really helps to set the tone,” adds Song. “Many patients feel they have not been heard, and establishing trust, communication and rapport at the beginning is essential to finding the best treatment for the patient.”

Sharing clinically sound information

Misinformation can fuel negative opinions on common treatments for endometriosis. Hormonal treatments, in particular, are misrepresented, says Wu. “There is this common idea that birth control will make you gain weight or impact your mood.” In addition to educating patients on the side effects of the birth control, Song says she informs patients on their efficacy. “A lot of patients are skeptical because they’ve tried birth control and are still experiencing pain, but when hormonal therapy or cycle control is presented within a bigger treatment plan, it’s often better received.”

Building confidence and trust

Because endometriosis is difficult to diagnose and treat, many women experience frustration while seeking effective solutions to manage chronic and painful symptoms. This frustration can become distrust when they feel they’re not being heard or receiving appropriate care. Through communication, collaboration, and comprehensive, proactive care, Song says physicians can build confidence and trust.

To ensure a safe, predictable pregnancy for patients with heart disease, a team of Duke Health specialists from anesthesiology, cardiology, and maternal-fetal medicine collaborate to provide comprehensive, personalized care through conception, delivery, and post-partum follow-up.

The Duke Pregnancy Heart Center offers convenient care from experienced physicians that allows patients to meet with several clinicians during a single visit, helping ensure that comprehensive care is planned and coordinated safely.

Experienced maternal nurse navigators establish relationships with patients and families to help simplify appointments, schedule follow-up care, and provide an accessible contact point for questions or concerns.

Jerome J. Federspiel, MD, PhD, a Duke maternal-fetal medicine specialist, leads a monthly planning conference created to coordinate planning for complex cases as well as proactive management for each stage of a pregnancy and delivery.

“Pregnancies involving patients with heart disease often have additional risks compared to those without heart disease,” says Federspiel. “We know that careful planning during pregnancy is essential. For this reason, our team discusses every patient during a monthly review throughout the pregnancy to monitor progress and, of course, more frequently when necessary.

“We want to make the delivery and postpartum period, which is the highest risk time for complications of some kinds of heart disease, as safe and happy as possible.”

During the past three years, a clinic created to treat cardiovascular conditions in women who are pregnant has become a fast-growing partner of Duke Maternal-Fetal Medicine Division (MFM) and the Pregnancy Heart Center.

Cary C. Ward, MD, an adult congenital heart disease specialist who occasionally treated pregnant patients as a part of her practice, now works closely with the Federspiel’s group. Her patients often presented with complex, challenging conditions, Ward says, which triggered her interest in addressing cardiovascular risk factors in a more effective manner. The combined program was launched in September 2022 with the addition of Mary-Louise Meng, MD, who helped form a third pillar of care with her anesthesiology partners. Ward and Meng join Federspiel in the monthly care planning sessions.

“Some patients in my congenital practice have mechanical heart valves and wanted to become pregnant,” says Ward. “These individuals required very specialized care and led to our interest in developing a program for women with cardiovascular disease and pregnancy.”

One contributor to the fast growth of the center is the fact that the multidisciplinary approach helped patients with immediate health risks, Ward says. The number of active patients cared for by the interdisciplinary team has tripled since 2022.

But the demand for comprehensive cardiac care before and during pregnancy remains high, Ward says. She has personally witnessed the medical challenges facing pregnant women in the United States. “Among nations of the same socioeconomic profile, the statistical risks associated with pregnancy are significantly higher in the U.S. than in other countries,” Ward says.

These risks have continued to rise in recent years. Since the creation of the CDC’s Pregnancy Mortality Surveillance System, the number of reported pregnancy-related deaths in the United States increased from 7.2 deaths per 100,000 live births in 1987 to 32.9  deaths per 100,000 live births in 2021. Among African American women who are pregnant, the maternal mortality rate is twice as high, a statistic that highlights the health care disparities in this field.

The reasons for the increase in overall maternal mortality are multifactorial, but the experience at Duke has convinced Ward and her colleagues that pregnant women need proactive care as soon as possible.

“Women are becoming pregnant later in life, and have higher rates of diabetes, obesity, and elevated blood pressure,” Ward adds. “These risk factors can contribute to hypertensive disorders of pregnancy such as preeclampsia, all of which are associated with a higher risk of maternal death.”

The pregnancy heart team is also active in research to improve the care of patients with cardiac disease. Duke physicians and nursing colleagues are part of the leadership team for a statewide quality initiative to improve the care of patients with pregnancy-related heart disease across North Carolina.

A specialized clinic created to treat cardiovascular conditions during pregnancy has become a fast-growing partner of Duke Maternal-Fetal Medicine Division and the Pregnancy Heart Center.

Cary C. Ward, MD, an adult congenital heart disease specialist, occasionally treated pregnant patients as a part of her practice. Those patients often presented with complex, challenging conditions, Ward says, which nurtured her personal interest in addressing cardiovascular risk factors in a more organized, effective way.

“Some patients in my congenital practice would be women with mechanical heart valves, for example, who were pregnant or wanted to become pregnant,” says Ward. “These individuals required very specialized care.”

Ward began to work more closely with physicians in the Maternal-Fetal Medicine Division early in 2019 by offering cardiovascular care recommendations for patients when consulted by maternal-fetal specialists. “When we started, they had my pager and contacted me when I could help,” she remembers.

By the end of 2019, a half-day clinic was created as part of a comprehensive clinical collaboration. Ward now joins a monthly multidisciplinary maternal-fetal medicine planning conference led by Jerome J. Federspiel, MD, PhD, that brings together cardiology, anesthesia, and maternal-fetal medicine. Anesthesiologist Marie-Louise Meng, MD, represents the anesthesiology team in the conference.

The case reviews help establish collaborative clinical plans for the highest-risk patients. Looking ahead, participants in the monthly planning sessions develop care guidelines and standardized documentation of delivery plans for their patients. This specialized, proactive approach to their care has resulted in more referrals and a fast-growing patient panel as more women from across North Carolina and adjoining states are referred to the clinic.

“One contributor to our fast growth is that the multidisciplinary approach creates an environment in which we are able to help patients with immediate health risks,” Ward says. The number of active patients cared for by the interdisciplinary team has tripled over the past year, Ward says.

But the demand for comprehensive cardiac care before and during pregnancy remains high, Ward says. She has personally witnessed the medical challenges facing pregnant individuals in the United States. “Among nations of the same socioeconomic profile, the statistical risks associated with pregnancy are significantly higher in the U.S. than in other countries,” Ward says.

These risks have  continued to rise in recent years. Since the creation of the CDC’s Pregnancy Mortality Surveillance System, the number of reported pregnancy-related deaths in the United States increased from 7.2 deaths per 100,000 live births in 1987 to 32.9  deaths per 100,000 live births in 2021. Among African American women who are pregnant, the maternal mortality rate is twice as high, a statistic that highlights the health care disparities in this field.

The reasons for the increase in overall maternal mortality are multifactorial, but the experience at Duke has convinced Ward and her colleagues that pregnant women need proactive care as soon as possible.

“Women are becoming pregnant later in life, and have higher rates of diabetes, obesity and elevated blood pressure,” Ward adds. “These risk factors can contribute to hypertensive disorders of pregnancy such as preeclampsia, all of which are associated with a higher risk of maternal death.”

One key step to providing proactive, efficient care to patients with high-risk pregnancies is the increasingly significant role played by maternal care navigators. These individuals are trained to develop outreach plans, help coordinate visits and check-ups, and create a proactive approach to maternal care. The trainees specializing in working with the patients and managing care.

Maternal care navigators represent an important part of the effort by Maternal-Fetal Medicine to provide outreach to individuals with the highest-risk pregnancies to proactively to ensure that the individuals receive care and can be directed to the correct providers efficiently and quickly. Pregnancy heart centers like the one at Duke are being created at many medical institutions to help address the gaps in care for patients who are pregnant.

Sarah Snow, MD, and Toi Spates, MD, from the Duke Cardiovascular Disease Fellowship Program assist Ward. Both are training to expand the number of providers who can participate in the care of pregnant women with cardiovascular disease, Ward says.

Duke’s approach sets the stage for future growth, Ward says. “We want to expand the clinic to a full day and add more providers.” In the future, she hopes the multidisciplinary approach can be offered in satellite clinics beyond Durham. The clinic is located at Pavilion East at Lakeview, 2608 Erwin Road #200 in Durham.

Duke Health’s experienced surgical teams have a long track record of integrating robotic surgical techniques in gynecological procedures. These minimally invasive surgeries have lower risk and produce better outcomes, with less pain and faster recovery time than surgery through large incisions — factors particularly important for patients who may be preparing for adjuvant therapy.
 
Six gynecological oncology surgeons with extensive expertise in robotic surgery offer less invasive therapy for patients at Duke Cancer Centers in Raleigh and Durham. Because surgery is usually the initial step in a series of treatments, successful outcomes and prompt recoveries are critical in accelerating care for patients with cancer.
 
“If you have a surgery that you can recover from faster because you have less insult to your body, then you’re going to feel well enough to tackle adjuvant therapies sooner. Faster surgical recovery can mean overcoming cancer sooner,” says Emma C. Rossi, MD, the newest member of the Duke gynecological oncology surgery team.
 
Approximately 85% of the surgeries Rossi performs are performed robotically. The procedures include radical hysterectomy, lymphadenectomy, sentinel lymph node biopsy, and cytoreduction. “Robotic surgery allows me to perform more complicated procedures with the minimally invasively technique than I otherwise could have,” she says.
 
Rossi emphasizes that the best outcomes come from centers where experienced surgeons have a record of performing a high volume of the robotic procedures.
 
“Volume matters,” Rossi says. “It’s important for providers to refer patients to a surgeon who has a high volume of experience and who has had more practice in robotic techniques. Data show these things impact outcomes and the likelihood of success.”
 
Because additional therapy following surgery is common for patients with cancer, Rossi says Duke’s collaborative approach among referring providers and cancer specialists is important in helping ensure continuity of care for these patients.
 
“We circle back after every new patient visit to let the referring provider know the diagnosis, the surgery recommended, and the timeframe for initiating that surgery so they have confidence that their patient is being taken care of in an expeditious fashion,” she says. “After the surgery, the same kind of communication continues with the referring provider to discuss the outcome and ongoing treatment recommendations.”

As a leader in the field of robotic surgery, Duke surgeons use the latest robotic surgical technology available; the surgeons also take an active role in shaping future robotic surgical innovations.
 
Rossi led the first-in-human trial of robotic-assisted sentinel lymph node mapping that has become standard for staging of endometrial and other gynecologic cancers. She will continue her research at the Duke Cancer Institute and will focus on exploring the potential of robotic surgery with near-infrared fluorescence imaging—paired with fluorescent markers—for mapping cancer.
 
Additionally, Rossi will be involved in a large, national clinical trial investigating the safety of robotic surgery to treat cervical cancer. The only cancer program in North Carolina participating in the randomized study, Duke will offer select patients an opportunity to have minimally invasive surgery rather than traditional surgery to treat cervical cancer. Inclusion in the study, says Rossi, is a testament to the team’s surgical expertise.
 
“Only very experienced robotic surgeons who've had large case numbers, a vast amount of experience, and demonstrated expertise with the procedure are included as part of this study,” she says. “We hope to enroll patients this summer.”

Bringing surgical expertise, technological know-how and a bold vision for the future of robotic surgery, renowned gynecologic oncology surgeon Emma Rossi, MD, is now serving patients at Duke Cancer Centers in Raleigh and Durham.
 
Rossi was an early adopter of robotic technology, realizing its potential during her surgical training just a few years after the U.S. Food and Drug Administration approved robotic surgery for gynecologic cancers. “I saw that robotic surgery had the potential to change the way I practice surgical care for the better,” she says. “It allows me to perform more complicated procedures minimally invasively than I otherwise could have.”
 
Around 85% of the surgeries she performs are now done robotically, according to Rossi. And, importantly, she does a high volume of these procedures, which include radical hysterectomy, lymphadenectomy, sentinel lymph node biopsy, and cytoreduction. “When you refer to Duke, you're optimizing the chance that your patient will be offered a minimally invasive surgical approach, which is associated with faster recoveries and fewer complications,” she says.

At Duke Health, Rossi has access to some of the most advanced technology available, including the next generation of robotic systems in research and development. She has the ability to share her knowledge training the next generation of surgeons, both at Duke University School of Medicine, and through a course she leads through the Society of Gynecologic Oncologists for fellows nationwide. Plus, she has the support and resources she needs to further her research on cancer mapping using image guidance, increasing the safety of robotic surgery for cervical cancer and more.
 
In every endeavor, improving patient outcomes is Rossi’s driving force. She has seen firsthand the value of robotic surgery, and believes it can make a difference in survival, particularly for cancer patients. “If you have a surgery that you can recover from faster because you have less insult to your body, then you’re going to feel well enough to tackle adjuvant therapies sooner. Faster surgical recovery can mean overcoming cancer sooner,” she says.
 
With two clinic locations, Rossi is accepting referrals from across the triangle. “My practice is the same in both locations,” she says. “But what makes the Raleigh clinic unique is that we're the only GYN-oncology practice in the Wake County area that delivers holistic care, with both surgery and chemotherapy for our patients. And we’re one of the few oncology practices that offers clinical trials for patients close to home, so they don’t have to travel.”

Duke OB/GYN’s Division of Maternal-Fetal Medicine (MFM) has recently expanded services at its multispecialty High-Risk Obstetrics Clinic for patients with high-risk pregnancies, adding a dedicated nurse navigator to coordinate complex maternal care.

The goals of this groundbreaking model are to improve the quality of care available, provide convenient access for Duke’s high-risk obstetrics patients, and decrease health disparities among this patient population.

“Many of our most significantly ill patients experience a lot of social determinants of health that can affect their care,” says Brenna Hughes, MD, MSc, the MFM division chief. “By having a dedicated care navigator, we hope to level out the field for those with significant medical problems and other complex social factors, so we can ensure they receive top-notch care during and after their pregnancy.”

The new complex maternal care coordinator, Dana McComb, RN, focuses on caring for mothers with significant cardiac disease, a history of transplant, or other rare, complicated diseases. Her expertise complements the team of specialty nurses who care for patients who need fetal surgeries or have fetal cardiac disease.

“At Duke, we are able to provide more patient-centered, team-based, multidisciplinary care and ensure that our patients with complex conditions have access to any medical specialists they might need,” Hughes adds.

The multispecialty clinic includes endocrinologists, who collaborate with the MFM division in the management of pre-gestational diabetes and complex endocrine disorders; cardiologists, who help treat maternal cardiac disorders; and anesthesiologists, who assist with complex deliveries. Care may also be provided by registered dietitians, diabetes nurse educators, and clinical social workers.

“Our integration of subspecialty care and consultation for the multidisciplinary care of pregnant women allows women with complex medical problems to get through pregnancy in a convenient and safe way,” notes Andra James, MD, MPH, MFM specialist and hematologist.

One such complex problem treated at the Duke High-Risk Obstetrics Clinic is placenta accreta, a disorder in which the placenta attaches abnormally to the uterus or other structures; placenta accrete is a significant cause of maternal morbidity and mortality around the world. Duke’s highly specialized Placenta Accreta Spectrum Program, led by MFM specialist Jennifer B. Gilner, MD, PhD, has become a regional referral center for this condition.

“Most patients have not heard about this condition until it impacts them, but a pregnant person who has had a cesarean delivery, placenta previa, or prior uterine surgery is at risk,” Hughes explains. “Our team’s unique approach to handling these cases has resulted in really spectacular outcomes for our patients.”

For young children and adolescents with gynecologic conditions, it can be challenging to find a pediatrician or adult gynecologist with the specialized training and experience necessary to accurately diagnose and treat conditions in this specific age group.

With the recent arrival of Jennifer O. Howell, MD, Duke now offers treatments for gynecologic issues in children from birth through age 21 at Duke Women's Health Associates Arringdon in Morrisville and Duke Women's Health Associates at Patterson Place in Durham.

Howell, who previously practiced at Rex and UNC clinics in the Triangle area, is one of the few gynecologists in North Carolina with a focused practice designation in Pediatric and Adolescent Gynecology from the American Board of Obstetrics and Gynecology.

Pediatric Gynecology

Howell says that pediatricians may not be trained to recognize and address the unique gynecologic issues that can affect young children at birth and at very young ages.

Common conditions in this age group include:

• Congenital abnormalities of the genitalia or in the reproductive tract, including vaginal agenesis

• Chromosomal abnormalities, including Turner syndrome—a condition in which a female is partly or completely missing an X chromosome

• Labial adhesions, which obstruct the vaginal opening and cause difficulty urinating

• Prepubertal vaginitis

Many parents of young children worry about gynecologists using an intravaginal device such as a speculum for an examination, but “at Duke, an awake child would never receive an invasive examination that could cause pain,” says Howell. “We have ways of making diagnoses without the use of intravaginal devices and can perform an examination under sedation if necessary,” she adds. “A gynecologic exam for a young child is not as intimidating as parents or providers might think.”

Adolescent Gynecology

“Teenagers are not little adults,” says Howell, “and our practice is finely tuned into the different factors involved in diagnosing and treating adolescents in this age group.” For example, she explains, young girls with abnormal bleeding usually don’t have structural issues such as fibroids or polyps and rarely need speculum exams; their issues tend to be hormonal in nature.

Common conditions and special needs in this age group include:

• Amenorrhea and dysmenorrhea

• Endometriosis and pelvic pain

• Adolescent gender care, including hormone therapy

• Fertility preservation associated with complex medical conditions

• Sexually transmitted disease and infection screenings

An often-overlooked aspect of treating adolescents and teenagers is knowing their social history, according to Howell. “I interview adolescents over age 13 without their parents and take a closer look at their social situation than an adult gynecologist normally would,” she says.

Howell uses an adolescent social history methodology known as HEADSS (Home, Education/employment, peer group Activities, Drugs, Sexuality, and Suicide/depression). “Any of these factors can play into the reason an adolescent is having gynecologic problems,” she says.

Patient Referrals

Howell encourages providers to refer children and adolescents to Duke for any gynecologic concern, noting the wealth of subspecialists for many uncommon conditions and the convenient community-based clinics that help parents avoid navigating large hospital-based clinics.

“We also have a clinical navigator to help ensure good communication with referring providers so they can stay involved in their patients’ care. All of this demonstrates Duke’s commitment to the community in terms of making sure specialty services are available and easily accessible.”