The State of Care: Women's Health

By Deborah Lynn Blumberg | Portraits by Jörg Meyer

Historically, physicians have treated endometriosis with hormonal medications to suppress estrogen levels, with surgery, or both. But for the one in 10 women with the chronic disease that causes crippling pelvic pain, depression, and infertility, these treatments are insufficient, says Jessica Opoku-Anane, MD, a gynecologic surgeon and director of Columbia’s comprehensive pelvic pain program.

“The current rates of endometriosis are so incredibly high that the traditional management we’ve been doing is not working,” Dr. Opoku-Anane says. “It’s a whole body disorder, not just what’s contained in the pelvis, so you have to incorporate methods of whole body treatment.”

Columbia recruited Dr. Opoku-Anane in part in recognition of the need for more comprehensive care for individuals with endometriosis. The program takes a multidisciplinary, holistic approach that also offers acupuncture. A team of specialists, including physical therapists and integrative medicine and mental health specialists, work to develop treatment models to better diagnose patients, many of whom go a decade or more before getting an accurate diagnosis.

“This patient population is very underserved,” says Dr. Opoku-Anane. “And in the delay to diagnosis, there’s a lot of stigma. Patients are told it’s in their head. They’re undertreated and they bounce back and forth among multiple providers.”

When surgery is needed, Columbia faculty use their expertise in laparoscopic and robotic-assisted surgery—optimal techniques when fertility preservation is a priority—to pursue the least invasive approach, preserving healthy tissue and speeding up recovery time with less scarring, pain, and complications.

The endometriosis initiative is one of several new and innovative programs Columbia has launched to advance women’s health amid rapid changes in the field. Significant developments in women’s health care have been noted in the past five years alone: The Covid-19 pandemic exposed gaps in women’s care—including health inequities and gender bias—and the Supreme Court’s overturning of Roe vs. Wade thrust women’s health care into the spotlight and ignited national debates about reproductive rights.

The U.S. maternal mortality rate is worsening, with some current rates three times higher than in the United Kingdom and Canada. Historically underrepresented groups fare far worse with pregnancy-related complications, with Black women about three times more likely than white women to die from a pregnancy-related issue. Research suggests the vast majority of pregnancy-related deaths in the United States are preventable.

Columbia has been at the forefront of providing women with comprehensive, compassionate care, including offering one of the first IVF programs in New York City. Now, Columbia is building on its solid foundation with initiatives that provide women with holistic, individualized care throughout their lives.

Focusing on Mom in High Risk Pregnancies

The Columbia Mothers Center, a first-of-its-kind space dedicated to providing coordinated care for pregnant individuals with complications, is unique, says Chief of Obstetrics Lisa Nathan, MD, because often maternal health care prioritizes the fetus. “This is putting the mom back into the picture.”

The center addresses the fragmented care received by some mothers who have multiple medical problems that can complicate their pregnancies. “This type of coordinated care can optimize outcomes,” says Dr. Nathan.

In the Mothers Center heart program, women with cardiovascular disease who are pregnant, or contemplating pregnancy, see a range of specialists in maternal-fetal medicine, cardiology, and obstetric anesthesiology. Women receive postpartum cardiovascular risk assessment and counseling on preventive measures to help reduce future pregnancy complications and long-term cardiovascular disease.

“We always think of pregnancy as a stress test on the heart,” says Jennifer Haythe, MD, director of the cardio-obstetrics program, “and we know now that heart disease during pregnancy is linked to heart disease later in life. So we provide really close, attentive care. The goal is to screen and monitor these women over time.”

The multidisciplinary team meets weekly to discuss upcoming deliveries. In a Columbia study that followed 306 women with high-risk pregnancies from 2010 through 2019, the 30-day readmission rate for the cardio-OB patients was 1.9%. Nationally, the rate was 3.6%. “Columbia has a really great ability to mobilize people quickly when women are sick, and it shows,” says Dr. Haythe.

Dr. Haythe and her team are enrolling patients in the REBIRTH study, an NIH-funded multicenter effort to test the effect of the drug bromocriptine, which blocks prolactin, hence lactation, in the treatment of peripartum cardiomyopathy.

For women with placenta accreta spectrum, or PAS, a condition in which the placenta grows inside the wall of the uterus and sometimes outside the uterus and invades surrounding organs, life-threatening hemorrhaging is possible when the placenta does not separate spontaneously from the uterus after delivery.

This condition is rare, but it has been on the rise. Columbia is a center of excellence for its accreta program, which includes a dedicated group of physicians from multiple specialties who closely follow women from early in their pregnancy through birth.

“Women’s lives are in danger when cases go undiagnosed or are not managed by specialists,” Dr. Nathan says. Outcomes from Columbia’s accreta program include low levels of blood transfusions and few complications. Patients who have PAS but live outside the United States sometimes move to New York for their pregnancy to receive care from Columbia doctors.

Specialized Surgeries In Utero

The Carmen and John Thain Center for Prenatal Pediatrics is a multidisciplinary fetal diagnosis and therapy center that cares for patients with pregnancies involving fetal anomalies, genetic conditions, complicated multiple gestations, and those who may be candidates for certain fetal interventions. In 2022, nearly 1,000 patients presented to the center for evaluation and care.

Russell Miller, MD, the center’s medical director, said the team offers specialized surgeries for certain conditions in utero, including prenatal repair of fetal myelomeningocele (spina bifida) and fetoscopic laser surgery for twin-twin transfusion syndrome. The center is one of a small handful of centers in the country that use a less invasive procedure for prenatal spina bifida repair. Columbia surgeons fetoscopically enter the uterus, as opposed to using a large uterine incision as practiced at many other fetal centers. This technique avoids creating a large uterine scar that can impact future pregnancies.

“What makes the center stand out is its multidisciplinary philosophy,” Dr. Miller says. “Multiple providers are involved in prenatal consultations, deliberations, and patient education, and these specialists work together to develop a unified, individualized care plan that makes the experience better for patients and we believe helps to optimize outcomes. We try to make it a unified experience for patients and families.”

The center has plans to offer FETO, or fetoscopic endoluminal tracheal occlusion, under the direction of Vincent Duron, MD, co-director of fetal therapy. During the procedure, which is used for fetuses diagnosed with severe congenital diaphragmatic hernia, a surgeon fetoscopically places a special balloon inside the fetus’ trachea, blocking it in an attempt to improve fetal lung development.

Considering the Role of the Environment

The medical profession is paying closer attention to the environment’s impact on women’s health because of growing awareness of climate change and high-profile media stories about the impact of lead exposure and contaminated water, says Blair Wylie, MD, founding director of the Collaborative for Women’s Environmental Health in the Department of Obstetrics & Gynecology.

She joined Columbia in 2022 to lead the new collaborative. “Ob/Gyn is a few steps behind pediatrics in thinking about environmental contributors to disease,” Dr. Wylie says. “Health issues related to the environment can start before birth. I see my goal as helping to amplify this, helping researchers in the department think about the various environmental contributors.”

A big part of her role is increasing literacy among Columbia’s clinicians and patients around environmental health concerns. More patients now ask about the effects of such things as mold growing in their homes, summer heat waves, and smoke from wildfires. “And, oftentimes clinicians throw up their hands because they don’t know what to do,” Dr. Wylie says.

Advocacy and community engagement are important, too. Partnerships with community-based organizations can help promote policy change around environmental problems that contribute to poor health. For example, Columbia physicians have partnered with organizations pushing for New York City buses to stop idling.

“We, as clinicians, have powerful voices when it comes to influencing policy and legislation,” says Dr. Wylie.

A focus on the environment is critical to see real change in health outcomes, she adds. Moving the needle on decreasing preterm birth rates, for example, may require a close look at air quality and air pollution and subsequent legislation to help. It’s the same with prenatal lead exposure affecting development and endocrine-disrupting chemicals, such as phthalates in personal care products, that impact fertility and menopause.

Part of the collaborative’s mission is sustainability, recognizing that climate change is an existential threat and helping Columbia reduce its carbon footprint and carry out effective disaster planning for its patient population ahead of events like heat waves and floods.

“The overall thought is to elevate the environment as a contributor to disease and to health care disparities,” says Dr. Wylie. “We’re trying to create these bridges both within our department and also with other parts of Columbia that are focused on the environment—law school, public health school—where we’re bringing obstetricians and gynecologists to the table.”

Comprehensive Cancer Care

A heritable genetic condition causes from 5% to 10% of breast cancer cases and up to 25% of ovarian cancers. Second only to age, a significant family history is the strongest known risk factor for breast and ovarian cancer.

Columbia’s hereditary breast and ovarian cancer program was created in 2017 to empower women with knowledge about their individual risk, create a personalized strategy, and coordinate and streamline what has been a disjointed array of diagnostic testing, risk-reducing strategies, and clinical research trials around cancer prevention and treatment. Meghna S. Trivedi, MD, and June Y. Hou, MD, co-lead the program.

“The thought behind the program was that we can make the team more complete,” says Dr. Trivedi. “It’s comforting for patients to know their doctors are all in one place.” Decision-making is shared and made with the patient rather than for the patient. A major benefit, adds Dr. Hou, is that the program cuts down on long wait times for genetic counseling and testing.

Women in the multidisciplinary program receive leading-edge genomic testing, genetic counseling from experts in hereditary cancers, MRIs, ultrasounds, and individualized consultations with specialists in genetics, breast oncology, surgical oncology, and gynecologic oncology.

Research is an important part of the program. Columbia participates in a multicenter breast cancer prevention trial for BRCA1+ women to study the preventive effect of the bone antiresorptive drug denosumab. Another trial is studying whether removal of fallopian tubes or removal of ovaries and fallopian tubes reduces the risk of cancer in individuals with BRCA1 mutations.

The hereditary breast and ovarian cancer program has grown in recent years and received positive patient feedback, says Dr. Hou. “Patients want a personalized approach and they want control over their cancer care. They also want convenience. They’re incredibly thankful they’ve found one physical space that can do everything for them.”

The program relies on education and partnerships with primary care practitioners and obstetricians and gynecologists, including a pilot program for hereditary cancer genetic counseling and testing.

“The feedback from this pilot initiative was overwhelmingly positive from the patient as well as the provider’s perspective,” Dr. Hou says. “We hope to expand this initiative more broadly and offer easier access to cancer genetic counseling and screening for all women.”

Who's Who

• Vincent Duron, MD, associate professor of surgery
• Jennifer Haythe, MD, the Irene and Sidney B. Silverman Associate Professor of Cardiology (in Medicine)
• June Y. Hou, MD, associate professor of obstetrics & gynecology
• Russell Miller, MD, the Sloane Hospital for Women Associate Professor of Prenatal Pediatrics (in Obstetrics and Gynecology)
• Lisa Nathan, MD, associate professor of obstetrics & gynecology
• Jessica Opoku-Anane, MD, assistant professor of obstetrics & gynecology
• Meghna S. Trivedi, MD, assistant professor of medicine
• Blair Wylie, MD, the Virgil G. Damon Professor of Obstetrics & Gynecology