Ep 98: Dr. Rachel Danis
Fertility Forward Episode 98:
In this episode of Fertility Forward, we are joined by our newest member of RMA New York, reproductive endocrinologist, Dr. Rachel Danis. Listening in, you will hear all about Rachel’s professional journey from her passion for how REI hits home for her as a woman, to why she chose reproductive endocrinology. Next, we delve into the new drug Elagolix, how it is helpful for women with endometriosis, why Rachel wanted to do research and studies on it, and what she discovered through her research process. Rachel also shares the side effects of the drug before talking about her goals to expand much-needed fertility care to Brooklyn during her time at RMA. As usual, to end off, Dr. Danis tells us what she is grateful for today. So tune in now to welcome Dr. Rachel Danis and hear more from her!
Rena: Hi everyone. We are Rena and Dara and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
Rena: We are so excited to welcome to Fertility Forward today, the newest RE at our Brooklyn office. Dr. Rachel, Danis. Dr. Danis graduated from Barnard College at Columbia University and earned her medical degree at Drexel University College of Medicine. She completed her residency training in obstetrics and gynecology at Hannaman University Hospital at Drexel and was appointed chief president. She then completed her fellowship training in reproductive endocrinology and infertility at the University of Southern California, while simultaneously completing a Master's of Science in Clinical Biomedical and Translational Investigation. Dr. Dan has a passion for academic medicine and research, which has led her to present at national conferences and publish in world renowned journals. She believes in increasing awareness of women's and reproductive health issues. She's very excited to be joining the RMA team and is devoted to providing the highest quality of care to her patients.
Rena: Yay! Thank you so much for coming on our podcast and we're so excited to welcome you to the RMA family.
Danis: Thanks for having me.
Dara: So happy to have you on today and let's start from the beginning. So did you know, you know, being a, a medical, a resident or a student, how early on did you know that you wanted to go into this specialized field of reproductive endocrinology? Was it something you knew right away or did it take time to kinda settle in and figure out?
Danis: I would say it was like a journey. I did an internship at Cornell Center for Reproductive Medicine before I was even in med school. I was still studying for my mcat so I was like a junior in college and I just kind of like got a, an internship and was excited that I had something to do that summer. But I really gravitated towards the counseling that I was observing back then. So I was in, this was like 15 years ago, PGT or genetic testing of embryos wasn't a thing and most of the conversations were focusing on advanced maternal age and risk of down syndrome in people's children. And my sister has down syndrome and she was my main driver for wanting to pursue medicine at the beginning. So I was like, wow, I would be really good at having these kinds of conversations with patients just as far as describing what it means to have those risks of having a child affected with genetic issues and coping with that, what does it mean. Anyway, but I put it on the back burner and then, then I went to med school and I then thought I'd be like a pediatric cardiologist. I thought I'd be a breast surgeon. I went into ob. I was like probably, I don't know if everyone in med school is that lost, but I was like everywhere. And then once I was an OB there was a time where I thought I wanted to do maternal fetal medicine, similar to what drew me to rei. I really enjoyed the maternal side and the counseling sessions. But I think I ultimately chose REI because I'm a very math oriented person and the field of REI is, it's all problem solving or as best as you can make it. It's very cerebral, it's fast paced. I, the surgeries are my favorite. It kind of just like fit all my criteria.
Dara: So that's great that you had kind of an idea, but you know, it took you some time I guess through experience firsthand kind of seeing what you liked and what you didn't like and then came to that conclusion which so nice that there's so many different reasons that kind of brought you to this specialty.
Danis: Yeah, it's definitely beneficial and applicable day to day. I, I think there are some people in medicine who like really love being in the OR or they really love office work and the field of REI kind of satisfies all of my interests and I feel like it hits home for me on a daily basis also as a woman.
Rena: I love that you also say that it's about problem solving.
Danis: Yeah, I mean every day you're taking what you're seeing on ultrasound with hormone values and someone's history and putting together an explanation for like the current days where they are in their menstrual cycle or how they're responding to treatment, how they're not responding to treatment and coming up with a game plan and it's every day.
Rena: You know, I use the analogy of a puzzle often with my patients and I always say, okay, remember you know, everything you're doing is a piece of your puzzle. You know, science and medicine is all about collecting data. Nothing's ever a waste in this process. Everything is leading you to where you wanna go. So I love that you're sort of,
Danis: I also use that analogy.
Rena: Oh I love that.
Danis: Yeah
Rena: It's so helpful. You know, cuz I think a lot of times people, they look at sort of outcomes and it's, they only view, it's like a positive beta as the only good outcome. And so I always sort of help people try and reframe as like, no, you know, you got the cycle, we collected all this data. That's huge.
Danis: Also, it's easy to get fixated on like your cervical mucus or your ovulation kits or your menstrual history. But there's so much more to be obtained with an ultrasound plus blood work. And also someone's prior treatment performance. So there's so many different variables to look at.
Dara: Yeah, it makes it exciting that way. I'm sure every day looks different for you.
Danis: Yeah, I don’t know if it's cuz of like a short attention span, but I definitely need the variety in patients and like my day's routine all the time.
Rena: I love that. Okay. And so I know that you also, you've written a thesis about the use of, I'm not gonna pronounce this correctly, so please correct me the oral medication.
Danis: Elagolix.
Rena: Elagolix?
Danis: Elagolix.
Rena: Elagolix. Okay, I've not heard of that. I've not come across that in any STIM protocols. So what is that and what is it used for that's so new?
Danis: Well hopefully one day it will be a part of STIM protocol. So to backtrack, to do your art, to be a fellow in REI, you have to do 18 months of research and you have to do a thesis. So one of the research studies that I did, because in fellowship you're encouraged to do a lot of research, but what I'm most proud of is I got this grant from a pharmaceutical company, AbbVie. They created this drug Elagolix and it is an oral form of the injectable medication that we often use in stimulation cetrotide or ganorelix, depending on whatever insurance you're will cover it for you. And the way it works, it's an antagonist at GnRH receptors. So in your brain, in our pituitary gland, we have these certain types of receptors that will then stimulate this cascade of hormone release from your brain to your ovary. And that's how our menstrual cycles function. Now in the fertility world we use cetrotide or ganorelix and the reason why we need those to block these receptors in our brain - no one can see my head. I'm pointing to my head - is because we don't want the person to ovulate. So we don't want that surge of hormone. And so that's how it works. That's why we need these hormones to block LH receptors or GnRH receptors so we don't have the surge of hormones. Now kind of switching gears, there's a lot of female or GYN conditions that are related to hormones other than just your menstrual cycle. So endometriosis for example is a gynecologic condition. We think estrogen feeds it. It's a pain disorder associated with periods or something like fibroids where you have these muscle cells in our uterus where you can even have cervical ones too. And if you, we think estrogen fuels these fibroids. So for people with these GYN conditions we think okay well let's block the same receptors that we would typically give for like a fertility patient. Let's block them in our brain so that we don't make estrogen. So elagolix has been FDA approved for decreasing pain associated with periods in women with endometriosis. There's also other formulations other than elagolix that contain the same mechanism, but the purpose is to block estrogen production. The thought being that that's what feeds fibroids in endometriosis. So that was a very long winded explanation and I apologize if I was speaking quickly, but basically I wanted to know, okay, so we know that this medication works, right? We know it works for endometriosis but we need to block hormones in many other situations in life like infertility medicine or for emergency contraception. That's how plan B essentially you have this feedback loop so that you are not getting pregnant. So if I could prove that maybe elagolix can decrease hormones in other parts of the menstrual cycle, maybe we could use it in other cases like as an emergency contraceptive or to resolve elevated hormones related to if there was a cyst being produced before stimulation or could you even use it orally instead of these injectable forms. These were all of like my theories, but first I had to focus on does this oral medication, is it sufficient to work? Cause this data that we have, usually you start using it at the start of your period. So if you have fibroids or endometriosis, you're gonna start using it on the first one to three days of your period, which is convenient to, like, know what day you start. But it's also easier that way cuz your hormones are all at their baseline lowest value. So what if your hormones weren't at their lowest value? What if it was like right before ovulation or in your luteal phase when your progesterone level is high? Can this drug still work? So I did a pilot study and a pilot study is a fancy term for just, it's small. Usually I just had about 13 women enter at different phases of their menstrual cycle and they took the most common dosing was 200 milligrams bid. That's what's at the time was the most commonly studied dose. So I used that dose and I measured hormone values. I did the ultrasound measurements on people for four to five days in a row at different points of their menstrual cycle to see if this oral drug could work, could it suppress estrogen, could it suppress progesterone and inhibit ovulation or quicken the luteal phase if you took it in the luteal phase, meaning like would it cause a drop in your progesterone level fast?
Dara: And what did you find?
Danis: Yeah, so the luteal phase had a bit of mixed findings but for the most part it did work. So fortunately elagolix has a short half life. So also I should have mentioned I did follow people 48 hours after their last dose. So eagolix’s half life is about four hours. So it's short meaning, which is great cause then your hormones can go back up to their normal values and most people resumed their cycles. They got their first period anywhere from two to four weeks after they took their last pill. So it doesn't postpone ovulation for example, for a long period of time like a depo shot might. It's not as suppressive as like OCP usage for a long period of time. It did suppress ovulation in three fourths of my patients who took it in their later follicular phase. Like when if you started around day 10 of your cycle. Certainly worked for the people who took it at the start of their period, but we already knew that was probably gonna happen. And then for people who took it in their luteal phase, like around day 20, 22 of their cycle and this I will say I really tried to pay attention to how long my participant cycle lengths were. So not everyone has a 28 day cycle. And the longer or shorter your cycle is, that kind of shifts when you ovulate without getting into the nitty gritty of a menstrual cycle physiology lecture. But so it did in the luteal phase make people get their period faster. So it shortened the luteal phase, it caused a decrease in progesterone and had you start your period sooner, which would be really useful in the fertility world. Like let's say you wanted to start a cycle and you would assist or your progesterone was elevated and the timing just didn't work well then I could say okay, well instead of waiting until next week, what if I just gave this person elagolix for three days, suppress their hormones, and then started stimulation? That's where like the next step could be.
Dara: So there's lots of potential in starting a cycle a little bit earlier if need be. And then on top of that, if the medication was initially used for endometriosis and for pain, can that also have a, another effect, a positive effect for those patients?
Danis: Like if you had endometriosis?
Dara: Yes.
Danis: Yeah, I mean the problem with stimulation, ovarian stimulation, in women with endometriosis is that you want your estrogen levels to rise. So the purpose of elagolix in that situation probably would just be to, in an attempt to suppress your LH surge. Your estrogen level would still be climbing because you're having so much follicular growth and development. So I don't know, I feel like in women with endometriosis, they're in a tough spot when it comes to fertility care.
Rena: Dara I was actually wondering the same thing.
Dara: Yeah. I find it so fascinating, like medication that could be used for multiple purposes and sometimes like discovering, you know, another use for it, you know, for something that could be equally if not more beneficial. My thought also is if it has a shorter half life , perhaps some, some other medications, does that necessarily mean like perhaps is there less contraindications too or less side effects?
Danis: So the side effect profile for elagolix is pretty great. I mean if you look at phase three and phase four trials that were published in like 2019 or so in a very, very small number of patients, like they say to be cautious in women with liver issues cuz it might cause an increase in liver enzymes. Most women who are taking this are of reproductive age, so you're less likely to have liver issues or hepatic diseases. I would say one patient of the 12 that I had in my study reported some nausea, but it was also a heat wave in Los Angeles. So you know, multifactorial probably, yeah. But it's usually very well tolerated. There's many different doses too that you could take 150 milligrams once a day. It's not as efficacious as far as hormone suppression and that's been looked at in larger studies. But I think the potential for elagolix or just the oral form of a GnRH antagonist is endless in the field of women's health.
Dara: Sounds very interesting. I feel like you should be on this trend of continuity of research. I'm sure you'd like to work with more patients.
Danis: I, honestly, got a grant from AbbVie to do this. I would totally wanna do more. It was hard with minimal funds, no funds really, to recruit patients because I wanted to use patients live. I would love to get back into it. That's one of the great things about Mount Sinai honestly is that there's the fellowship and who knows where I'll take this. But it was an amazing experience. It was a lot of hard work every day, you know, drawing blood, scanning my patients or participants. But I loved it.
Rena: Well your passion and enthusiasm really comes across, so we're so excited to have you here. You're gonna be such an asset and I mean this is fascinating and it just, it's very clear how much you care about patients and this work. So it's so wonderful.
Danis: Also, it's one less shot that if like, let's say it could be used in case of ganorelix or cetrotide cause there's some studies out there that use Provera, which is an oral, progesterone-based medication to suppress ovulation or to suppress that LH surge during your STIM. So if elagolix could be used, I mean, who wouldn't say no to one less shot?
Rena: That is definitely, I do not think anyone would argue with that for sure.
Danis: Yeah. So one day maybe we'll be able to say elagolix can be added to your regimen.
Rena: Well that is fascinating. Do you have any goals for working at RMA and and starting here?
Danis: Well, I definitely wanna expand to Brooklyn. I think Brooklyn is an untapped but needy market for reproductive healthcare. As a young professional myself, a lot of people in my, I would say demographic pool live in Brooklyn and it's an untapped market. So I wanna definitely expand care to Brooklyn. Also, the fact that it's affiliated with Mount Sinai, I think lends itself. I naturally enjoy academia. I like teaching residents, med students, fellows. I do like engaging in research. And so I'm looking forward to just expanding my career for a more academic path.
Rena: Well I love that. We're so excited to have you here. So excited to work with you and love your goal of expanding Brooklyn too.
Danis: Yeah, I mean also it's a huge borough, but yeah, it's needed.
Dara: Well, we're very excited to have you on board and to see what's to come down the road with you.
Danis: Thank you. Thanks for having me.
Dara: Of course. I'm so happy that you're here and how we end our sessions is with words of gratitude. So Dr. Danis, what are you grateful for at this very moment?
Danis: Well, I am really grateful for joining RMA. It's a new chapter for me in many avenues of my life, but I'm really excited to start this new career opportunity. That's cheesy, but it's true.
Rena: Now you're speaking from the heart. I love it. It sounds exciting to start a new thing and to, you know, start a new job at a new place. So of course
We have a really great team, especially in Brooklyn. I'm with other female physicians. I think it's gonna be a powerhouse.
Rena: Definitely. You are definitely in good company there. That is for sure.
Dara: It's funny, I was thinking about, okay, what, what am I grateful for today? One of the things I was grateful for was having more women representation on the, you know, the RMA team. It's so nice. When I first started out, it was only male doctors and it's so nice to see a fabulous mix and also just like how far RMA, you know, has come in terms of expansion over the years. So definitely grateful for that. What about you, Rena?
Rena: I guess, let's see, I could piggyback onto that for sure. You know, grateful for new colleagues, new amazing women to work with. You know, Dare and I love meeting women. One of the things we always talk about is how, especially this podcast, allows us to meet, you know, a lot of other females, particularly in this space who are just passionate about this work and improving patient care. And so it's so wonderful to meet you and have someone else come on who feels the same way we do. So that's definitely a gratitude. And then the other one is that my dog. You guys saw her in the recording and she did not bark because it's been raining here. So she really needs to go out. But she's been very good. She did not bark and she also did not decide to use my rug as her litter box, which is always a thrill.
Dara: Definitely an important thing to be grateful of. And I also wanted to acknowledge, I believe this, by the time this airs, I believe this may be our a hundred and first episode. So I wanted to give gratitude for, you know, everyone, the team that's involved in this podcast and all of our listeners. The fact that we have made it to 101 episodes is pretty unbelievable. Who would've thought? You know, we're coming on almost say, I believe three years later that we are still forging along and disseminating interesting and, you know, wonderful information and you know, spreading so much information to everyone on various topics on fertility.
Rena: Yeah, I'm so glad you said that. And it's interesting, you know, we started pre pandemic and we used to record in an office, which I mean, frankly, I think this is recording via Zoom is so much easier for everybody. It used to be such a hassle to coordinate with people, have them come uptown. And this is so much more accessible. So I think that's also a pandemic positive. It's recording remote via Zoom has made it so much easier. So yeah, so I can't believe, yeah, 101 episodes.
Dara: Unbelievable.
Rena: Well, thank you everyone for listening, tuning in. And as always, reach out to us through our channels with comments or if you have ideas for guests, anybody that you want on, we are always, always open.
Dara: Thanks Dr. Danis.
Danis: Oh, thank you. And everyone stay dry.
Dara: Thank you so much for listening today. And always remember: practice gratitude, give a little love to someone else and yourself, and remember you are not alone. Find us on Instagram @fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.