Women's Health

Vitamin D and Women's Health

2009-11-04T12:53:00.000-08:00

One of the most interesting sessions of the recent 2009 North American Menopause Society discussed the impact of Vitamin D on health issues important to women. Did you know that low levels of vitamin D have been linked to breast cancer, colon cancer, ovarian cancer, high blood pressure, and strokes? This is in addition to the well established role that vitamin D plays in bone health. Condensing the most current research down to a practical level let's answer these questions:

• Is all Vitamin D the same?
• What are some common sources of Vitamin D?
• How much Vitamin D is recommended?
• How much of an impact does vitamin D have on female cancers?
• What about other health problems?
• Should I get my blood Vitamin D level tested?

Is all Vitamin D the same?

Vitamin D from sunlight, foods, and even vitamin supplements is not biologically active. It has to undergo two processes, the first occurring in the liver which converts vitamin D to the 25(OH)D form, also known as calcidiol or Vitamin D². The kidney then makes the most active form 1,25(OH)²D, also known as calcitriol or Vitamin D³. If you check your bottle of vitamins, or calcium + vitamin D supplements, you can see which type you have been taking. Currently the preferred supplement form may be Vitamin D³ as it increases the amount of active Vitamin D while increasing the time Vitamin D is active in the blood and tissues.

What are some common sources of Vitamin D?

Vitamin D is made when UV-B rays strike the skin. One general recommendation has been to have 20 minutes of sun exposure to face, arms, leg or back twice a week during the most intense times for sun exposure (i.e., 10:00 AM through 3:00 PM). Alas, the amount of Vitamin D that can be obtained this way can be limited by several factors. If one has dark skin, uses an 8 or greater SPF sunscreen, wears occlusive clothing, or gets sun exposure only through window glass-the amount of Vitamin D is greatly decreased. If one lives above the 42nd parallel, the months of November through February do not produce sufficient Vitamin D even when the sun is not hidden by clouds. Cloud cover, shade, and air pollution will further reduce the amount of UV-B.

Many of us prefer to get vitamins naturally from whole foods as opposed to supplements. Some of the highest sources of Vitamin D are listed below:

Cod liver oil, 1 tablespoon	1360 IU
Cooked salmon, 3.5 ounces	400 IU
Sardines in oil, drained 1.75 ounces	250 IU
Tuna in oil, drained 3 ounces	200 IU
Vit D fortified orange juice, 1 cup	142 IU
Vit D fortified milk, 1 cup	98 IU
Vit D fortified yoghurts, 6 ounces	80 IU
Egg yolk, 1	20 IU

For comparison, the usual amount of Vitamin D in a multivitamin pill is 400 IU (International Units).

How much Vitamin D is recommended?

Since the 1930's, when milk was first fortified with vitamin D to prevent rickets, the usual recommendation has been 200 IU to 400 IU daily during times of inadequate sun exposure. Women above age 50 should be receiving 400 IU to 800 IU. Recently, experts in the area have been lobbying for a new recommended level of 1000 IU daily among adults (Vieth, 2007). The Food and Nutritional Board at the Institute of Medicine began reviewing the published studies in 2008 and are expected to publish new guidelines in spring of 2010.

For comparison, the upper tolerable limit (adverse results begin to appear) has been reputed to be 2000 IU/day. Many researchers in the field have suggested that the toxic level is closer to 10,000 IU/day over a more prolonged period of time.

How much of an impact does Vitamin D have on female cancers?

Breast Cancer
Given what you now know about the different types of Vitamin D and the different amounts used by women you can appreciate the difficulties in trying to establish the clear cut role of Vitamin D in cancer prevention. In the most recent, largest study (meta-analysis) of Vitamin D, calcium and the prevention of breast cancer (Chen, 2009), both Vitamin D and calcium seemed to be protective for the development of breast cancer. The best results were among women with the highest intakes of Vitamin D and calcium as compared to the lowest levels of consumption. The top quarter of women having the highest blood 25(OH)D levels had a 45% decreased risk of breast cancer.

Another study of 562 women (Rejnmark, 2009) found that the 142 women with a diagnosed breast cancer had, on average, lower blood levels of 25(OH)D. Women with the highest levels of 25(OH)D had a significantly reduced risk for breast cancer. Surprisingly, use of Vitamin D supplements, sunbathing, and fish intake did increase blood levels of 25(OH)D-but the lifestyle factors did not directly impact the risk of breast cancer.

Conversely McCullough and colleagues (2009), studying almost 22,000 women, found no impact of blood levels of 25(OH)D on the risk of breast cancer. A study of almost 42,000 Swedish women (Kuper, 2009) did not identify linkages between breast cancer risk and sun exposure, nor Vitamin D intake through diet or multivitamin use.

Ovarian Cancer
The impact of Vitamin D on ovarian cancer has not been as well studied but it has been purported to have a protective effect. Researchers at the Channing Laboratory (associated with Harvard University) used data from four large studies to examine the effects of Vitamin D (Tworoger, 2009) on ovarian cancer. It was determined that blood levels of Vitamin D did not directly impact cancer risk from any of the four genotypes. However, a specific type of the Vitamin D receptor gene was significantly tied to ovarian cancer risk.

What about other health problems?

Colon Cancer
Several studies have found that blood levels of 25(OH)D could be predictive of colon cancer risk. More recently Ng (2009) and fellow investigators looked at both risk for getting colon cancer, and the ability to survive, as it related to 25(OH)D blood levels among 1017 persons. Participants in the top quarter of 25(OH)D levels, as opposed to the lowest quarter, had significantly less colon cancer. They also had the lowest death rates from colon cancer, and the lowest rates of over all mortality.

Cardiovascular Disease
In Finland a 25-30 year study of over 6,000 persons found an increased risk of fatal vascular disease in those who had the lowest blood levels of 25(OH)D. Interestingly, this relationship was apparent for the incidence of strokes but not heart attacks (Kikkinen, 2009). Proposed mechanisms for improved blood vessel health include Vitamin D's beneficial impact on high blood pressure via kidney hormones, decreased inflammation inside the arteries, and improved insulin resistance via changes in parathyroid hormone (Lee, 2008).

Depression
There have been studies suggesting that high dose supplements of Vitamin D, or fish oil supplements, may improve mild depression. Jorde (2008) noted an improvement in scores on the Beck Depression Inventory after a year of supplementation with 20,000-40,000 IU per week of Vitamin D as compared to placebo. This was a study of overweight and obese subjects, not persons with diagnosed depression. At this point, treatment with high dose Vitamin D for depressive symptoms is considered experimental and should be considered only with medical supervision.

Systemic Lupus Erythematosus (SLE) & Rheumatoid Arthritis (RA)
Vitamin D has found to have effects on immune function and inflammation. Earlier studies suggested a relationship of Vitamin D to autoimmune conditions. A group of women within the Nurses Health Study was targeted with food and vitamin questionnaires. There was no apparent association between increasing Vitamin D intake and the risk of developing these autoimmune disorders (Costenbader, 2008).

Should I get my blood level of Vitamin D checked?

As with many blood tests (e.g., hormone levels) there can be considerable variation in results from lab to lab, time of day or season (e.g., Vitamin D levels tend to be best at the end of summer). Perhaps the best indicator of general Vitamin D levels is 25(OH)D blood test for it measures Vitamin D from both sun and dietary sources. This form of Vitamin D also lasts in the body for around 30 days.

In many cases the "normal" or preventative level of Vitamin D has yet to be determined. Cardiovascular risk begins to rise steeply when the blood level of 25(OH)D is below 10-15 ng/mL. Optimal levels may be at least 30 ng/mL. Depending upon all other factors present it might take a daily intake of 1000-2000 IU per day get to blood levels of 30 ng/mL (Giovannucci, 2009). The following blood 25(OH)D levels are taken from an updated National Institutes of Health document:

Blood level		Health Status
Ng/mL	nmo/L	Health Status
<10-15	<25-37	Consistent with rickets, low bone density, poor health
>15	>37.5	Adequate for healthy persons
>200	>500	Potentially toxic

Some Vitamin D researchers have stated that most benefits level out at blood levels of 30-40 ng/mL (Giovannucci, NAMS 2009). It will remain to be seen if the new recommendations due to be published in May of 2010 will have different cut off levels for defining optimal blood levels.

So, who should push for blood testing? Bearing in mind that the 25(OH)D blood test can cost upwards of $200, many primary care providers have chosen to just recommend an increased intake of Vitamin D. The dose is based upon the person's specific health history. Until there are studies set specifically to establish optimal dosage and blood levels the primary care model makes sense. Among healthy adult women, without excessive sun contact, consuming 800 IU per day of Vitamin D is a reasonable choice. For your specific Vitamin D recommendation, check with your GYN or primary care provider.

If you are interested in more information, the following site offers an excellent overview, especially of the effects of Vitamin D on specific health conditions:

http://dietary-supplements.info.nih.gov/factsheets/vitamind.asp

Stay tuned for a discussion of the newest recommendations when they are released!

My Female Organs Are Falling Down

2009-10-19T09:00:00.000-07:00

Have you ever looked "down there" with a mirror (or had a lover say to you) that there seemed to be a "bulge" or "ball of tissue" at the vaginal opening? The medical name for this condition is pelvic organ prolapse (POP). POP is purported to effect up to 50% of women who have had a vaginal delivery (Maher, 2008). In other studies of women in general, rates of POP with marked symptoms are reported to be 3.6 - 6%.

The first concern is that one's uterus, or other pelvic parts, might be falling out. In one of the more severe forms of POP the uterus can drop so far down into the vaginal canal that the cervix will scrape against the woman's underpants! Fortunately this is one of the least common forms of POP. So if you were to see a "bulge" of tissue what is that likely to mean to you? The goal of this blog is to share facts about the types of POP, the risk factors, and what treatment options you might have if POP seems to be linked to other, bothersome symptoms.

How do I know what type of prolapse I have?
When you go see your GYN or clinic you might expect questions about: urinary or bowel incontinence, difficulty emptying the rectum, or sexual problems. This can suggest areas which are involved with the "bulge". An exam should be done with you standing and/or bearing down when you are on the exam table. If loss of urine is a concurrent problem then a urinalysis may be done along with a Q-tip test and/or a measure of urine left in the bladder after you have go to the bathroom.

There are several types of prolapses. When the upper part of the vaginal canal loses its muscle tone or attachments holding the vagina up (especially common among women with hysterectomies) that is called vaginal prolapse. If muscle support is poor, or interrupted, the bladder can prolapse down through the "roof" of the vagina causing a cystocele. The urethra may drop down as well (urethrocele). If the weakness is in the "floor" of the vagina the rectum can bulge upward. As was mentioned above, the uterus and cervix can slump down through the vaginal canal.

What are the risk factors for pelvic prolapse?
The most consistently cited risk factors are: increasing age, being overweight, and increased number of vaginal deliveries. Number of deliveries by C-section does not increase prolapse risk (Luckacz, 2006). Other associated factors can include irritable bowel syndrome, constipation, and overall poor health (Rortveit, 2007). African American women are less likely to have symptomatic pelvic prolapse (Rortveit, 2007). One small study even found that having a history of stretch marks doubled one's risk for prolapse (Salter, 2006).

"Stretch marks," you might be thinking "why would that be?" The bones of the female pelvis do a great job protecting lower abdominal contents, but they do not provide support. The pelvic organs are supported by the muscles in the pelvic floor and the ligaments which can attach from the organs to the bones. It has been theorized that pelvic muscle and ligament strength may be linked to strength of collagen. Collagen, along with fibrillin, is decreased in women with stretch marks (Mitts,2005).

What can be done if I have a mild form of prolapse, or do not want to have surgery?
According to the American College of Obstetrics and Gynecology (ACOG, 2007): "Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse." A pessary is a doughnut shaped device which can be made of various materials. There are also pessaries shaped like a cube, and similar to a shoe horn. If one has ever used a diaphragm for birth control, inserting and removing a pessary may seem familiar. Like a diaphragm, a pessary should be fit by a GYN as they come in different sizes.

Kegel exercises have been recommended for POP but, unlike urinary stress incontinence, there are few large studies demonstrating the effectiveness of Kegels. According to one recent study of 48 women, pelvic floor exercise/Kegels significantly improved symptoms of prolapse (Hagen, 2009). Kegels may not be as successful as they are with urinary incontinence for once the attachment ligaments are damaged, strengthening the pelvic muscles may not fix the prolapse.

What about surgery?
If one has a prolapse of the uterus, hysterectomy may be suggested. Care is taken to refasten the top of the vaginal canal to other structures so it does not droop down after the hysterectomy.

If the prolapse is coming from the top or "roof "of the vagina, pelvic fascia tissue can be used to bridge the weak area. If the prolapse is coming from the lower or "floor" of the vagina (causing a bulging of the rectum into the vaginal canal), the rectal muscles can be used to close the defect.

More recently synthetic mesh has been used to support the weakened areas. Mesh has been used extensively for repair of abdominal hernias. Overall, the use of mesh seems to decrease the reoccurrence of cystocele when an anterior ("top") of the vagina repair is done (Maher, 2008). The primary concern for mesh is that long term follow up in large numbers of POP women is lacking. Cases of the mesh eroding through vaginal tissues have been reported (Altman, 2007). By October of 2008 the FDA released a notification to GYN surgeons relating adverse events connected to mesh use as reported by manufacturers of different types of mesh. Some of these unwanted events included erosion, infection, and pain. Not surprisingly, the strength and health of the woman's own tissues will have an impact. Her own tissues will have to be incorporated into the mesh to form a strong bond.

In one study of 2,460 of women in their 50's, about 3% of women reported having surgery for POP (Fritel, 2009). Further, women who had such symptoms of POP as problems having a bowel movement or urinating, and abdominal pain reported a much lower quality of life than other women. In one very large study (Barber, 2009), 85% of women considered themselves "much better" when compared to before their surgery. Bottom line, surgery of some type can be very helpful if a woman has symptoms from her prolapse.

My mom and her sisters had prolapse; can I do anything to prevent it happening to me?
We cannot change our genetics, age, or number of vaginal births! Sadly there are not many scientific studies testing different forms of POP prevention. The strategies for prevention that are most often suggested include:

Kegel exercises up to four times daily. The hope is that by strengthening muscles in the pelvic floor that those muscles can help delay, or reduce, the onset of prolapse. For information about how to do Kegels correctly check out this article: Kegel Exercises - Topic Overview

Physical exercise. Regular exercise can help keep one's body weight down, and being overweight is linked to prolapse. Exercise is also reputed to keep muscles and ligaments more flexible.

Decrease straining to have a bowel movement. Constipation, or having to bear down, increases pressure in the abdomen which "pushes down" on pelvic organs. Eating a healthy diet with whole grains, fruits, and vegetable not only helps constipation, but can improve body weight.

Treat chronic coughs. If one is a smoker - quit. If there is another reason for a chronic cough - have it treated. A cough increases the pressure inside the abdomen which can "push down" on pelvic organs. There are studies linking smoking with poorer tissue integrity after POP repair (Araco, 2009).

Use a correct technique for heavy lifting. Straining to lift increases pressure within the abdomen. Here is a good over view of safe lifting: Back Problems - Proper Lifting

Hysterectomy surgery considerations. If one is having a hysterectomy there are studies which suggest that attaching the uterine ligaments to the top of the vagina may help to keep the vagina from dropping down (Yazdany, 2008).

If you would like more information about pelvic prolapse, consider checking these articles:

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Test Your PAP Smear IQ

2009-10-05T14:40:00.000-07:00

The first PAP smears were done over 60 years ago! Within the past decade we have seen the development of a vaccine reported to reduce the risk of cervical cancer, the widespread use of liquid based PAPs ("PAP in a bottle"), human papilloma virus (HPV) testing, and altered recommendations about when to do a PAP smear. So sharpen your pencils and test your PAP Smear IQ! Correct answers and scoring follow this "PAP Quiz"

The time to begin getting PAP smears is either age 18 or shortly after you first have sex.
True/False

A PAP can diagnose sexually transmitted infections such as gonorrhea or Chlamydia.
True/False

Most forms of cervical cancer can be linked to the HPV virus.
True/False

If I get the new HPV vaccine I don't need to get PAP smears.
True/False

By age 30, if a woman has had three, consecutive, normal PAPs she can drop down to PAP smears every two to three years.
True/False

If a woman was exposed to the drug DES before birth, has HIV, or depressed immune function (e.g., on organ transplant drugs) she can now defer her PAP smears to every other year.
True/False

About 50% of women with cervical cancer in the US had not had a PAP within the past five years.
True/False

DNA tests for HPV are better able to discriminate the really worrisome cell changes than a PAP smear.
True/False

The newer liquid based PAP smears are definitely better at identifying abnormal cells.
True/False

Once you have had a hysterectomy you can stop getting PAP smears.
True/False

ANSWERS

False. This was true seven to nine years ago, but newer studies have suggested that HPV infections (linked to abnormal PAP smears) tend to resolve in younger women. This may be due to better immune system function which fights off the HPV more effectively. The recommendation to wait until three years after starting intercourse is based upon the hope that many HPV infections will be spontaneously cleared. Also, abnormal cervical cells do not progress quickly to cervical cancer - especially within three years.

One well done study by Ho and colleagues (1998) followed older adolescents over three years. At the end of the study some 43% became HPV positive. This confirms the ease with which HPV can be passed between sexual partners. Surprisingly, of this group of newly infected women, only 9% continued to show persisting evidence of HPV.

For women who have been assaulted or sexually molested while very young, it is important that they get a PAP smear earlier. If the assault was in childhood, she should get a PAP as a teenager for there are several factors which place her at increased risk for abnormal PAP smears.

False. A PAP smear examines cells from the face of the cervix and the cervical canal. It does not diagnose chlamydia, gonorrhea or other sexually transmitted infections. A special test for HPV (considered a sexually transmitted infection) can be done using liquid left after doing a liquid based type of PAP smear.

True. Most forms of cervical cancer have been linked to HPV. Particularly strong links exist between the high risk subtypes of HPV (e.g., subtypes 16 and 18). There are more than 30 types of HPV which are sexually transmitted. These have been classified into "low risk" and "high risk" subtypes. HPV subtypes 6 and 11 are considered to be low risk. They are linked primarily to the cauliflower-appearing genital warts, and low grade cervical lesions (e.g., LGSIL, CIN 1). Subtypes 16 and 18 are considered to be high risk as they are linked with persisting HPV infections and severely abnormal PAP smears. These two high risk subtypes are the probable cause of about 70% of cervical cancers.

False. If one gets the newer vaccine designed to decrease the risk of cervical cancer, one is protected from HPV subtypes 16 and 18. One of the two versions of the vaccine will provide protection from subtypes 6 and 11 as well. Both vaccines have been shown in large research studies to provide 100% protection for the high risk subtypes. However, the vaccine does not cover all HPV subtypes (e.g., HPV subtypes numbered in the 30's) which have been linked to persisting abnormal PAP smears. This is why PAP smears are still recommended even in those who have had the HPV vaccine.

True. Between the time one gets her first PAP smear and age 30 or so, she should get PAP smears every one to three years. Then, if she has had three normal PAP smears in a row, she can drop back to PAP smears every two years or so. Once one is over the age of 30, a GYN may order an HPV test on her cervical cells. If the HPV test is positive it will likely be repeated within the next 6-12 months. A persisting HPV infection is correlated to abnormal cell changes-even if the PAP smear seems normal. By contrast, a normal PAP smear result coupled with a negative HPV test result suggests that cervical cancer is unlikely to emerge over the next several years.

False. Unfortunately, women exposed to DES, or those who have conditions which suppress the immune system (e.g., HIV, organ transplant drugs) still need to have yearly PAP smears. Women whose mothers took DES while pregnant have an increased risk of an unusual type of cervical/vaginal cancer. Women with blunted immune system function are less likely to be able to clear HPV infections (new or old).

True. Therefore it is important not to be lax about getting PAP smears within the required interval for your age. It should also be noted that some of the women who were found to have cervical cancer had NEVER had a PAP smear.

True. DNA based tests for HPV are better at discriminating high grade cervical lesions than PAP smears. HPV test have a high degree of sensitivity (ability to detect HPV) of 94.6%. This is compared to a conventional PAP smears had a 55% sensitivity (Mayrand, 2007). However it costs more to do HPV testing, and more importantly, has a lower specificity (more "false positives").

False. Initially, most all studies reported liquid based PAP smears had a better ability to detect abnormal cervical cells. Currently over three fourths of PAP smears done in the US use this method rather than conventional PAP smears where a spatula collects cells which are smeared on a glass slide. There are other advantages of the liquid PAP method such as the ability to use leftover liquid if the GYN wants to order an HPV test as well.

Recently Ronco and associates (2007) studied 45,000 Italian women, and determined that both liquid based and conventional PAP smears were equal in their ability to detect CIN 2 or higher. These are the more worrisome cervical cell changes. The liquid based PAPs were able to pick up more CIN 1 (less concerning), as well as decrease the number of unsatisfactory specimens.

True & False. This was not meant to be a trick question. Whether one continues to need PAP smears after hysterectomy depends upon the reason for hysterectomy and the type of hysterectomy done. If the uterus and cervix were removed for a non-cancer condition (e.g., fibroids, endometriosis, abnormal bleeding) there is no need to continue getting PAP smears.

By contrast, if surgery left the cervix in place (even if the hysterectomy was for benign reasons) PAP smears must be continued until the usual time of discontinuation (e.g., age 65-70). If the uterus and cervix were removed in a woman with CIN 2-3, she should have PAPs for a minimum of ten years after the surgery. For women who have had removal of cervix and uterus for a cancer, a PAP smear of the back wall of the vagina should be done until the woman is in frail health.

So tally up your score of correct answers and give yourself a grade:

100% - You probably work in a GYN office!
90% - You could work in a GYN setting.
60%-80% - Your PAP smear knowledge is way ahead of the average person.
Less than 60% - Having learned more you can now educate your friends.

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Mysteries of Birth Control Pills Solved!

2009-09-01T10:07:00.000-07:00

While most every birth control pill (BCP) user is familiar with information usually found in BCP package inserts and patient handouts, there are some questions which take a detective to answer. For that purpose I'm putting on my "Nancy Drew, Girl Detective" hat to share with you the answers to the following mysteries of birth control pills:

Am I ovulating at mid-cycle when on my BCPs?

Am I protected during my week of sugar pills?

When will my cycle return?

When will I be able to conceive?

Which of my lifestyle choices might impact BCP effectiveness?

Midcycle ovulation should not be happening on birth control pills.
One of the most important ways that BCPs protect against unintended pregnancy is by suppressing ovulation. The most commonly used BCPs contain both synthetic estrogen and synthetic progesterone ("progestin"). Both types of hormones work to suppress development of follicles and the dominant follicle which was intended to ovulate. This is why BCPs are sometimes prescribed to help prevent growth of ovarian cysts. In one study (Egarter, 1995) 97% of women on birth control pills did not ovulate at any time in their pill pack. Interestingly, the two women who did have evidence of ovulation did not become pregnant.

By contrast, among women who use the progestin only "mini pill," only 29% did not ovulate (Tayob, 1986). Remember that the progestin only mini pills have no synthetic estrogen, and their doses of synthetic progesterone are very small. Pregnancy is prevented by other, additional mechanisms such as thicker cervical mucus and thinner lining of the uterus.

You should be protected during the placebo week of sugar or iron containing pills.
The suppression of ovulation described above is based upon the long "half-life" of synthetic estrogen and progestin. The two hormones were designed to last a longer time before being broken down than their "natural" counterparts. This increases contraceptive protection so that missed, or late pills, do not leave an opportunity for accidental pregnancy.

You may have been told, when starting BCPs for the first time, to take the first pill on the first day of your period-rather than waiting until the first Sunday. This is to provide better suppression of ovulation right away. In the "start your new prescription on the first day of your period" regimen, a woman will not need to use a back up method (e.g. condoms). Once the BCPs are started, one simply takes an active or sugar pill every day. They will be protected during the placebo week.

One study of 99 women (Elomaa, 1998) the women were asked to deliberately start their new pill pack three days late. This would create a ten day vacation off the hormones. Ultrasounds of the ovaries and blood hormone levels were taken. While many women showed enlarged follicles in the ovaries, no one actually ovulated. Thus suppression of ovulation may actually extend beyond the recommended seven days of sugar pills. However, as lower doses of synthetic estrogen are used (e.g. 20 micrograms), it becomes more likely that a dominant follicle might actually ovulate (van Huesden, 1999). In summary, to provide the widest protection to the greatest number of women, we still say protection is best when seven days (or less) of placebo pills are used.

Spontaneous periods should resume within 90 days.
Among 187 women using continuous BPCs (Lybrel) for one year, periods resumed most frequently only 32 days after the last BCP was taken. The incidence of spontaneous periods and/or pregnancy was 98.9% within three months of stopping BCPs. In this study (Davis, 2008) the time to return of periods was not related to duration of missed or very light flows while on Lybrel.

Lybrel is a very low dose BCP. If one is using a higher dose BCP the return of periods MIGHT take longer. This is especially true if you had a history of missed or irregular periods before starting to use BCPs - although some women with previously normal periods can have a delay in restarting as well. The incidence of no periods for six months after stopping BCPs ("post Pill amenorrhea") is probably less than 1%. Also, delay in return of menses does not seem to be linked to length of usage nor brand of BCP (Huggins, 1990)

Generally, if a woman has not resumed natural flows by six months after stopping BCPs it is time to get follow up with a GYN.

Within 12 months of stopping BCPs, conception rates are the same as untreated women.
In women using a very low dose, continuous BCP (Lybrel), the rates of conception were followed after they stopped their Lybrel. It took 57% three months to conceive, 81% twelve months to conceive, and by thirteen months 86% had conceived. (Barnhart, 2009).

This compares favorably to pregnancy rates among the general population where 57% have conceived within three months of trying. By twelve months of unprotected sex 85% of women will have conceived.

Both smoking and drinking can have a theoretical impact on BCPs.
Most women are aware that combining smoking and BCPs can increase the likelihood of blood clots in the arms, legs, lungs, heart (i.e. heart attack) or even the brain (i.e. stroke). But did you know that smoking cigarettes can actually lower blood estrogen levels? Among women smokers using postmenopausal hormone therapy, it may take higher doses of estrogen to get the same effects as seen in non-smokers. (Transavatdi, 2004). Nicotine can decrease blood estrogen levels whether in a BCP user or a condom user. This effect is thought to occur starting at about one pack per day. The concern is, among low dose BCP users, the blood levels of estrogen may not be high enough to suppress ovulation.

Given the known risk of clots in blood vessels, and the theoretical concern about reducing active hormone levels, one should consider quitting smoking if they use BCPs.

In one large study of over 17,000 women, women who consumed the equivalent of 8 oz of wine or 12 oz of beer had higher blood levels of several types of estrogens (Onland-Moret, 2005). None of the women studied were using hormones, but it is presumed that hormone users may show similar effects where alcohol increases estrogen levels.

Another study looked at the effects of using either grapefruit juice or herb tea to take a 50 microgram dose of synthetic estrogen (the type found in BCPs). Grapefruit juice, when used to take the estrogen pill, increased both the levels of estrogen and the duration of its effects. The herb tea did not show this result. It was postulated that the grapefruit juice inhibited the metabolism of the estrogen thus increasing estrogen effects (Weber, 1996).

Are you curious to know more about the various types of BCPs?
While your own GYN or family planning clinic are the best sources of individualized advice, you can learn more fascinating facts about BCPs from this great overview at WebMD: Comparing Birth Control Pill Types: Combination, Minipills, and More.

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Postcoital Bleeding

2009-07-31T06:44:00.000-07:00

Whether the "wet spot" on the bed after sex turns out to be blood, or there is spotting on toilet paper when you wipe, bleeding after sex is a disconcerting climax to intimacy. There are two basic culprits that can cause bleeding after sex (also known as postcoital bleeding or PCB). The first potential problems are with the cervix. The second tier of possibilities encompass things that cause bleeding from the lining of the uterus.

Bleeding from the Cervix

Bleeding coming from the cervix could come from a cervical lesion – if one has had a recent normal PAP smear this is thought to be unlikely. One study found that only 49% of British gynecologists will do a repeat PAP if the woman with bleeding after sex has had a recent, normal PAP smear (Alfhaily, 2009). However, several studies from colposcopy clinics have found, even with a normal PAP, women with postcoital bleeding did have abnormal cells of the cervix. The rates for abnormal cervical cells ranged from 2.2% of high grade SIL (Ray & Kaul, 2008) to 9% of CIN (Khattab, 2005). The rate of actual cervical cancer was reported by Khattab to be 3.6%!

An infection of the cervix (cervicitis) can make the cervix more friable (easier to bleed). Both Gonorrhea and Chlamydia can produce bleeding from the cervix. Some 80% of British gynecologists report doing a Chlamydia screening on their patients with PCB. Thus, Chlamydia may be picked up by a primary care MD or GYN. By the time a woman is referred for colposcopy, only 2.3% of bleeding episodes after sex were linked to Chlamydia (Sahu, 2007).

In some women there is a normal enlargement of the area of glandular type tissue (cervical ectopi). These women can have bleeding even when the cervix is sampled with a PAP smear. Some common causes of cervical ectopi can include: being a young teenager, using birth control pills, or being pregnant. Studies have found that cervical ectopi can be the cause for bleeding after sex in 25% to 33.6% of cases.

A polyp coming from the cervical canal may bleed only when the cervix is touched. This could include sex toys, fingers, or a penis. Cervical polyps may account for 5% to 12.5% of bleeding after sex. Fortunately, most cervical polyps of this type can be readily seen during a speculum exam.

Bleeding from the Lining of the Uterus

If the uterine lining (endometrium) is easily destabilized, having sex can prompt spotting or breakthough bleeding. Some women will have this type of spotting if sex occurs during ovulation or right before menstrual flow is ready to begin. Women using hormonal forms of birth control may also have less stability of the uterine lining. Many birth control pill users have noted breakthrough bleeding after sex or even heavy exercise.

The same infections (eg Gonorrhea, Chlamydia) that infect the cervix can also infect the lining of the uterus. Infections of the uterine lining can make it easier to destabilize causing erratic bleeding as well as bleeding after sex.

Endometrial polyps or uterine fibroids can create a focus for unstable uterine lining. Additionally, some women with adenomyosis (endometriosis in the wall of the uterus) report bleeding after sex.

As WebMD readers know, if a woman has a history of missed periods, her uterine lining may be very thickened. In that situation, spotting after sex can represent small amounts of the lining being shed – just off the top layer.

Last, but certainly not least, pregnancy needs to be ruled out. Other, less common causes for bleeding include small tears in vaginal tissue. This would be most often seen in a postmenopausal woman who is not using estrogen-especially if she is resuming sex. If the spotting is after the first time having intercourse (losing your virginity) there can be spotting from tissues at the vaginal opening.

Could this bleeding after sex be no big deal?

Having heard about all the possible causes of bleeding after sex one would think that a culprit could be found to explain the bleeding. I was surprised to learn that, in three separate studies, about 50% of women evaluated showed no obvious reason for the bleeding! In each of these three studies women received thorough evaluations including colposcopies. However, given the multiple causes of bleeding after sex, one should go see a GYN if the spotting persists or is recurrent. When all the possible causes have been ruled out, then you might be one of the 50% where there is no pathological reason for the bleeding. Until a work up has been done, I would suggest that bleeding after sex is not a symptom to be ignored.

Vaginal Weights for Stress Incontinence

2009-07-27T08:06:00.000-07:00

Q: I leak urine when I laugh, sneeze or jump. A friend told me that vaginal weights can help with this, but it seems sort of weird. Are they really effective?

A: About one in three women leak urine after giving birth. This is called "stress incontinence" and it's due to weakened pelvic floor muscles, allowing for the neck of the bladder to "sag down" so that urine can escape with laughing, coughing, or sneezing.

Most doctors tell women to do Kegel exercises to strengthen their pelvic floor muscles. In some cases, surgery is required. But studies have also shown that vaginal weights can strengthen the muscles enough to reduce incontinence as well.

Here's how they work: You insert a cone-shaped weight into your vagina and then work on squeezing your muscles to keep the weights in place for about 15 minutes, once or twice a day. (You can actually go about your daily business while doing this!) Once you're able to hold this weight in easily, you try a slightly heavier weight (they are sold in sets).

Advocates of the weights believe that it's easier for a woman to learn to isolate and train her pelvic floor muscles properly using the weights than it is using just Kegels, which are easy to do incorrectly.

You can get vaginal weights over-the-counter, on-line, or as a prescription, via your health care provider.

The first published study on vaginal cones for urinary stress incontinence was published in 1988! While only 30 women completed the full month of using the cones, the results were amazing. Originally scheduled for surgery for stress incontinence, 63% of the women felt cured or improved enough to cancel their surgeries.

Now, after over 40 additional studies, the results are some what more measured. While some studies show the cones to be superior to pelvic floor muscle training using Kegel exercises (Arvonen, 2001), others have not (BØ, 1999). A critical evaluation of all trials done with cones was published in 2001 as a part of the famous Cochrane Database System Review. This excellent summary found the following:

Cones were definitely better than no treatment.
No significance was found between cones, Kegel exercises, and electro-stimulation of the pelvic floor muscles in their effectiveness.
There is not enough evidence to show that combining cones plus Kegels gave any better results than any single treatment.

Generally most healthcare providers will adhere to a recommendation given by the Cochrane Review. But if you are a woman considering the use of weighted vaginal cones here are some additional things to think about.

First, one really needs to be sure that they have stress incontinence. Cones may not be as successful with other types of urine leakage.
Second, there may be better results among women who can advance to using the heaviest cones vs the lightest.
Third, like different forms of birth control, one type of pelvic muscle strengthening may work better for you than your friend.

With some 5% of younger women, and almost 50% of elderly women, having symptoms of stress incontinence we should be able to access as many effective treatments as possible. Your best bet is to see your own MD or GYN to confirm that the urine loss is from stress incontinence. Then investigate your options as to cost, convenience, and preference. Weighted vaginal cones may be an excellent choice for you.

All About Breasts

2009-06-04T16:35:00.000-07:00

My Breasts Don't Look Normal. Is Something Wrong?

Given the breast centered focus of western civilization it's no surprise that many women are critical of the size and shape of their breasts. But what if something is truly abnormal about a young woman's breasts - would she know it? The purpose of this post is to try and address what is within the range of normal for breast appearance - and what may not be.

Age Matters
What is too early for the beginnings of breast development? Many mothers would be surprised to hear that breast development is not considered premature if it appears in African American girls by age of seven, or in other girls by age eight! Mothers then worry about the development of premature/precocious puberty (full breast development, menstrual periods, etc). Fortunately 80% of early-developing girls will not come fully into puberty. In fact, breast development may halt, only to reappear at the more usual time.

So what is the usual time to be "developed"? Lack of any breast development by age thirteen merits some monitoring. The small, firm breast buds usually appear about age eleven. By age thirteen a majority of girls have the beginnings of a mound-shape of breast tissue. Unless there is an overt reason for lack of development such as illness, radiation exposure, or hormonal problems there is evidence that breast development can continue until one's early 20's.

Size Might Matter
While most all of us have at least some difference in size between our two breasts, there are situations where the size difference is very apparent. Size differences which onset in teen years will likely equalize for about 75% of women.

Very large breasts can develop in teen women. This can occur on just one side or be bilateral. In this instance normalization of size is unlikely to happen. While a tumor can prompt a very large breast, most enlargement is related to a robust tissue response to normal hormonal influences. According to DeSilva (2006) there is no increased risk for breast cancer among young women with an extremely enlarged breast. Cosmetic surgery, if indicated, can be done. Reduction of a very large breast(s) is called reduction mammoplasty. Unlike breast augmentation (i.e. breast implants) there is usually more apparent scarring.

Conversely, there can be insufficient breast development on one or both breasts. One type that seems to cause particular distress creates a tall tube shaped breast. There is tissue growth under the nipple, but no rounded breast mound. Again, plastic surgery is the usual treatment.

Extra Nipples?
Having extra nipples has been reported in 1-2% of women. The line along which extra nipples are usually found extends from the armpit to the groin. Extra nipples do not usually have associated breast tissue so they may go unnoticed. A woman may think that the "accessory nipple" is a mole or other skin lesion. These do not have to be surgically removed unless, like a mole, they become inflamed by restrictive underwear or clothes.

Hormonal Medications
It has been noted that women using birth control pills may experience bilateral breast enlargement. This has been attributed to the hormone estrogen. A similar effect can occur in older women using post-menopausal hormonal therapy. Usually this is not a lasting effect, and size goes back down when the medication is stopped.

Previously, medications which block estrogen effects were tried as a treatment for too early or excessive breast development (Bloom 2008). This is not a standard treatment, however.

Breast Enlargement Options?
There are breast enlarging creams and herbal products advertised on the internet. As new products are touted, our Women's Health Board gets a spate of questions about the effectiveness of such products. The array of products includes pills, creams, devices, and even a chewing gum! I would concur with the review article written by Dr. A. Fugh-Berman (2003) published in the journal Obstetrics/Gynecology. She investigated many of the herbal ingredients touted to increase breast size. A few ingredients have the possibility of producing weak estrogen-like hormones. Yet most have no data to support their use for breast enlargement. Perhaps most concerning is there are no long term safety studies. In the real world, women may not use such products for very long when the promised 3-5 cup size increase does not appear.

Honestly, the most reliable way to get a larger breast size (short of weight gain or pregnancy) is breast augmentation done by surgically inserting a saline or silicone implant. The American Society of Plastic Surgeons reports an increase for cosmetic surgery from 14,000 in 1996 to 333,000 in 2005 for patients under age eighteen. At least 90% of those were females. Breast augmentation is one of the two most frequent plastic surgery procedures performed on teens (Zuckerman, 2008).

Since most health insurance will not cover breast augmentation, the costs have to be borne by the young woman, or her family. While the decision to do augmentation is a very personal decision it is worth understanding some of the risks. The FDA has not approved the use of saline implants in women under age 18, nor the use of silicone implants in women age 21 and younger. Surgeons can still do the procedure, but the benefits have not been demonstrated to out weigh the risks to the satisfaction of the FDA. Currently breast implants have a limited life expectancy. According to Zuckerman breast implants typically last about 10 years, and there is an increased of scar tissue formation the longer the implant is in place.

Interestingly, a study of women planning to get breast implants because of dissatisfaction with being too small, found that there was no difference in bra sizes compared to a group of women who were satisfied with their breast sizes (Didie, 2003).

Jane's Economy Breast Lift
Thus far we have moved from discussing medically focused breast issues through more self-concept, or cosmetic, concerns. Most women can think of a change in breast size, or firmness which they would prefer if the Fairy Godmother of Breast Structure was to grant them a wish. Would you be willing to develop a firmer breast profile without drugs, surgery, or any cost? OK, I was skeptical, too. But here it is-free to my readers:

Chest Exercises to Help Tone and More

If you do a few simple exercises, especially if combined with a balanced body work out, you will get better contours. As a bonus, saggy underarms (triceps flop) can improve. It will not increase or decrease your cup size by three to five sizes, but it will make what you have look better. And after all, isn't enhancing what we have been given what it's all about?

Related Topics:

Can A Vagina Be Too Big?

2009-05-04T09:15:00.000-07:00

Faithful readers of this blog may remember that Masters and Johnson examined the vaginal sizes of 100 women who had never been pregnant. These women showed an un-stimulated vaginal length of 2 ¾-3 ¼ inches , with a ¾ inch width at the back of the vagina. During the sexual excitement phase the vaginal lengths increased to 3 ¾- 5 ¾ inches, with the width at the back of the vagina being 2 ¼-2 ½ inches. This correlates with our most common diaphragm sizes which are between 2 ½ -3 ½ inches in length.

"But I'm not worried about vaginal length," you might be thinking. "My problem is that I think my vagina is too loose - or too wide. Is that possible? If so what can I do?" Let's examine some of the medical data available to answer these questions.

Is my vagina too loose?
The vagina is like a collapsed, expandable tube lined with skin; the tissue below the skin is loose and contains large veins. Next are smaller circular muscles surrounded by stronger bands of muscle which run the length of the vagina. In addition, the lower third of the vagina is surrounded by a ring of muscles. This is covered by more connective tissue and blood vessels. Damage to these muscles, or if they become thin and weak, can allow the bladder ("cytocele") or rectum ("rectocele") to pouch into the vagina. Thus you can understand the importance of strong vaginal muscles. The ring of muscles around the vaginal opening contract during orgasm and may contribute to the intensity of an orgasm.

So what is too loose? This can be a matter of opinion based upon the input of a sexual partner, or one's observations of vaginal tone. Researchers have devised some ways to measure vaginal tone such as a pressure sensitive intravaginal balloon device, and ultrasound measurements of vaginal area ("pelvic floor") muscle thickness. A study of 30 women aged 20-42 found that better developed vaginal muscles were linked to having orgasms, and getting physical exercise. Conversely, increased age and having been pregnant were linked to decreased strength of vaginal muscles (McKey and Dougherty 1986).

A more recent study using ultrasound measurements (Bernstein,1997) found similar connections. Muscle thickness decreases with age, especially in women older than 60. Women with urinary incontinence had thinner pelvic floor muscles than women who were not incontinent.

Will exercising the vaginal muscles make my vagina tighter?
Two ultrasound studies of women who exercised their vaginal muscles did find that their muscles were thicker and stronger after pelvic floor muscle training. Among women with urine leakage, their thinner muscles became the thickness of healthy women's pelvic floor muscles. Additionally, they had less urine leakage - whether the problem was from stress or urge types of incontinence. The use of vaginal cones and/or Kegel exercises to increase muscle strength were both found to improve tone and decrease urine loss. While some of these studies did not measure vaginal tightness per se, when muscle bulk is increased, a woman can voluntarily contract those muscles to make the vaginal opening tighter.

Do tighter vaginal muscles really improve sexual response?
Despite the fact that most every discussion of Kegel exercises includes improved sex, there are not many scientific studies to back up this claim. One recent publication (Dean, 2008) reported on sexual function and pelvic muscle factors for some 2,800 women. Women who delivered only by Caesarean section (and their partners) perceived they had better vaginal tone leading to improved sexual satisfaction. Women who were currently doing pelvic muscle exercises scored much better on sexual satisfaction questions than women who did not. Women with incontinence (probably thinner muscles) scored the worst on the sex questions.

I've tried Kegel exercises but they don't work for me.
Assuming that the Kegel exercises have been done correctly, it may be time to move to other options. One low tech choice is weighted vaginal cones. This is a set of weights, shaped more like a tampon than a cone, where one inserts the lightest version then uses the vaginal muscles to hold it up inside. This is done twice daily. When this is easy the next heaviest cone is used - and so on. This is to be done while going about normal activities so that gravity provides an additional challenge to keeping the weight up inside.

More technology is involved in the electrical stimulator. A tampon shaped probe is inserted in the vagina and small electric shocks cause the muscles to contract then relax. This is done about 20 minutes up to several times a week. One patient of mine who used this device found it sexually pleasurable.

Less commonly used may be the "magnetic chair" ("Neocontrol"). This chair uses magnetic action to stimulate the muscles. I know this sounds very "woo, woo", but there is good data showing its effectiveness. This device is not for home use; treatments are given twice weekly by specially trained health care personnel.

Will plastic surgery make my vagina smaller?
Many genital plastic surgery techniques are based upon GYN surgical procedures used for medical problems such as reconstruction after cancer treatment, gender change, repair of cystocele/rectocele, etc. Unfortunately there are few good studies showing benefit where there is no overt medical problem.

One study of 53 women in Santiago, Chile (Pardo, 2006) was done specifically for complaints of wide vagina and decreased sexual satisfaction. The surgeons did two procedures. The first was inside the vagina where tissue along the roof was stitched tighter. This is similar to the type of repair done for a cystocele. Secondly, tissue around the vaginal opening and between the vagina and anus was stitched tighter. This is similar to the type of repair done for episiotomies after childbirth. Six months after surgery 94% claimed they experienced a tighter vagina, and had regained or improved orgasms. Yet some 4% of the women said they regretted the surgery.

The problem with this type of study is that sexual response can be very subjective. There is no easy way to measure sexual satisfaction in a group of diverse women. Every woman knew she got the surgical treatment so six months may not be a long enough time for any placebo response to wear off.

The American College of Obstetricians and Gynecologists (ACOG, 2007) has noted the lack of both safety and effectiveness data for genital plastic surgery. The possible complications for such surgery might include: infection, changes in sensation, pain with intercourse, and scar tissue. One GYN who has been performing genital plastic surgery for a number of years (Goodman, 2009) concluded that agreed upon terminology and training standards are still lacking.

What are you going to do, Jane?
As a big advocate of resistance/weight training to build muscles, I personally think exercise is a better place to start than surgery. As always, if a woman has concerns about sexual function, vaginal/genital structures, etc she should bring these up to her GYN. A GYN sees the wide range of "normal" in vaginal appearances. Yet, if one is having sexual problems due to genital changes, your GYN needs to know that is an issue.

If you are interested in exercising your vaginal muscles here are some instructions to get your started: Kegel Exercises - Topic Overview.

Related Topics:

Missed Periods - Premature Menopause?

2009-02-24T08:00:00.000-08:00

As a reader of this blog you probably know that missed periods, very late, and erratic periods usually can be attributed to missed ovulations. Yet when hot flashes or night sweats are also present many younger women wonder "Could I have premature menopause?" After reading this post you should have the information needed to work with your GYN to get a definitive answer.

Is there a difference between early menopause, premature menopause, and premature ovarian failure?

Overall, menopause means the failure of ovaries to produce estrogen. Estrogen builds up the lining of the uterus so that there is something to shed as a period. Technically, if your uterus is removed with a hysterectomy you will have no more periods. Yet if the ovaries are still in place and working, a woman is not yet in menopause. If ovaries are taken out that is considered "surgical menopause."

According to the North American Menopause Society, early menopause is when the last, natural menstrual period occurs before age 45, while premature menopause indicates a woman aged 40 or less. Premature ovarian failure (POF), like premature menopause, also is linked to being age 40 or younger. Among researchers who study POF, a term used first by the French "Ovarian Insufficiency" may become the new standard term for POF. I'll explain why that is the most appropriate term in a moment.

How common is POF?
Overall the incidence in the USA is reported to be 1-4% of women. While POF can be triggered by medical interventions such as chemotherapy, radiation, or surgery, the greatest number of women will not have an observable cause. The majority of woman with POF will have had prior menstrual periods.

The exceptions to these generalizations are in teenagers, who have not yet had a first period. In this specific group there is a 50% incidence of an abnormal, genetic karyotype. If this is suspected specialized testing is done, along with genetic counseling.

Is it true that POF can reverse back to normal?
The answer here is both "yes" and "no". About half of younger women (age less than 40) with a clear diagnosis of POF will experience normal function of the ovary that can come and go. That's why the term "Ovarian Insufficiency" may end up as the new standard name for POF. Insufficiency suggests the status quo might return - it is not permanent as implied by the idea of "menopause."

Does that mean I COULD get pregnant after a diagnosis of POF?
The data suggests that 5-10% of POF women will conceive unexpectedly. That is good news if women are trying to conceive. But the majority of women with POF will usually have a family via donor eggs, or adoption. There have been numerous studies of ovulation induction treatments (eg. Clomid, estrogens, GnRH, FSH, etc.) for women with POF. Alas, the best designed studies have failed to show ovulation rates any better than in untreated POF women (Sinha, 2007).

What if I don't want to get pregnant?
Among women who become menopausal at around age 50, we suggest some type of birth control should be used for one year after the last period. For women with POF, contraception should be used for a minimum of two years. Because of the intermittent, and unpredictable, ovulations in some women there are reports of POF women conceiving 8-15 years after there diagnosis of POF! For birth control, barrier methods (eg condoms/spermicide, diaphragm) or birth control pills (BCPs) can be used. BCPs have the additional benefit of adding needed estrogen if a woman's ovaries are not producing their own estrogen. One study (Buckler, 1993) found that BCP use did not enhance the return of normal ovary function.

What should I ask of my GYN if I want them to check for POF?
There is no completely standardized evaluation for POF. Generally, the following four elements need to be present to make a diagnosis of POF:

Absent periods for 4, or more, months
Age 40 or less
Evidence of low estrogen (eg vaginal dryness, hot flashes, etc)
FSH blood test results of more than 40mIU on two tests taken a little over a month apart

Probably the most important part of the work up for POF is for the GYN to consider it as a possibility. One study of 48 women with POF found age 25 to be the average age of symptom onset, but it took two years to get the correct diagnosis. Almost two thirds of the women had to see three or more MDs before getting the correct diagnosis (Alzubaidi, 2002).

Where can I learn more?
Of all the internet sites I reviewed, I believe that these two have some of the best information.

Related Topics:

I Have Pelvic Pain: Is It Cancer?

2008-11-13T13:37:00.000-08:00

When women post to the Women's Health message board about pelvic pain they can describe symptoms which have recently started, or pain which has been present for six months or more. Despite the difference in duration of pain, everyone wants to know if cancer is a possible cause--and if cancer is not the cause then what is the culprit?

Fortunately cancer is not the usual suspect. Yet the list of possible causes extends beyond uterus, Fallopian tubes, and ovaries. The "female organs" are near the intestines, the bladder sits in front of the uterus, and there are networks of nerves which can conduct pain sensations from the actual site of pain to a more distant location ("referred pain"). The purpose of this post and the ones following is to share with you with some possible causes of pelvic pain. The information will be organized into recent pelvic pain, and pain of longer duration. Within those two categories pain sources from different body systems can be designated.

Acute Pelvic Pain
Acute pelvic pain is the medical term for pain that has recently started. Sometimes the onset can be very abrupt, in other conditions the pain builds slowly. Then too the pain can be present only at one time of the menstrual month. Let's look at true OB/GYN pain first.

Pregnancy caused pain:

Miscarriage

Tubal pregnancy ("ectopic") which has ruptured. This usually occurs before 7-10 weeks from the first day of the last period.

Breakdown ("degeneration") of fibroid whose blood supply has been cut off. This can occur in the later part of pregnancy.

Gynecologic pain:

Ruptured ovarian cyst. This can onset very suddenly, and if an ultrasound is done promptly it can image "free fluid in the "cul de sac" or fluid leaked by the cyst now present in the lowest part of the abdominal cavity.

Large intact ovarian cyst. While this can prompt discomfort, the greatest pain occurs when a large cyst twists the ovary like a too heavy flower on a thin stalk. "Ovarian torsion" creates severe pain as the ovary's blood supply is twisted off leading to the ovary's death.

Pelvic infection. This can be an infection of the lining of the uterus ("endometritis"), or a generalized infection of the uterus/tubes/ovaries ("pelvic inflammatory disease"/"PID"). If an infection has been present for a while the Fallopian tubes and/or the ovaries can develop an abscess or become fluid filled ("hydrosalpinx").

Painful ovulation ("Mittelschmertz "). This pain generally occurs around midcycle (eg cycle day 14). It is prompted by the release of the egg/oocycte. As the oocyte is ejected from its follicle, the fluid from the follicle splashes the lining of the abdomen and creates a sharp sudden pain. Mittleschmertz generally resolves on its own after 48-72 hours.

Cramps of menstruation ("primary dysmenorrhea"). Common menstrual cramps are caused by the release of prostaglandins from the lining of the uterus. Prostaglandins create both the cramps of labor and menstrual cramps by making the uterus contract. Common cramps may start prior to the onset of flow and usually last 72 hours. Cramps that increase in intensity, last increasingly longer over time, and start later in life suggest that endometriosis, not just prostaglandins, may be the villain.

Bladder & kidney sources of pain:

Bladder infection (Urinary tract infection - UTI). Pain from a sudden bladder infection may be described as cramping, with burning during urination. Frequency, urgency, and small amounts of urine passed are common symptoms.

Kidney infections ("pyelonephritis") will often start with UTI symptoms and progress to back pain at the level of the lower ribs.

Kidney stone. Pain from a kidney stone can be sudden and so severe that the woman begins to vomit. There may be blood in the urine.

Bowel caused pain:

Irritable bowel syndrome ("IBS") can start up after eating, or during stressful events. Bloating, gas, and constipation or diarrhea may be present.

Infection ("gastroenteritis") of the intestines can be caused by bacteria, viruses, or even parasites. Diarrhea and nausea may accompany the painful cramping.

Diverticulitis is a localized infection in a pouching out section of the bowel.

Appendicitis pain may manifest with a fever, loss of appetite, and pain focused in the right lower part of the abdomen.

Crohns disease or inflammatory bowel syndrome may have bloody diarrhea along with the pain.

Less common sources of acute pain include:

Abdominal aortic aneurysm

Blood clot in the large pelvic blood vessels

Acute intermittent poryphyia

Chronic Pelvic Pain
When used as a medical diagnosis, chronic pelvic pain indicates that the pain has been more or less constant for at least six months. The same general body systems, except for pregnancy, that produce acute pain can be a source of chronic pain. Additionally, problems with muscles and nerves can create pain in the pelvis. Let's look at some of the more common causes.

Gynecologic pain:

Endometriosis (bits of uterine lining tissue growing on the bowel, bladder, ovaries, etc). The endometriosis implants go through the same cycle as uterine lining--they slough off and bleed monthly. Because there is no outflow for the bleeding, the body creates bands of filmy scar tissue ("adhesions") as a response to the inflammation of monthly bleeding into the abdomen. These adhesions can "glue" together organs in the abdomen.

Adhesions can also be formed if a woman has had an abdominal surgery or a serious abdominal infection (eg PID or ruptured appendix).

Ovarian remnant syndrome is an ovarian cyst that occurs after oophorectomy. Despite the removal of an ovary, a small bit of ovarian tissue remains behind. This tissue can still produce ovarian cysts. Ovarian remnants tend to be more common in women who have multiple adhesions which "web together" ovaries to the intestines making it more difficult to be sure that all the ovary was removed.

Adenomyosis is endometriosis that has grown into the muscular walls of the uterus. In addition to pain it can produce a uterus that is enlarged, tender, and boggy. Unfortunately, adenomyosis is usually diagnosed only after hysterectomy has been performed. One could have a suspicion for adenomyosis if the woman, or her family, has a history of endometriosis.

Pelvic congestion syndrome is also more difficult condition to diagnosis. It involves varicose veins of the uterus or ovaries.

Uterine prolapse can create a dragging, heavy pain. The supportive tissues become relaxed and the uterus drops down into the vaginal canal.

Large uterine or ovarian masses. Even benign masses such as large external uterine fibroids, or large dermoid cysts, can put pressure on surrounding organs.

Bladder & kidney sources of pain:

Interstitial cystitis ("IC") can present like a urinary tract infection (UTI) with urgency, frequency, and pain with urination. Unlike a UTI there can be pain in the vagina, urethra, or pelvis; there can be pain with intercourse. Unlike a UTI pain may be less at the end of urination. Urine cultures are negative for bacteria, and antibiotics do not relieve the symptoms.

Urethral syndrome will also have urinary urgency, frequency, pain with urination, and no evidence of bacteria in the urine. Sometimes women are given a longer than normal duration of broad spectrum antibiotics as a trial treatment. If the woman is postmenopausal she may be prescribed estrogen therapy.

Problems with the ureters leading from the kidney to the bladder can include obstructions or diverticulum (a pouch in the walls). These are an uncommon source of pain.

Bowel caused pain:

Irritable bowel syndrome ("IBS") can start up after eating, or during stressful events. Bloating, gas, and constipation or diarrhea may be present. Excluding GYN causes, IBS is the most common cause of chronic pelvic pain.

Infection ("gastroenteritis") of the intestines can be caused by bacteria, viruses, or even parasites. Diarrhea and nausea may accompany the painful cramping.

Diverticulitis is a localized infection in a pouching out section of the bowel.

Appendicitis pain may manifest with a fever, loss of appetite, and pain focused in the right lower part of the abdomen.

Crohn's disease or inflammatory bowel syndrome may have bloody diarrhea along with the pain.

Hernias may be evident and uncomfortable when the woman is standing upright, then not apparent when she is lying flat on the exam table.

Cancer of the bowel, while not a common cause of pelvic pain, needs to be ruled out with a sigmoidoscopy. This is especially important if there are other bowel symptoms such as blood in the stool.

Neurologic sources:

Myofascial pain creates abdominal wall pain along the lines of major nerve pathways. The area of pain can often be identified very specifically with a finger tip. It is believed that the pain can be instigated by a deeper organ which then refers the pain to the area served by the shared nerve. Performing a straight leg raise (tightens the abdomen) can make the pain worse. Treatment involves injection of the shared nerve with a local anesthetic at the specific site of pain identified by the finger tip.

Nerve entrapment or injury may follow a GYN surgical incision (eg laparoscope or C-section scar). The pain may be described as burning, or aching and like myofacial pain follows the shared pathway of a nerve ("dermatome"). As noted above abdominal tightening or exercise can make the pain worse, and treatment includes injection with a local anesthetic at the specific site of pain on the outside of the abdomen.

Neuroma is a mass, or thickening, of nerve tissue. Often these can arise where there has been trauma to a nerve. In pelvic pain a neuroma can occur in the area of a hysterectomy scar (including inside the vagina), or other surgical scars.

Pudendal neuropathy results from damage to the pudendal nerve. Women may experience vaginal pain with sex, rectal pain with bowel movements, bladder pain with urination, and pain with sitting.

Finally, less common sources of chronic pain can include:

Systemic lupus erythematosis

Low back injury with pain referred to the abdomen

Acute intermittent porphyria

Given this long list of reasons to have pelvic or lower abdominal pain, one can see why it may take more than a single office visit to get an accurate diagnosis. It may take more than one type of imaging technique. If a GYN cause is strongly suspected, an ultrasound is usually performed first. If the ultrasound results are equivocal then either a CT or MRI scan may be ordered. More than one specialist may be needed to examine specific organs in the abdomen--for example a gastroenterologist, or urologist.

WebMD has an extensive library of information here. If you are interested in more information consider visiting these sites. The International Pelvic Pain Society has a list of pelvic pain specialists indexed by geographic location. One can also review the lectures from past conferences on a variety of pelvic pain issues. Also, the NIH has an extensive list of resources.

Related Topics:

Vaginal Discharge: Normal or Not?

2008-06-26T09:50:00.000-07:00

With so many women wondering if their vaginal discharge is normal, it seemed time to review the basics of "vaginal ecology". We’ll be examining the following questions:

What is normal?

How often does it change?

Do hormones make a difference?

What about douching or washing?

Does my choice of birth control have an impact?

What is "normal" vaginal discharge?

A normal discharge is made up from exfoliated vaginal skin cells, bacteria, and secretions from the cervix and vaginal walls. While as many as 30 types of bacteria can be found in normal vaginal discharge, about 95% of a healthy vaginal bacteria population consists of lactobacilli. There are several subtypes of lactobacilli, but the most important type produces hydrogen peroxide. Just like hydrogen peroxide is used to clean cuts and scrapes on the surface of external skin, the hydrogen peroxide produced by the lactobacilli helps decrease the numbers of undesirable bacteria such as E. coli, a common bowel bacteria responsible for urinary tract infections. A healthy vaginal pH is relatively acidic (pH 3.8-4.5). An acidic pH also discourages undesirable bacteria.

In one study (Mijac, 2006), women with yeast were found to have almost as many of the beneficial, hydrogen peroxide producing lactobacilli as women without infections (77% vs 80% respectively). By contrast, women with trichomoniasis had 63%, and those with bacterial vaginosis (BV) were found to have only 25.6% ! In all categories, women who smoked had fewer of the beneficial lactobacilli than nonsmokers.

Women have tried various home remedies to increase lactobacilli numbers in their vagina. Use of natural yogurt as a douche or on a tampon has been advocated. Yet studies suggest that the type of lactobacilli in yogurt lack both the hydrogen peroxide producing qualities, and an ability to cling to vaginal membranes. In a recent experiment (Larsson, 2008) women treated for BV were given 10 days of freeze dried human lactobacilli, or a placebo, as a vaginal capsule. After three months of this treatment the researchers found that the lactobacilli treatment was most effective in preventing relapse of BV in women who were initially cured using antibiotics.

Group B strep, E. Coli, and Staph aureus (normal skin bacteria) were frequently cultured in a group of 631 women, many of whom had no symptoms (Donder, 2002). In a study of 141 GYN surgical patients, Group B strep was found in the vaginal secretions of 20% (Song, 1999). This suggests that many types of bacteria can be a part of the vaginal ecology.

To summarize, normal discharge has a pH of less than 4.5, no overt malodor, a thick or clumpy appearance, and white color. These characteristics can vary over a menstrual month depending upon hormones, changes in pH, brief overgrowths of different species of normal vaginal bacteria, and exposure to semen or menstrual flow.

How often does discharge change?

Among 26 women followed for two months, only four maintained "normal" vaginal conditions. Eight had intermittent yeast ("candida") overgrowths. Nine had intermittent overgrowth of BV linked bacterias, while one other had BV all month long. Interestingly, many women complained of abnormal discharge or other signs of vaginitis, but symptoms did not correlate to lab testing (Priestly, 1997). Among a different group of 51 women, 22% maintained a "normal" vaginal environment with high levels of lactobacilli. The other 78% had significant but transient changes in their vaginal ecosystem (Schwebke, 1999).

A much larger study of 1,193 women was conducted over three years. About 20% of those women developed BV after 6-12 months. Surprisingly about 20% who had BV at the beginning of the study had no evidence of BV infection at the next follow up exam.

Such studies suggest that many bacterias and fungi (yeast) found in normal vaginal secretions can either overgrow and provoke symptoms - or can return to very low levels where they do not produce ill effects.

Do hormones make a difference in vaginal discharge?

Hormones are one variable which can change over the course of a month. We know that estrogen improves vaginal pH by increasing lactic acid production by vaginal cells. Increased levels of estrogen are also responsible for the increased amount of clear, stretchy cervical secretions seen around ovulation. After ovulation, discharge tends to become less watery and may look more like library paste in its consistency.

Conversely, in a post-menopausal woman who has low levels of estrogen, her vagina is more likely to contain gram positive cocci (e.g. staph aureus, staph epidermis, group A strep) and gram negative rods (e.g. proteus, E Coli). Her vaginal pH will be more alkaline, and there will be fewer of the beneficial lactobacilli bacteria. There will be diminished vaginal secretions, and decreased vaginal lubrication during sex. One innovative study (Gorodeski, 2005), determined that the effects of estrogen on the vaginal ecology differed depending upon the age of the vaginal tissues. This suggests that estrogen's effects work directly on vaginal cells, not just by encouraging beneficial bacteria and inducing an acidic pH.

What about douching or washing?

Douching has been linked to increased incidence of BV in many, but not all studies. One of the better studies also examined the reason for douching. It would make sense that if one had the malodorous BV discharge that douching might be tried to temporarily get rid of the smell. Of the 1200 women studied, douching for hygiene, as well as for symptoms, both shared an increased incidence of BV. While douching once a month incurred an increased risk of having BV, those who had douched within the past week had the highest risk of all. Women who douched also had decreased concentrations of the beneficial lactobacilli bacteria (Ness, 2002). More recently (Brotman, 2008), it was determined that incidence of BV could be decreased if women refrained from douching for hygiene purposes after menstruation.

Among sex workers in Kenya, women who used any type of vaginal washing (as compared to no washing) had an increased risk for HIV was present after ten years of follow up. The greatest risk was to women who used soap or other substances for cleaning the inside of the vagina rather than plain water (McClelland, 2006).

Type of external cleansing techniques (e.g. soap vs water vs antiseptics) did not predict incidence of candida (yeast) infections in 1004 women cultured for yeast (Oliveira, 1993). This suggests that external cleaning choices do not impact vaginal ecology.

Does my choice of birth control have an impact?

It should come as no surprise that the answer to this question is, "Yes, probably so." Birth control pills do not change the numbers of beneficial lactobacilli, keep the pH at about 4.4, and do not change the thickness of protective vaginal skin cells (Eschenbach, 2000). Over all the risk for BV is about 50% less in birth control pill users (Calzolari, 2000). Yet the risk for yeast infections is increased when birth control pills are used (Baeten 2001, Fosch 2006)).

Women who wear the NuvaRing have the same healthy vaginal pH as Pill users, but they may have 2-3 times more hydrogen peroxide producing lactobacilli (Vernes, 2004). One study has shown that several subtypes of vaginal yeast can adhere to the NuvaRing (Camacho, 2007), but an increased risk for yeast infections has not been reported. Should a Ring user develop yeast, use of either a cream or suppository antifungal medication does not decrease the Ring's effectiveness as a birth control method (Verhoeven, 2004).

By contrast, DepoProvera can decrease hydrogen peroxide producing bacteria within six months of use. There can also be a slight thinning of the tissues which keep vaginal pH acidic (Miller, 2000). These effects are likely related to the degree in which DepoProvera decreases estrogen levels. In some women blood estrogen levels can be depressed enough to impact bone density and vaginal symptoms - while in others blood estrogen levels remain well within the usual range.

The use of a copper IUD has been linked to increased BV in four studies. One study (Avonts, 1990), which followed women for two years, found that 50% of IUD users developed BV as compared to 20% of birth control pill users. More recently Ocak and colleagues (2007), followed IUD wearing women for three years. Similarly, it was shown that BV was more common in IUD wearers (11.7%), than in birth control pill consumers (5.9%) or women using neither method (2.9%).

When barrier methods of birth control are utilized there is a spectrum of effects on vaginal ecology. Condoms without spermicide do not change vaginal pH or bacterial parameters. Condoms may protect the vagina from any bacteria present in the ejaculate. However, use of the common spermicide nonoxynol 9 may predispose a woman to abnormal bacterial changes. When used with a diaphragm or cervical cap, this spermicide can transiently decrease lactobacilli, and increase the proportion of E. Coli, enteroccoccus, and anaerobic gram negative bacteria (Gupta, 2000).

You should now be able to make more informed choices about your own vaginal health. As always, seeing a GYN or family planning clinic will yield the most accurate diagnosis and advice.

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My Ultrasound Found An Ovarian Cyst!

2008-03-31T12:21:00.001-07:00

There are two types of small ovarian cysts which can be considered "normal". During the first half of the menstrual month ("follicular phase") estrogen stimulates the growth of a dominant follicle. This follicle fills with fluid which is spilled out when the ready egg ("oocyte") is ejected ("ovulation"). After the egg is released, its former follicle closes off and becomes the "corpus luteum" which produces progesterone during the following two weeks ("luteal phase").

If, in either of these phases, larger than normal amounts of fluid collect, one can develop ovarian cysts that will cause pain or menstrual bleeding changes. A normal ovary is about 2 x 3 cm (almond sized). A follicular ovarian cyst, if the egg is not ejected and the amount of fluid continues to increase, can reach sizes of up to 10 cm. Fortunately most follicular cysts are smaller and will resolve within one to three months. If the size is large (eg greater than 8 cm) the heavy cyst can prompt the ovary to twist on itself like a heavy flower on a too fragile stalk. This twisting ("ovarian torsion") causes intense pain as it cuts off the blood supply to the ovary. While follicular cysts are the most common type of ovarian cysts, torsion is uncommon.

In another condition, polycystic ovaries ("polycystic ovarian syndrome/PCOS"), the ovary will contain multiple small follicular cysts. Unlike the cysts described above, PCOS cysts will usually stay small. Yet, like other follicular cysts the egg is not ejected. This lack of ovulations contributes to the fertility problems seen in PCOS.

Normally after ovulation a corpus luteum of less than 3 cm resolves within two weeks. This type of cyst will be maintained, if conception occurs, to produce hormones needed in early pregnancy. If excessive amounts of fluid collect, a corpus luteum cyst can also get large enough to cause pain—or very rarely, ovarian torsion. Occasionally, this type of cyst will have a small blood vessel which continues to bleed into a corpus luteum cyst. This is called a "hemorrhagic ovarian cyst". A cyst of this type can either leak small amounts of blood, or it can rupture, spilling blood into the abdomen. This hemorrhagic ovarian cyst can be linked to prolonged pain, and merits closer follow up.

Each of the cysts described above can start with a normal process and become a medically significant cyst. They are all described as benign cysts. By contrast there are ovarian cysts which are not related to variations in normal processes. Endometriomas are cysts filled with old blood. This gave rise to the nickname "chocolate cysts" as the cyst fluid looked like chocolate syrup. Endometriomas can grow to 6-8 cm. They are formed when bits of uterine lining tissue ("endometriosis") attach to pelvic organs such as ovaries. Dermoid cysts ("cystic teratomas") can contain bits of hair, teeth, or other body tissues. It is still not known why demoid cysts form. At an incidence of 66%, dermoids are most common kind of benign tumors of the ovary. Cystadenomas ("serous cystadenomas") are formed from epithelial cells on the covering of the ovary. These cysts are filled with a fluid or a gel like material. Cystadenomas comprise 20% of benign tumors. The concept of benign tumors sounds like a contradiction in terms. It means that there is a very small chance of this type of ovarian cyst to become cancerous. For example, in one study (Scully, 1973) less than 2% of dermoid cysts showed evidence of malignancy.

What If My Ultrasound Does Not Say What Type of Cyst I Have?

Often, when women get copies of their pelvic ultrasounds there is no definite diagnosis. The ovarian mass may only be described by location, size, and other attributes. The importance of size has been discussed above. The descriptors used can give an indication of the type of cyst that might be present. A cyst described as fluid filled with regular borders is often a simple follicular cyst. The ultrasound term anechoic (no echos) may be used to describe fluid, either cyst fluid or fresh blood.

A complex ovarian cyst generates more concern. A cyst that is a mixture of solid and fluid elements, or is solid, is not a simple follicular cyst. The presence of irregular borders, or septations (internal walls dividing the cyst into separate spaces) are more concerning features found in complex cysts. Other terms which may be linked to complex cysts are: mural nodule, fluid-debris level, retracting blood clot, or a mix of anechoic to hyperechoic appearances.

How Reliable is Ultrasound?

While simple ovarian cysts can usually be diagnosed by vaginal ultrasound, the question arises "How reliable is ultrasound when the cyst is complex?" One well done study (Jermy, 2001), looked at the reliability of ultrasound to make a correct diagnosis for possible endometriosis or dermoid types of complex ovarian cysts. After the mass was removed it was found that ultrasound was successful in predicting 96% of endometriosis cysts and 97% of dermoids. There were no ovarian cancers found.

What Should I Expect for Treatment?

If a simple cyst is suspected, the only treatment may be a repeat ultrasound in six to eight weeks to be sure that it is resolving. If the cyst is very large, and ovarian torsion is a concern, then more frequent ultrasounds may be performed.

Previously, birth control pills (BCPs) were commonly prescribed in an attempt to treat simple ovarian cysts. Studies comparing the use of BCPs to "expectant treatment" (Turan, 1994) began to suggest that "watch and wait" was as effective as treating with BCPs. More recently (Sanersak, 2006) found that low dose monophasic pills were not statistically better at treating functional ovarian cysts than following women with routine ultrasound screening.

In terms of prevention of ovarian cysts, several studies have examined the role for birth control pills. In an older study (Vessey, 1987) there was a 78% reduction in corpus luteum cysts and a 49% reduction in follicular cysts among women who had taken high dose birth control pills within the previous six months. A later study (Lanes, 1992) compared older, high dose mono-phasic pills to lower dose mono-phasic pills, and lower dose tri-phasic pills. This group found that the lower dose pills conferred less protection for functional cysts than did the older types of birth control pills.

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If It's Not Menopause, What Is It?

2008-03-24T12:05:00.001-07:00

It's hard to believe, but the first landmark study of women's perceptions of menopause (Neugarten, 1965) found that, "Not knowing what to expect" was midlife women's greatest concern. Since that time there has been an explosion in scientific, and popular, publications pertaining to menopause. Women now are well acquainted with menopausal signs and symptoms. They know what to expect. So the question has shifted to "If it's not menopause, then what is the cause of my menopause-like symptoms?" Let's examine some of the more common symptoms and see what else might be at fault.

Irregular or absent menstrual periods

While a few women will suddenly reach menopause, or the last natural period, most will have sign posts for the upcoming change. The most common sign is marked menstrual changes. The official definition of "perimenopause" is the four to five years before last menstrual period. Perimenopause also includes the first year of no periods following the last menstrual flow. Marked menstrual changes are considered to be: cycle length between flows more than seven days different from normal, and/or more than 60 days of no periods.

There can be other reasons for missed, or irregular, periods. It is possible to conceive right up until the last natural period. If birth control is not being used, pregnancy must be ruled out. If pregnancy is not detected then the next most common cause of menstrual changes is missed, or late, ovulations. In a normal cycle, estrogen is produced all month. Estrogen is responsible for building up the lining of your uterus so you have something to shed each month.

In a normal cycle, progesterone production increases following ovulation and release of an egg.. Progesterone "stabilizes" the uterine lining in preparation for possible implantation of a new pregnancy. If you are not pregnant that month, the levels of estrogen and progesterone fall, triggering the release of the uterine lining--your period. So, if you do not ovulate, the estrogen build up of the lining continues, but without the usual ovulation associated progesterone. Thus, the hormone levels don't decline, and the lining stays up inside the uterus--your missed period.

One can enter a pattern of non-ovulation at any time after menstrual periods first begin. Causes for not ovulating are multifold: thyroid problems, pituitary problems, ovarian cysts, physical stressors (eg sudden increases in exercise, crash dieting), emotional stressors (problems with parents or boyfriends/girlfriends, exams), increased body weight, anorexia, rotating shifts at work, etc. Yet as women move into their 40's one of the most common causes for not ovulating regularly is "old eggs"--the aging of the remaining follicles in their ovaries. This possibility for erratic ovulations can make the diagnosis of menopause more difficult. If one is experiencing irregular or missed periods at any age it is important to check with a GYN, or other healthcare provider, to help make a correct diagnosis.

Hot flashes

Flashes are the second most often reported symptom by perimenopausal women. Hot flashes and night sweats can onset during perimenopause, and generally peak during the first two years after the last menstrual period.

Hot flashes have been linked to abrupt changes in estrogen levels. Typically they are seen during the hormone swings of perimenopause. Yet other medical conditions can prompt flashes and/or night sweats. These include: hyperthyroidism, infections (eg HIV/AIDS, TB, malaria), some types of cancers (eg pancreas, adrenal gland, leukemia), generalized anxiety/panic, and autoimmune disorders. Many women have noted a sensation of flushing when the sympathetic nervous system ("fight or flight" response) is activated. Even being a heavy cigarette smoker can be linked to more hot flash activity as smoking decreases blood estrogen levels. Lastly, some medications (eg serotonin [SSRI]antidepressants, raloxifene, and others) have been noted to prompt flashes. If your flashes appeared after starting a new medication be sure to ask your pharmacist if flashes are noted as a possible side effect.

Sleep disturbances

One study (National Sleep Foundation, 2002) confirmed what many midlife women have suspected. Perimenopausal and postmenopausal women do have less sleep, marred by shortened sleep hours, and more problems with either difficulty initiating sleep or remaining asleep. While night sweats are a prime suspect in the problem of poor sleep, sleep disturbances can arise from other sources.

Physical causes of poor sleep include sleep apnea and other problems with breathing, digestive problems such as gastro-esophageal reflex disorder ("GERD"), painful conditions such as arthritis or diabetic neuropathy, and hyperthyroidism. Some medications (eg asthma drugs, steroids such as prednisone, Dilantin, and stimulants) have side effects which alter sleep architecture. Psychological causes for insomnia can comprise high stress life events, and/or depression, anxiety, or psychosis.

Mood swings

Longitudinal studies, where a large group of women is followed through the transition into menopause, have contributed the best information about mood swings. The women in such studies are not presenting at their doctor's office with specific complaints of mood problems. Rather they are living their daily routines and are surveyed using questionnaires, or interviews. Earlier studies (Kaufert 1992, McKinley 1992, and Woods 1997) found that a prior history of mood disorders, including PMS/PMDD, helped predict who was likely to become depressed during perimenopause. As might be expected, poor health, and increased levels of life stressors, made depression more likely to occur.

Interestingly, when the presence of severe hot flashes/poor sleep, and a history of prior depression were controlled for when analyzing the women's data an interesting fact was found. The greatest incidence of down moods was in the perimenopause, not in pre-menopause (Bromberger 2003) or post-menopause (Freeman 2004). It would seem that there is a time of increased vulnerability to mood swings as one approaches menopause.

Other causes of mood swings can include: unrecognized clinical depression or anxiety, life stressors unique to midlife (eg new medical problems, changes in relationship or parental dynamics, one's aging parents needs, etc.), low thyroid, and endocrine disorders. If one is experiencing mood swings which are impacting her quality of life, it is important to see a healthcare provider for an assessment of physical and psychological causes.

Vaginal dryness

Vaginal dryness can arise at any age. Frequently it is seen in breastfeeding women as low estrogen levels are triggered by the hormone of lactation, prolactin. Some young women using DepoProvera as a contraceptive can also develop lowered estrogen levels and experience vaginal dryness. The sensation of vaginal dryness, when due to lowered estrogen level is marked by both decreased lubrication, and thinner, more fragile vaginal tissues. The vaginal pH will be more alkaline. Fewer of the beneficial, hydrogen peroxide producing lactobacilli will be present.

Other medical conditions which can create vaginal dryness include: benign pituitary mass, diabetes, and Sjogren's syndrome. Medications such as Lupron, antihistamines, diuretics, or drugs which create dry mouth (eg tricyclic antidepressants) have the potential to create vaginal dryness as well. Radiation therapy may prompt vaginal dryness and tissue fragility. Yeast infections, or vulvar dermatology problems (eg lichen planus, or lichen sclerosus), can be interpreted as a dry, uncomfortable feeling in the vagina. Even poor lubrication due to genital pain, or inadequate sexual arousal, can create a subjective sensation of vaginal dryness.

Heart palpitations

It is common with hot flashes to experience an increase in heart rate during the flash. Increased heart rates can also arise when one is stressed, anxious, or having a panic attack. There are cardiac conditions where heart rate can dramatically speed up or actually become quite irregular. If one is experiencing irregular or very elevated heart rates it may necessitate an electrocardiogram (ECG), a treadmill ECG, or a monitor to be worn for 24 hours to detect the arrhythmia.

Is There a "False Negative" on a Test for Menopause?

One can be in perimenopause and have blood tests which do not confirm that diagnosis. This is the reason many healthcare providers chose not to do such tests routinely. There are blood tests (eg inhibin B) used in research settings which are very sensitive indicators of ovarian aging. But the two most common tests FSH, (follicle stimulating hormone) and estrogen (estradiol), are subject to swings in and out of "normal" range.

With ovarian aging it can take much more FSH to push the ovary to produce normal, "young women" levels of estrogen. In general an FSH level greater than 20 mlU/ml suggests approaching menopause. The problem arises when the increasing FSH levels push the ovary to create more estrogen. The resulting spike in estrogen pushes FSH levels back down. This is similar to a thermostat turning off once the heat in the room has returned to an appropriate temperature. Thus, if your GYN were to draw an FSH or estrogen level they would look normal---whereas several weeks before the FSH would be higher than 20 and the estrogen less than 40. This unpredictable variability makes diagnosis of perimenopause less reliable than, say, a blood sugar to rule out diabetes.

Some GYNs will add an additional blood test called LH (lutenizing hormone) which also becomes higher at menopause. However, this increase in LH happens later in the menopause transition so it is not very helpful in early perimenopause.

Finally, the journey into menopause can take a varying amount of time. One source maintains that the range of years during the transition can be from "zero to ten years". Up to 20% of women will enter menopause without significant symptoms. While I would hope that this would be the case for you, any significant symptoms should be assessed before being reflexively attributed to menopause.

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What ARE Those Little White Bumps?

2008-02-26T13:17:00.001-08:00

One of the most frequent concerns expressed on our WebMD GYN message board, and our "Friends Talking" message boards relates to "bumps" or "pimples" on the vulva. Usually these lesions have just been noticed, rather than being present for a long time. So let's consider what some of the causes might be.

Occasionally a woman will refer to the raised lesion as a "cyst". Cysts are a common occurrence, and can arise most any place on the body. In the area of the vulva a cyst is usually created by a blocked sweat ("apocrine") or skin ("sebaceous gland") gland. For example, if a hair follicle gets blocked it can fill with the debris of exfoliated/shed skin cells which causes the lining of the follicle to get distended. This is similar to what happens when one develops a "white head" pimple on the face. On the genitals, such cysts are called "epithelial inclusion cysts".

If the cyst continues to enlarge to a size greater than a half inch, it can incised with a sterile instrument and drained in a sterile fashion. While some women attempt to "squeeze" a cyst to extrude the "cheese-like" skin-cell debris, this is not a good idea. Normal skin bacteria can enter through the break in the skin and set up an infection.

There are some specific genital sites where drainage ducts can get blocked and create cysts. These are named after the area in which they occur:

Skene's duct cysts are located on either side of the urethra. These may be treated with warm moist soaks--or can require incision and drainage.

Vaginal cysts of embryonic origin typically are not a recent blocked duct opening. Rather they are a cyst which developed in utero. These are treated with surgical excision if they continue to grow in size over time.
Bartholin's duct cysts can develop on either side of the lower portion of the labia majora. These can grow to be the size of walnuts and usually are noticed because of a rapid increase in size and tenderness. Three times per day warm soaks or sitz baths are tried first, followed by incision and drainage if needed. Bartholin's cysts tend to reoccur. If this happens the cyst may be surgically opened and the sides sewn open (like keeping a purse permanently open) to be sure no fluid or skin cells accumulate. This procedure is called "marsupialization."

There are two conditions where clogged sweat glands can create bumps on the vulva:

Fox Fordyce is an itchy type of skin lesion which can range in size from small papules to cyst sized bumps. They may also be found on the lower abdomen and thighs. Keratin or skin debris clogs the apocrine/sweat glands, thus it is not a bacterial infection which requires antibiotics. It may be treated with a steroid cream or phototherapy.

Hiradenitis suppurativa, by contrast, is a clogged sweat gland which often has a secondary bacterial infection associated with the bumps. This condition does not itch, but can be very painful if deep, infected cysts or nodules form. These areas tend to leave a shiny scar of darkened skin. Somewhat more common in women who have acne, these lesions are often treated with acne-type approaches such as oral or topical antibiotics, or even oral Accutane. Steroids and birth control pills have also been tried. If there are large hardened nodules, or draining fistulas (tracts for pus to travel from one nodule to another), the area can be surgically treated

While on the subject of infections we should mention some of the most common vulvar infections which can create bumps or pimples:

Folliculitis is the most common cause of irritated or tender, raised lesions. Common skin bacterias such as staph or strep get into a hair follicle through a tiny break in the skin (eg bikini shave nicks). The area of infection can remain a small "folliculitis" or it can increase in size to become a "furuncle." A larger, or deeper, infected skin abscess is called a "carbuncle." Depending upon the size and degree of infection, incision/drainage or antibiotics may be utilized as treatments.

Skene's duct, or Bartholin's duct, abscesses might require antibiotics if a bacterial infection takes advantage of the cyst formed in the clitoral or labial area.

Sometimes the infection is viral rather than bacterial:

Molluscum contagiosum is caused by a pox virus. The bumps on the vulva or thighs are small, fleshy, and round often with a small indentation in the middle of the round lesion--like a bellybutton. These bumps tend to regress in time even without treatment. For cosmetic purposes they can be removed by freezing/cryo.

Human papilloma virus (HPV) subtypes 6 and 11 cause the visible genital warts which look like little cauliflowers. These rough to touch, raised growths can expand in size and number--especially in times of a suppressed immune system (eg pregnancy, illness, etc.). HPV lesions can be treated with applications of bi or trichlorocetic acid, freezing/cryo, or an immune system enhancing cream ("Aldara").

Herpes simplex virus (HSV) is more often linked to an itching, burning area which might be slightly raised. It can look like a bug bite in its early stages, but within several days it becomes an open ulcer or cut in the skin--not a bump.

There are a number of medical conditions which can produce bumps which are not related to clogged ducts or infections:

Acanthosis nigricans produces velvety, dark raised areas on the vulva, armpits, and neckline. It is linked with insulin resistance, the metabolic change found in polycystic ovarian syndrome ("PCOS").

Neurofibromatosis creates nodular areas all over the body, not just the vulva. This is an uncommon, genetically transmitted disorder.

Angiokeratomas as the name implies are created by small blood vessels. When there are dilated capillaries grouped together dark red to purple raised spots are visible. There may not be any symptoms until friction to the capillaries causes bleeding. Treatment is by freezing/cryo or surgical removal.

Lastly there are "normal" findings which a woman may suddenly discover:

Skin tags, or even remnants of the hymenal ring around the vaginal opening, can be mistaken for bumps. As one might expect these are soft and fleshy with irregular shapes.

Papillomatosis is frequently mistaken for genital warts, but is a normal variation in the vaginal/vulvar anatomy. If genital warts look like a cauliflower, these look like stalks of asparagus--more fingerlike than raised bumps.

Given the multitude of possible causes of bumps or lesions in the genital area it is important to have them examined by a GYN or other healthcare provider to ensure proper treatment. For more in-depth information you can visit this WebMD site targeted to healthcare personnel.

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Chlamydia: From Whom, How Long Ago, and What About My Fertility?

2008-01-28T12:57:00.001-08:00

Given that Chlamydia is the most common of the reportable sexually transmitted infection/sexually transmitted disease (STI or STD) we get many questions here at WebMD from very worried women. The most concerned questions tend to be focused on how/when the infection was acquired, and what impact will it have on future fertility. The following is a summary of the answers to those questions, and some related issues as well.

Who Gave Me Chlamydia?

If you are a sexually active woman aged twenty five years or less--and especially if you are aged less than twenty--you are a part of the largest Chlamydia infection demographic. If you are a female performing receptive oral, anal, or vaginal sex you can get Chlamydia, if secretion contact is present. Thus you need to be honest with your GYN about your sexual practices so you can be screened for possible Chlamydia infections of the pharynx, rectum, or vagina/cervix. Chlamydia can be passed between both heterosexual, and same sex couples-although its incidence is less than 1% in women who are exclusively lesbian.

How Long Ago Did I Get Chlamydia?

The incubation of a Chlamydia infection is reported to be one to three weeks. It can take up to six weeks in some cases. From one perspective it would be great if one could count back a few weeks to find the culprit-partner. But that would require that tell-tale symptoms be present. Alas, up to 75% of women and perhaps 50% of men have no symptoms. This can make it difficult to establish blame for the infection. It also means that infected persons can unknowingly continue to spread Chlamydia for a long time.

Many family planning programs do universal screening for Chlamydia among women aged twenty five or less--or if there is a new sexual partner. Certainly if a woman comes in with symptoms of vaginal discharge, the GYN or clinic would be likely to test for STDs, as well as for other vaginal infections. There is often screening during the initial prenatal visits in an attempt to prevent the infant from becoming infected during delivery with Chlamydial infections of the eyes or lungs.

Other instances when a woman might be tested for Chlamydia would be if she presents for an infertility work up, or with pain from a pelvic infection. These two conditions are linked. If Chlamydia ascends up through the cervix to infect the uterus/tubes/ovaries a woman can develop "Pelvic Inflammatory Disease" ("PID"). Some symptoms of PID include: lower abdominal pain, pain with sex, breakthrough bleeding, fever, or even nausea.

Studies have shown that between 20-40% of women with untreated Chlamydia will go on to develop scarring inside the Fallopian tubes, or bands of scar tissue ("adhesions") inside the pelvis. Inflammation from the untreated infection creates this scarring. This impacts fertility by blocking the tubes so fertilization cannot occur, and by "webbing" the open end of the Fallopian tubes to impair egg "capture" at ovulation. One author (Mardah, 2004 ) posits that the "The tubal infection may become chronic in spite of antibiotic therapy." This would infer that even after treatment a percentage of women may have tubal damage.

How Will Chlamydia Affect MY Fertility?

It has been calculated that perhaps 1,000,000 women per year will get PID of some type. Of those, an estimated 10% will develop infertility. One landmark study (Westrom, 1996) followed almost 1,500 women, of whom about 2/3 had confirmed PID as documented by a laproscope. Among the women with a PID history 7.8% had tubal occlusion where the tube was scarred closed. By contrast, a comparison group without PID had less than 1% tubal occlusions.

In this same study it was determined that the risk of PID caused infertility was tied to:

The number of times a woman had PID:
Zero episodes---1%
Two episodes---11.3%
Three episodes--19.8%

The severity of the infection influenced the relative risk (RR) of tubal infertility:

Mild infection-------- RR 1.0
Moderate infection---RR 1.8
Severe infection------RR 5.6

PID can be caused by other organisms (eg gonorrhea, anaerobic bacteria), thus this study attempted to identify the risk of tubal damage from having only Chlamydia :

Nonchlamydial--------RR 1.0
Chlamydia-------------RR 1.7

From this data it can be inferred that the greatest impact of Chlamydia on fertility would arise if a woman had a severe PID and/or repeated infections.

Could I have had a false positive Chlamydia test?

There are a variety of tests for Chlamydia; each has its own specificity and sensitivity which means that each has a different risk of false results. There are three basic types: culture, immunoassay, and nucleic acid amplification (NAAT). For a clear explanation of each, click here.

To summarize the scientific studies comparing the reliability of the various tests, the culture and immunoassay types are between 10-30% less sensitive than the nucleic acid amplification tests (Gaydos, 2004). A few of the immunoassay tests will cross react with the subtypes of Chlamydia which are not implicated in GYN infections. Some labs will do a confirmatory test if the screening test is positive--especially if a non-NAAT variety. It is important to note that false negative tests can occur as well.

Thus if Chlamydia is suspected a clinician will often "treat first; ask questions later." Given the lack of symptoms in many Chlamydia infections this may be the best way to prevent its GYN outcomes.

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So You Want to Leave Your Period Behind?

2007-09-25T11:45:00.000-07:00

Remember the passage in The Diary of Anne Frank where she talks about the excitement and "sweet secret" of getting her first period? Perhaps many of us felt some excitement, a rite of passage into the world of women, when first visited by "Aunt Flo." But with passing years the perceptions of menstruation might be less kindly. "The Curse" with its pads/tampons/cramps and various inconveniences was not a welcome visitor anymore - unless one was concerned about an unintended pregnancy.

For an excellent read about the cultural history of menstruation I highly recommend that you check out a copy of Delaney, Lupton, and Toth's entertaining discourse The Curse: A Cultural History of Menstruation, first published in 1976. Within that book one can visit "Menstrual Images in Literature," "Menstrual Taboos" and other fascinating topics from a feminist viewpoint.

At the time of the most recent edition of that book (1988), DepoProvera was not yet approved for use in the USA (that happened in October 1992), and all birth control pills were packaged with seven days of milk sugar or iron placebo pills. Women were routinely instructed to start their birth control pills (BCPs) on the first Sunday after the beginning of menses. This would ensure that most women would not be on their "pill periods" during a weekend. More progressive GYNs were suggesting starting BCPs on the first day of flow to decrease the need of a back up method. A few GYNs were advising patients to take only the active pills to try and avoid a scheduled bleed. Usually, this method of pill taking was reserved for medical indications such as menstrual migraines, severe premenstrual symptoms, or endometriosis.

Things have certainly changed. In May of 2007 the Food and Drug Administration approved Lybrel, the first birth control pill approved to be used without any placebo pills. This was the final step that followed the introduction of four days of placebo pills (Yaz), and a week of placebo pills only every third month (Seasonale). What are the pluses or minuses around trying to eliminate menstrual periods? Let's look at things you might want to consider.

"No Period on the Pill" is not the same as "Missed Periods on Your Own"

In a normal menstrual month, estrogen is produced all month long, and the majority of progesterone is produced in the two weeks after ovulation. If your uterine lining could be considered as your grass or lawn—then estrogen is like fertilizer (it stimulates the lining to grow thicker). In this analogy, progesterone is like the lawn mower—it prevents the grass from getting too thick and tall. When progesterone leaves the scene (ie conception does not occur with that ovulation), the grass clippings are dumped—your menstrual flow.

DepoProvera ("the shot") is a very large dose of synthetic progesterone. This is like having heavy duty lawnmower activity everyday. That's why DepoProvera for birth control can prompt women to not have periods. There is not that much lining to shed. All birth control pills (BCPs) contain synthetic progesterone. This is why most women on BCPs will have shorter, lighter periods. Even BCP users can develop such a thin uterine lining that their periods will disappear. So for a woman using hormonal forms of birth control (even the progesterone containing IUD) menstruation can disappear as the uterine lining becomes thin. Generally speaking a thin uterine lining is a good thing. It decreases the risk of the most common form of uterine cancer. Once the hormonal contribution of the birth control is out of the woman's body her original menstruation pattern will return.

By contrast, when a woman misses a period(s), and she is not taking hormonal forms of birth control, that can result in health problems. The most common reason for not having a period (once pregnancy is ruled out) is missed ovulations. In this instance, the uterine lining grows very thick from continued estrogen effects. Without the lawn mower effects of progesterone the lining becomes very thick. When the lining begins to shed, the bleeding can be very heavy and/or prolonged. An overly thickened lining provides a setting for abnormal cells to arise. These can set the stage for cancer of the uterine lining.

What Happens When Continuous Birth Control Pills Are Taken?

Remember in most birth control pills (BCPs) there is both synthetic estrogen and progesterone in each active pill. So everyday the uterine lining gets some fertilizer effects and some lawn mowing effects. During the placebo week of a pill pack, the blood levels of synthetic estrogen and progesterone fall. This causes the lining of the uterus to become destabilized and shed. When pills/patch/ring are used continuously a thick lining is NOT being created, or retained, inside the uterus. If there is no week when the hormones are withdrawn, there is no regular "pill period" ("hormone withdrawal bleed").

In the ideal world this would mean that there is no bleeding until the medication is stopped. However, as many women know from experience, breakthrough bleeding and unscheduled spotting can be common among users of pill/patch/shot/vaginal ring forms of birth control. This is one of the greatest possible drawbacks to "continuous" or "long cycle" regimens of BCPs. In the initial studies on Lybrel, only one third of participants had no bleeding or spotting after about a year's use.

So What Are the Downsides - If Any?

As discussed above, having to deal with some breakthrough bleeding or spotting is a real possibility. Absent menstrual periods can be a big advantage, but if one is worried about an undetected pregnancy, theoretically a woman could be spending more on pregnancy tests. For women who experience decreased sex drive on hormonal birth control (due to loss of pre-ovulatory testosterone, and lower free testosterone levels) increased pill usage would likely not improve the problem. Finally, there is no long term data on using BCPs continuously. With intensive scrutiny for almost fifty years, the largest studies have not suggested a link between BCP use and development of breast cancer.

For some women there is a strong symbolic link between regular menstruation and their concept of femininity. There is a subculture of menstrual rituals including the use of washable menstrual pads, then using the soaking water to water plants. The loss of the cyclic rituals, shared or private, might be mourned with the absence of regular flows.

Am I a Good Candidate to Try and Eliminate My Periods?

Only your own GYN or clinic can give you a conclusive answer. Yet, if you are a successful and satisfied user of hormonal forms of birth control you could easily try an extended use regimen. Your own GYN can discuss the various options such as the FDA approved Lybrel or even using your current method without a hormone free week. Whatever you try, just remember you can always decide to bail out and try something else.

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Feel Pregnant but the Pregnancy Test is Negative?

2007-09-20T00:31:00.000-07:00

I frequently see posts on my message board which state, "My pregnancy test is negative, but I feel pregnant" or "What about common symptoms of pregnancy; if I’m not pregnant what could be causing them?" Let's look at some of the most common signs of pregnancy:

Nausea and vomiting. Generally speaking the nausea and vomiting of pregnancy are presumed to start about four weeks from conception. Some other causes of nausea and vomiting are viral, or bacterial, infections in the bowel. Appendicitis, or problems with the gall bladder or pancreas, can provoke nausea. Neurologic conditions such as migraine headaches or increased intracranial pressure can induce nausea. Even severe emotional or physical stressors can make one queasy. Less common are the psychiatric causes including anorexia, bulimia, and anxiety disorders.

Breast tenderness/sensitivity. Bilateral breast tenderness can be a very early sign of pregnancy, appearing as early as two weeks after conception. This is thought to be related to increasing levels of hormones such as estrogen. In a month without an ovulation, not only can a menstrual period be missed, but there can be breast tenderness as well. This is similar to the increased breast tenderness experienced by some women when first taking postmenopausal hormone therapy. There are many other causes of breast pain (e.g., infections, herpes zoster) but most often these occur on one breast - not both.

Enlarging abdomen. It is not until the second trimester that most women can begin to feel an enlarging uterus by pressing on the abdomen. Sometimes a large fibroid can feel and look like a pregnancy, but this is not very common. Overall abdominal distension can arise from fluid shifts in the bowel (cause of premenstrual bloating), air in the bowel, or food intolerances (lactose, gluten, etc). Much more remotely, fluid in the abdominal cavity ("ascites") can be a product of ovarian cancer or liver disease.

Fatigue. While many women complain of fatigue in their premenstrual week, early pregnancy can produce profound tiredness. Fatigue in the first trimester has been attributed to the rapid rise in progesterone. One of the metabolites of natural progesterone uses the same brain binding sites as the "Valium-type" drugs. Fatigue is also one of the most common symptoms for a myriad of medical conditions as well. Infections, anemia, electrolyte imbalances, low thyroid, diabetes, MS, cortisol abnormalities, cancer, depression, stress, and a variety of medications have all been linked to the symptom of fatigue.

****************

Is your pregnancy test giving you a "false negative" result when you are in fact very early pregnant? In this instance the false negative can arise from three problems.

First of all check the box to be sure that the product has not expired or shows visible signs of damage.
Second, check to see if the sensitivity of the test purchased is 20 international units of pregnancy hormone (HCG). If it is more than that, it could be less sensitive to low levels of HCG. In this instance you might wish to wait until at least a week after the missed period so that HCG levels are high enough to trigger a "true positive".
Third, and the least common problem, would be a missed miscarriage. If there was an early pregnancy, which was then lost but has not yet produced bleeding, the pregnancy test would return as "not pregnant". This is a difficult diagnosis to make. The most conclusive way to confirm a miscarriage is to have sequential blood pregnancy tests which show dropping HCG levels in amount which may be too low for a standard urine test to detect.

To summarize, there are many conditions which can produce "pregnancy symptoms". If one continues to have such symptoms despite a negative pregnancy test, it is best to see your GYN or clinic and get some additional testing.

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4 Self-Help Strategies for PMS

2007-09-13T15:08:00.000-07:00

Perhaps some 90% of women have symptoms that indicate that their menstrual period is due to arrive. About 60% of those women will indicate that their premenstrual symptoms are troublesome. Nearly all cultures have a set of physical or mood symptoms which are attributed to being "premenstrual". Interestingly, this set of common symptoms varies from culture to culture. Studies done with the US subjects suggest that the "American Top Ten" of bothersome premenstrual symptoms include:

Irritability
Mood swings
Swelling of abdomen/breasts
Restlessness
Tension
Depression
Anxiety
painful breasts
Decreased concentration
Forgetfulness

The first approach to improving premenstrual symptoms is a trial of "lifestyle" and non-prescription treatments. Which of these is most likely to benefit you?

EXERCISE

Stanley (1989), in a study of exercise and PMS symptom relief, found that women should start to obtain some symptom improvement from as little as: 110 minutes/week of swimming, 70 minutes/week of aerobic dance, or 50 minutes/week of jogging. You will note that aerobic exercise seems to dominate the list. The effectiveness of aerobic exercise was confirmed in a study of women with documented PMS (Steege, 1993). The women were randomly assigned into either aerobic or weight training groups. The aerobic exercise group showed the best symptom relief.

SUPPLEMENTS

Several well designed studies have suggested that an increased daily intake of vitamin D to 800 IU/day, accompanied by an increased intake of dietary calcium to 1200 mg/day may prevent PMS symptoms (Bertone-Johnson, 2005). ThysJacobs (1998) treated women with documented PMS using 1200 mg of calcium carbonate daily to gain significant reductions in mood symptoms, pain, fluid retention, and food cravings.

Magnesium supplementation has also been studied (Facchineti, 1997). Taking up to 360 mg of magnesium daily from cycle day 15 until flow has been found to decrease negative moods when compared to a placebo/sugar pill (Facchineti, 1991).

Vitamin B6 is a cofactor in the formation of serotonin, a neurotransmitter that figures prominently in studies of severe mood swings and depression. Without adequate Vitamin B6 less serotonin can be converted from the essential amino acid tryptophan. The RDA for vitamin B6 is 2mg/day, yet PMS studies have used doses ranging from 50-800 mg/day. For treatment of premenstrual mood swings, irritability and depression doses should be no more than 300 mg/day. Reversible nerve injury has been reported at higher doses.

DIET

Studies have shown that women with PMS crave carbohydrates. In animal models increased carbohydrate intake causes increased release of serotonin, that neurotransmitter in the brain which prompts feelings of improved mood. It has been theorized that women with PMS may be attempting to self medicate for their down moods by increased cravings for starches and sweets. Yet simple sugars can cause the body to release additional insulin, so it is recommended that "complex carbohydrates" be consumed instead. The use of whole grain bread and cereal products can be part of a morning or lunch meal. Legumes in the form of lentils, split peas, or beans can help buffer blood sugar. Think bean burritos on a whole grain tortilla...or lentil soup with a whole wheat bagel plus low fat cheese.

The recommendations to decrease intake of caffeine, alcohol, and salt are based upon much less rigorous science. Early studies in the US (1985) and China (1989) found that increased PMS symptoms were linked to as little as one cup of caffeine beverage per day. Women given an intravenous dose of alcohol were noted to have decreased tolerance for alcohol effects in the premenstrual week, as opposed to their postmenstrual week. The average American diet can contain as many as 8,000-9,000 mg of sodium per day. For women with salt sensitive fluid retention, restricting salt intake to less than 2,000 mg per day may be helpful. Take a look at you favorite snack foods, even among the low fat variety there can be considerable sodium content.

COMPLEMENTARY & ALTERNATIVE TREATMENTS

With an increased interest in "alternative therapies" some researchers have chosen to study herbal, or body work therapies for common premenstrual symptoms.

Soy isoflavones (68 mg/day) may be helpful for breast tenderness, abdominal bloating, cramps and headaches (Bryant, 2005).
Chasteberry (in the form of Vitex agnus castus extract, 20 mg daily) was found to be more effective than placebo for the relief of mood swings, headache, breast tenderness, and bloating (Schellenberg, 2001).
Ginko biloba (80 mg twice a day from cycle day 15) was most successful in treating breast pain. (Tamborini, 1993).
The only study utilizing St. Johns Wort (900 mg/day in divided doses) for anxiety and depression showed benefit. However, it was evaluated in only 19 women—all of whom knew they were getting the real herb treatment.

Ear, hand, and foot reflexology demonstrated improvement in premenstrual symptoms (Oleson & Flocco, 1993), as did one which utilized nine sessions of Qi therapy (Jang, 2004). Acupuncture on the outer part of the ear decreased cramps, nervousness, food cravings and other premenstrual problems (Gerhard, 1992).

WHEN TO SEEK PROFESSIONAL INPUT

If your symptoms have not responded to self help measures then it is time to see your GYN, or clinic, for some additional evaluations. There may be an underlying medical disorder (e.g., thyroid disease, depression, anemia, atypical migraines, etc) which is responsible for low grade symptoms which are worsened during the premenstrual week.

When symptoms are determined to be PMDD (Premenstrual Dysphoric Disorder) there are numerous prescriptive medication options. While PMDD has a greater emphasis on the mood symptoms of "PMS", if a woman is having marked physical symptoms she might be tried on drugs to target her specific physical concerns such as bloating or severe headache.

The most important take home message: If premenstrual symptoms are bad enough to impair your relationships or quality of life then it is time to take action. Try the self help strategies first. If those do not provide enough relief then your GYN provider may be able to help.

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Do You Want to Spare Your Daughter a Colposcopy and LEEP?

2007-09-10T11:21:00.000-07:00

Between 50%- 75% of adults will acquire some type of human papilloma virus (HPV) if they are sexually active. This is particularly likely if they, or their partner, have had more than one partner. The FDA has recently approved the first vaccine (Gardasil ®) which prevents HPV infections linked to cervical cancer, abnormal PAP smears, and even genital warts. Here are some points to consider if you are thinking about immunizing your daughter - or yourself.

Who Should Get Vaccinated?

The FDA has approved Gardasil for females between the ages of 9 and 26. The greatest number of persons acquiring HPV are young women 15 to 24 years old. The vaccine is most protective for women who have not yet become sexually active. Thus, if a woman is virginal the vaccine might still be given if she over 26 years of age.

Acquiring the virus when a teenager is particularly worrisome. In a young woman there is a proportionally larger area of a more delicate, vulnerable tissue (glandular epithelium) on the face of the cervix. With time this tissue is replaced by squamous epithelium which provides a thicker protective layer—more like our external skin. Viruses are opportunists. The mild tissue trauma of intercourse coupled with a more fragile cervical skin could make it easier for the virus to gain entry.

One well done study by Ho and colleagues (1998) followed older adolescents over three years. At the end of the study some 43% became HPV positive. This confirms the ease with which HPV can be passed between sexual partners. Surprisingly, of this group of newly infected women, only 9% continued to show persisting evidence of HPV. In many cases, especially with the "low risk" subtypes of HPV, a competent immune system can appear to clear the evidences of viral infection. Yet HPV can be acquired and be "dormant". Then, in times of a lowered immune function (e.g., pregnancy, chronic illness, or use of immune suppression drugs), dormant viruses such as herpes and HPV can produce significant infections.

Which Vaccine Should You Choose?

There are more than 30 types of HPV which are sexually transmitted. These have been classified into "low risk" and "high risk" subtypes. HPV subtypes 6 and 11 are considered to be low risk. They are linked primarily to the cauliflower-appearing genital warts, and low grade cervical lesions (eg LGSIL, CIN 1). Subtypes 16 and 18 are considered to be high risk as they are linked with persisting HPV infections and severely abnormal PAP smears. These two high risk subtypes are the probable cause of about 70% of cervical cancers.

The currently available Gardasil vaccine provides protection for all four of the HPV subtypes mentioned above. Another vaccine, "Cervarix" will likely be available in the near future. The Cervarix vaccine has been shown to protect from HPV high risk subtypes 16 and 18. Both vaccines have been shown in large research studies to provide 100% protection for the high risk subtypes.

OK, What Are the Downsides to Getting an HPV Vaccine?

Both vaccine require a series of three injections spread over a six month period. Currently it is not known if a booster shot would be needed when the woman is older to help keep her immunity at a protective level. Studies are ongoing to try and answer this question

While most major insurance companies are hopefully going to cover the cost of this vaccine, paying for the series of injections would be $360.00 if paid out of pocket. If a low income young woman is covered by the Vaccines for Children Program, this vaccine is paid for by the program.

Gardasil is a non-live virus type of vaccine. It does not contain the controversial ingredients thimersol or mercury. There is not enough long term data to suggest that it can be given during pregnancy. There are several medical conditions (eg immune suppressed) where a vaccine may not be as effective.

Like many other immunizations where an injection is required there is the trauma of getting "a shot". The most common side effect of this injection was redness and swelling at the injection site—this was experienced by about 25% of subjects receiving the vaccine. Other less common side effects were soreness or itching at the injection site, or low grade fever.

Are You Going to Get This, Jane?

Alas, I am too old, and have had too many sexual partners over my early life. But if I had the opportunity I would certainly do this. My parents had me vaccinated against smallpox. This was considered routine at the time. Some countries routinely vaccinate for tuberculosis. I believe all parents have to consider the pluses and minuses of giving preventative vaccines to some pathogen their child may never encounter. HPV is an infection that a majority of persons will contract. In my professional opinion this vaccine offers advantages to women not yet sexually active.

For more in depth information consider reading this report from the Centers for Disease Control (CDC): Recommendations of the Advisory Committee on Immunization Practices.

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Why Do I Itch "Down There?"

2007-07-19T10:00:00.000-07:00

There are lots of comments around the blogs here about itching and burning in the vaginal area and what might cause it. Here are some possibilities:

Yeast Infections: Yeast infections of the labial area can be treated with an over-the-counter vaginal yeast cream (e.g., containing miconazole or clotrimazole).

Pubic Lice or Scabies: Two other causes of itching that is worse at night or with heat are scabies or crab lice. One does not have to be sexually active to acquire one of these infections. Over-the-counter remedies are available to kill the lice and eggs.

Genital Herpes: Another possibility would be a herpes outbreak. Sometimes a woman could have a very mild first outbreak then years later have a more severe second outbreak. If herpes is a culprit, you may notice several discrete lesions rather than a generalized rash in that area. If you have NEVER been sexually active then I would discount herpes as a possible cause.

Eczema: One can get an eczema type rash on the vulva as well. This would be treated with a steroid cream.

If you're here because you've got an itch you'd rather not be scratching in public, your best bet is to try and have someone examine the area as soon as possible. The treatments for each of the conditions mentioned above are very different, so getting a correct diagnosis is essential.

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Is The Thong All Wrong for Women's Health?

2007-07-12T12:06:00.000-07:00

Photo Credit: Vince Viloria

If you search on the internet for GYN problems attributed to thong underwear you can find sites which claim thongs increase the risk for urinary tract infections, vaginal infections, clitoral pain, and irritation of hemorrhoids. Is there research which can validate such claims? What about the claims that a type of fabric (e.g. cotton vs synthetic) can make a difference if one wears a thong? In the interest of science, I went on a mission to answer such questions.

Some 93% of urinary tract infections (UTIs) in women are caused by the enteric (bowel) bacteria called E. Coli. Theoretically, any mechanical movement which moves stray E. Coli from the anal opening toward the urethra should increase risk of UTIs. Thongs with their positioning in the gluteal fold would seem ideally suited to providing transit opportunities for E. Coli. Yet there is no published data which suggests that UTIs are more frequent in thong wearers. Looking back to earlier studies one can find that, despite popular opinion, there is not association between tight pants or other restrictive clothing and UTIs (Remis, Am J Epidemiol,1987; Foxman, Am J Pub Health, 1985). Overwhelmingly the strongest predictive factors for UTIs in younger women are: increased frequency of intercourse, use of diaphragm + spermicide, spermicide use, and past history of other UTIs (Hooton, N Engl J Med, 1996).

E. Coli can also be found in the vagina. Yet it is not a common cause for vaginal infections. As with UTIs one of the easier ways for bowel bacteria to get into the vagina is via intercourse. Perhaps the most important preventative measure is to clean well after bowel movements (always wiping away from the vagina/urethra) - and never have sex (just kidding).

As anyone who has ever used thongs can attest, there is a wide range in fit. The strap can be thick or thin, and the overall fit can be loose or what one women's magazine called "atomic buttocks' floss." It may be true that tight thongs can cause irritative pressure to the clitoris or to other friction sensitive conditions such as lichen sclerosus or external hemorrhoids. Alas, no one has published any data about the incidence of such problems.

Surprisingly, researchers have done experiments about the type of fabrics used in undergarments. Comparing 100% cotton to 100% acrylic, under resting and exercise conditions, both materials were found to be equal in their wicking abilities. Only in the subjects who perspired most heavily was there a difference. Cotton accululated 71 grams of sweat compared to 46 grams in the acrylic (Rissanen, Ann Physiol Anthropol, 1994).

When types of underwear material were correlated to frequency of UTIs, Foxman and Frerichs (1984) found cotton panty use linked to increased UITs. When women with documented UTIs were asked about underwear habits over the preceding month, both initial and recurrent UTI sufferers stated cotton rather than synthetic panty use.

The above fact illustrates the scientific principle, "association does not always prove causation." Rather than cotton underpants causing increased UTIs, perhaps cotton is chosen by women who are at risk for getting more bladder infections. By the same logic, before we condemn thong underwear, one would need to take into account the individual GYN history of the woman wearing the thong. In some instances the thong may be wrong, in others - no problem.

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Missed Your Period But You're Not Pregnant?

2007-06-19T18:12:00.000-07:00

In addition to posting updates about important breakthroughs in women's health, there are some questions that many women ask on my message board. From time to time, I'll going to post some of the information I share with those women in the hope that it will help others who visit WebMD with similar questions.

A very common cause of a missed period is not having ovulated that cycle. In a normal cycle, estrogen is produced all month. Estrogen is responsible for building up the lining of your uterus so you have something to shed each month. In a normal cycle, progesterone production increases following ovulation.

Progesterone "stabilizes" the uterine lining in preparation for a possible implantation of a new pregnancy. If you are not pregnant that month the levels of estrogen and progesterone fall, triggering the release of the uterine lining - your period. So, if you do not ovulate, the estrogen build up of the lining continues, but without the usual ovulation-associated progesterone. Thus, the hormone levels don't decline, and the lining stays up inside the uterus - your missed period.

If you have been several months without a period, a gynecologist may give you some progesterone in a pill form (eg Provera 10 mg for 5 days). Within 48-72 hours after stopping the progesterone your "progesterone blood level" will fall, triggering the release of the lining that has been building up. Alternatively, the built-up lining may begin to shed under its own weight. Either way, women report that these periods are very heavy - as though several months of lining are shed.

Such flows can also be prolonged or have a stop and start pattern. The reason for this erratic or prolonged bleeding is this: without the progesterone the lining does not have a clean shed down to the base layer.

Causes for not ovulating are multifold: thyroid problems, pituitary problems, ovarian cysts, physical stressors (eg sudden increases in exercise, crash dieting), emotional stressors (problems with parents or boyfriends/girlfriends, exams), increased body weight, anorexia, rotating shifts at work, etc.

If the bleeding persists you should contact your GYN or clinic. The bleeding can be stopped with hormones, and any possible causes of not ovulating assessed. Hopefully your cycle will reset itself.

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Pelvic Muscle Twitches

2007-06-12T13:34:00.000-07:00

Amazingly, questions arise on the Women's Health Board about vibrating sensations in the vagina or pelvic floor at least once a month. I have done MULTIPLE literature searches at the National Library of Medicine site, and other search engines - none of which have ever yielded a conclusive answer. My best GUESS is fasciculations - small nerve twitches which induce small muscle twitches. This would be analogous to twitches of the muscles of the eye lid.

Most of us have had these uncontrollable eye lid spasms ("blepharospasms") at one time or another. The triggers for eye lid spasms are fatigue, caffeine use, stress. Some treatments are pressure applied near to the twitching muscle, or even Botox.

There is another name for involuntary sustained muscle contractions which can lead to abnormal movements. They are called focal dystonias. Most of the focal dystonias include the neck, eye lid, mouth/jawbone, even writer's cramp. The start of such conditions can be after a trauma to the body part - or they can arise without apparent cause. There may be a genetic predisposition. The exact cause is not well understood, but the area can be injected with botox which causes the affected muscle to relax.

For more information on the more severe forms of focal dystonias, the Dystonia Society website offers a good overview.

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Fighting Midlife "Weight Creep"

2007-06-07T11:49:00.000-07:00

The Pelvis Queen's Guide to Fighting the Effects of a "Permissive Environment"

Weight Loss Pills

There are pharmaceutical options, most of which are by prescription. For short term use phentermine can be prescribed as an appetite suppressant. It is related to amphetamine type medications so it can increase heart rate, and in some women worsen symptoms of anxiety and insomnia. For longer term use the US FDA has approved subtramine which works via serotonin signals from the gut to the brain creating a feeling of satiety.

Orlistat, formerly a prescription drug has been approved for over the counter sale in the US. When taken with a high fat meal it causes some of the fat to move rapidly through the gut so it cannot be absorbed. The side effects, if one eats a high fat diet can include oily stools and some rectal leakage. With most of the prescription drug treatments a weight loss of 5-10% of original body weight is considered a good result.

But is weight loss really as simple as taking a pill?

Women often ask on my message board if there are "natural" or alternative treatments to pharmaceutical approaches. There have been two recent reviews of the alternative medicine literature concerning weight loss. All proposed treatments were studied in combination with a placebo. These reviews found the best outcomes for ephedra, conjugated linoleic acid, pyruvate, and hypnotherapy.

In terms of diets, a meta-analysis of many diet studies (Nordman, Archives of Internal Medicine, 2006) identified that both low carbohydrate and low fat diets were equally effective for inducing weight loss for up to one year. The "A to Z Weight Loss Study" (Gardner, JAMA, 2007) showed that the Atkins diet (very low carbohydrate) produced the most weight loss. In this group the mean loss was 9.2 pounds. But the differences between the Atkins, Ornish, Zone and LEARN (traditional 60% carbohydrate + calorie restriction) would likely have diminished over a longer follow up time according to the authors.

Even small improvements in diet can stop "weight creep". While there were no differences in the incidence of heart attacks and strokes, participants in the Women' Health Initiative diet study did not gain weight compared to a control group (Howard, JAMA, 2006). Both groups were followed for three years. The "winning" women ate one serving more of a fruit or vegetable, ate ½ more serving of whole grains, and decreased their intake of saturated fat.

How Much Weight Loss Is Really Feasible, or Will I Ever Be a Size 4 Again?

If midlife women are enrolled in an intensive four-month program that encompasses a 400 calorie deficit and 150 calorie increase in exercise (eg waking two miles/day) what could one expect as a result? This intervention was done with 136 women where the average age was 48 years old (Teixeira, Medicine and Science in Sports & Exercise, 2006). After 4 months there was an average loss of 6% of initial body weight. By 16 months the mean loss was 5.5% of their initial body weight. Individual variation was large at every assessment. That means that some women had much better results than others. Yet it was noted that exercise was one of the strongest predictors of success.

How Much Exercise Is Needed?

The Centers for Disease Control (CDC) suggests a "minimum of 30 minutes most days to improve health." That would be about 150 minutes/week. The Institute of Medicine in the USA specifically addresses weight issues: "Minimum of 60 minutes per day on most days per week to control weight." That would be 300 minutes of some type of exercise per week. If one walked a mile in 20 minutes, whether at the mall, pushing a stroller, or taking with a friend, walking two miles per day would fulfill this "exercise prescription."

If exercise is combined with decreased calories the outcome is enhanced. Among 200 subjects taking about 1500 calories per day, those that exercised 200 or more minutes per week had an average 13% loss from their baseline weight. Those that exercised less than 150 minutes per week the average loss was about 5% (Jakicic, JAMA, 2003).

But I Have a BUSY Family Life, You Say...

Ok, it is true that women have way too much to do and never much time for themselves. It is a gift to have a few minutes of alone time at night. So what can one do? A registered dietitian (C. Nonas, NAMS, 2006) got straight to the point in a recent presentation. She asserted that women have a harder time losing weight as they move into middle age - if they can just maintain they are doing well. She suggested starting early in the cycle of "weight creep." If your body mass index (BMI) is less than 25 lose 3-5 pounds by age 40. If your BMI is more than 25 consider losing 5-10 pounds.

Given that most diets show similar results over the long haul, choose one that is workable for your preferences. Since the secret of many commercial diets is portion control or decreased calories by eliminating certain types of foods, you could try something even simpler. Ms. Nonas suggested a 1200 calorie meal plan which utilizes easily obtained meal replacements such as bars or shakes. For example: Breakfast is a shake plus a fruit, Snack is one fruit or protein serving, Lunch is a bar and a vegetable serving, Dinner is a reasonable portion of what you have fixed for others in the family.

Say you don't have time to do 30-60 minutes of exercise on most days. It is an option to break that time up into smaller segments. Keep track of the walks across campus, walking at work, walking kids to school and back home. All those trips up and own stairs, yard work--all those minutes count. And it's never too late to learn a new physical skill. For me it was cross-county skiing, and backpacking in my 30's. I took up running in my early 40's, and began weight lifting at 50. This was a departure for a person who was always last to be chosen for a team because I was so uncoordinated (I still am).

In Conclusion...

What I learned can be summarized in a few words. While becoming menopausal may impact weight and fat distribution, the effect of menopause is smaller than that of general aging and lifestyle choices. Genes do play a role but their impact is modulated by age and how we eat and exercise. ...Thanks for all the good questions which pushed me to make this investigation.

Yours,

Jane

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Are Our Genes Responsible for Midlife Weight Gain?

2007-06-06T11:44:00.000-07:00

This was an area where I received my biggest change in attitude. This is also an area where there has been a recent explosion in knowledge. One review on this subject studied family, twin and adoption research trials. Within this broad section of groups the suggested heritability of obesity ranged from 10-80%! Within my reading the number 20% of overweight is due to genes kept appearing. Remember that single gene defects are relatively rare. More common is a multitude of genetic changes which make one susceptible to weight gain - especially in a permissive environment.

One study which illustrates this point was performed in the Framingham Offspring Study (Corella, Journal of Molecular Medicine, 2007). Of the 1207 women tested, 13% had single neucleotide polymorphism called APOA5-1131T>C. Those that were genetically at risk for obesity by this trait had increased body mass index when their diet contained more than 30% of its calories from fat. In those with the "obesity gene" who followed a low fat diet there was no increase in body mass index.

Now that you know what age, genes and menopause have to do (or not) with midlife weight gain, my next post will deal with how to prevent it.

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