Getting Pregnant!

Fertility FriendBecoming pregnant can be fun, happy, exciting, or sometimes unplanned. Knowing how it happens is very useful information to make it easier to achieve when desired, and to be avoided if that is the goal.

 

The average menstrual cycle lasts for 28 days and can range from 21 to 35 days. In an average cycle ovulation occurs on day 14. Signs may include a cramp in the lower abdomen or back, breast tenderness, increase in a clear vaginal discharge, or an increase in sexual desire.

 

SpermFor pregnancy to happen, sperm must be present in the fallopian tubes and meet with an egg. When a man climaxes during sex millions of sperm go into the vagina and some can make their way through the cervical mucus and into the uterus and from there into the fallopian tubes. Sperm can live inside a woman’s body for 3 days or more, but an egg’s life is much shorter, only 1 day. So pregnancy can occur if an egg is already present when you have sex, or if you ovulate within a day or two after you have sex. This means that your fertility time is limited. You are fertile from 3-5 days before ovulation to 1 day after ovulation. Trying to time intercourse so that you have sex just before ovulation seems to be a good way of thinking about it. There is also a new theory that ovulation is not just a random event. Research has discovered a special protein in semen that can actually cause ovulation.

 

Knowing when you are fertile can be a challenge. There are different methods to predict it. For planning purposes, there are phone apps that can be helpful such as Fertility Friend or My Days. These apps calculate your expected next period and make predictions based upon it. The predictions are less accurate if your cycles are less regular. You can also go to the drug store and purchase an ovulation predictor test kit such as Ovutime or Ovutest. These urine tests indicate when the hormone LH becomes present. When LH rises in your circulation it causes ovulation and this hormone can be detected in your urine. When the ovulation test turns positive, this means you should have intercourse that day and the next day for best results. You may also notice changes in your cervical mucus where it becomes increased in amount and more clear and watery in quality. To promote pregnancy you should time intercourse to be daily or every other day when good quality cervical mucus is present. It should not be less often than every other day or more frequent than once a day for the best fertility results. You can also track your temperature with a special thermometer to measure your basal body temperature. Your temperature rises after you ovulate and stays up by a small amount for 2 weeks. This method is not that useful in that by the time you discover you have ovulated, it’s already too late for timing of sex.

 

You can start trying for pregnancy soon after you stop using a birth control method, but not too soon. If you are using the pill or a similar hormonal birth control method, it is a good idea to wait at least a month or two to allow your body to return to normal. If you get pregnant in the first cycle after stopping the pill you will have double the chance of having twins. While that may sound exciting, having one baby at a time is a much safer way to go, and much more manageable for taking care of children later on. We recommend stopping the birth control method, waiting 1-2 months before trying for pregnancy, and being on vitamins that contain iron, folic acid and DHA. In a given cycle the chance of success is only 20%, and it is normal to take months for pregnancy to happen. Do not be discouraged if it does not happen right away. With normal fertility you will become pregnant within 1 year, and 85% of couples will be successful in having this happen. 15% of couples will take longer than a year (that is called infertility), but only 1% of couples are unable to conceive. If you are trying for pregnancy and it seems to be taking too long, don’t worry about it. Sometimes you can be trying too hard for pregnancy. Increasing your anxiety about it is not helpful for fertility. Relaxing and having a good time is usually the best recipe for success.

 

First signs of pregnancy include feeling very tired, feeling nauseous, having breast tenderness, and your period being late. If you think you may be pregnant, doing a home test is helpful. If positive, these tests are usually reliable. If a test is negative it may be accurate or not. Sometimes the level of pregnancy hormone is elevated by too little to be detected by the urine method. If you really need to know (for example when a tubal pregnancy is suspected), then a blood test is much more reliable to detect an early pregnancy. Blood tests and ultrasound are also very helpful if you are bleeding and concerned about a possible miscarriage.

 

When you have a positive test, call us to make an appointment to come in and confirm your pregnancy. If you are at least six weeks and one day from the first day of your last period, we should be able to see the fetus and its heart beat by ultrasound. Once we see the fetal heartbeat the chance of successfully having a baby goes up to 85%! Then you are on your way to having a new life in your family. Good luck!

 

This article is partially based on information in ACOG’s book, Your Pregnancy and Childbirth, Month to Month.Your Pregnancy and Childbirth

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Menopause and Hormone Therapy – What’s New?

estrogen replacementIt was only about 100 years ago that the average woman’s life expectancy increased to the extent she would live past the time of menopause. Now with the average life expectancy into the 80’s, a woman may live more than 1/3 of her life in the menopause. The number of women in the menopause is increasing and expected to go up even more. The consequences of menopause include hot flashes, night sweats, insomnia, skin changes, mood changes, depression, anxiety, irritability, loss of libido, vaginal atrophy, cardiovascular disease and weakened bones. How can hormone therapy be safely used to help treat this problem affecting so many women?

We need to put hormone therapy in perspective, and also consider risks and benefits of treatment. Although there is a lot of controversy in the media, patients look to their doctors to be their advocates and give good advice about treatment. It’s our duty as doctors to be informed and advocate for our patients. We need to treat disease in a preventive way, rather than wait for the damage to be done. Disease often starts off in a pre-clinical way, and with some diseases it can be difficult to detect early on. Many diseases that occur have their roots decades before they can be detected, and similarly their treatment may take time to demonstrate a benefit.

Menopausal symptoms

Hot flashes are one of the most bothersome symptoms of menopause. 50% of women have them longer than 4 years, 23% more than 13 years. Temperature regulation helps your body maintain the proper temperature by causing sweating when you are hot and chills when you are cold, thus maintaining a neutral zone of comfort. Hot flashes are a disturbance of this system which are thought to be due to a change in the temperature regulatory system where a decrease in estrogen causes a decrease in the size of the normal thermo-neutral zone in-between sweating and shivering. The end result can interfere with your sleep and your comfort.

Benefits and risks of treatment

Combination estrogen and progestin therapy is FDA approved to treat menopausal hot flashes, prevent osteoporosis, treat vaginal atrophy, and provide other benefits to reduce insomnia, irritability and short-term memory loss. Hormone therapy is highly effective to relieve hot flashes, both their amount and intensity. In women who have a uterus, estrogen alone therapy can increase the risk of uterine cancer, but the increased risk is removed once progesterone therapy is added to estrogen. In 2002 the Women’s Health Initiative study came out and revealed risks of this treatment, including an increased risk of heart disease, stroke, blood clots and breast cancer when both estrogen with progesterone are taken. This had the effect of scaring women into avoiding estrogen therapy even though the absolute risk was only 8 per 10,000 women and the study was based on doses higher than are in use today. This risk is roughly equivalent to the risk of dying in a car accident, and is relatively rare. Rather than being misled by percentages of change, it’s more scientific to consider the absolute risk, and when the risk is less than 1 per 1000 you must weigh that small risk against the improvement in relieving symptoms you get with the right treatment. Other variables to consider include age and method of treatment. Women receiving hormones in the age group of 50-59 have a much less risk of coronary heart disease, stroke, and breast cancer than those in the 70-79 age group. Also women who receive estrogen through a transdermal patch have a significantly reduced risk of a blood clot compared with oral treatment, possibly due to a more stable delivery system and avoiding metabolism by the liver where clotting proteins are made.

Having a uterus makes a difference

Having had a hysterectomy means that hormone replacement therapy need only include estrogen, which is the hormone that conveys most all of the benefits and very little risk. This good hormone decreases the risk of heart disease, protects against breast cancer, and reduces damage to blood vessels with benefits in the brain leading to less risk of Alzheimer’s disease. Women who don’t have a uterus are in a much better position because the only major risks to consider are those related to blood clots and much of this risk can be reduced by getting estrogen through transdermal medications that don’t affect the liver where clotting proteins are made. There are benefits in vaginal lubrication, increased vaginal thickness, better sexual function, better support of the bladder, improved bone strength and decreased cancer of the colon.

Having a uterus makes treatment more complex, because an progestin needs to be added to treatment to decrease the risk of uterine cancer. But what if there were a medication available that can still provide estrogen benefits without the progesterone risk? Well, there is a new type of estrogen now available called a SERM, or selective estrogen receptor modulator, and when combined with a traditional estrogen, its called a TSEC, or tissue selective estrogen complex. The new estrogen has been designed to have some progesterone-like beneficial effects on the uterus (but without a progestin) and also when combined with a traditional estrogen conveys an improved quality of life, more satisfaction with treatment, improved vaginal health, improved sleep, improved bone density, significantly less hot flashes, with less breast pain and less bleeding. The new medication, Duavee, combines an estrogen with a synthetic “designer” estrogen called Bazedoxifene and represents an improved hormone therapy for those women who have a uterus.

While combined traditional hormone replacement therapy can still be used for the majority of women being treated, there are groups of women who are particularly good candidates for this new approach, including women with a family history of breast cancer, women who have had a problem with combined therapy such as tender breasts, those with increased breast density, or if they have had bleeding issues.

Conclusions 

We need safe and effective treatment for menopausal symptoms. The risk of breast cancer is slightly increased with hormone therapies that combine estrogen with progesterone, but not with estrogen alone or in combination with a new estrogen (called a SERM). TSECS combine an estrogen with a SERM to provide relief of menopausal symptoms without the increased risks caused by progestins and offer a new, safer treatment for menopause. These new developments in hormone therapy are just the beginning of designing new safe treatments that provide more benefit at less risk.

This information is from a course “Menopause and Hormone Therapy” given at the 2015 ACOG Annual Clinical Meeting and was presented by Drs Hugh Taylor and JoAnn Pinkerton.

Vaccinations are good for you.

From December 28, 2014 through January 21, 2015 more than 50 people from six states were reported to have measles, mostly from an outbreak linked to Disneyland in California.

Measles is a highly contagious, acute viral illness. It begins with fever, cough, runny nose, and pink eye 2-4 days prior to developing a rash. It can cause severe health complications including pneumonia, encephalitis and death. Measles is transmitted by contact with an infected person through coughing and sneezing. Infected people are contagious from 4 days before their rash starts through 4 days afterwards. After an infected person leaves a location, the virus remains viable for up to 2 hours on surfaces and in the air.

Measles was declared eliminated in the United States in 2000 because of high population immunity brought about by a safe, highly effective measles vaccine (MMR). However, measles is still present in many parts of the world and outbreaks still occur in the U.S. when unvaccinated people become infected. Disney and other theme parks are international attractions, and visitors come from many parts of the world where the measles vaccine is not readily available.

More disturbing though, are people who refuse to vaccinate their children due to a “philosophical” objection. As it turns out, there is no medical support for theory that vaccines are harmful. There is no evidence that the MMR vaccine causes any chronic illness. The question about vaccine safety started with a bogus report published in the British Medical Journal in 1998 claiming the vaccine caused autism. By the time that scientists determined that the data had been falsified so the author could collect hundreds of thousands of dollars from a lawyer suing vaccine companies, the damage had been done: many people believed that the MMR vaccine was harmful. The BMJ retracted the article in 2010 when the pattern of falsified data to support a lawsuit was found out. However, a damaging public health scare that associated MMR with autism had been falsely created.

Vaccine facts include that more than 100 million diseases have been prevented by vaccinations in the US alone. The HPV vaccine (Gardasil) is safe and is nearly 100% effective in preventing cervical cancer produced by certain HPV strains. Gardasil coverage has been strengthened and an even better version (Gardasil 9) will be available soon. The flu vaccine does not cause the flu and is safe for pregnant women to take. TDAP vaccine has been found to be safe during pregnancy and should be given to all pregnant women between 27 and 36 weeks of gestation to decrease the risk of pertussis (whooping cough) in newborn babies.

Giant PeachThe famous author Roald Dahl dedicated his book “James and the Giant Peach” to his daughter Olivia, who died of measles. He hoped that telling people about her death would serve to protect others from illness and death from this disease. He wrote: “Here in Britain, because so many people refuse, either out of obstinacy or ignorance or fear, to allow their children to be immunized, we still have 100,000 cases of measles a year. More than 10,000 will suffer side effects and about 20 will die.“

The exponential rise of the latest measles epidemic in California due to large numbers of unvaccinated people should serve as a warning about the dangers of giving people the right to not vaccinate their children based only on “personal beliefs.” Vaccines are good for you and we encourage our patients to receive them to improve their health and the health of their children.