Vitamin D and Women's Health

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
<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 WebMD, LLC. All rights reserved.

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:

• Repair of Vaginal Wall Prolapse (Vaginal Vault Prolapse)
• Pelvic Organ Prolapse

Related Topics:

• GYN Issues with Jane Harrison-Hohner, RN, RNP
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Test Your PAP Smear IQ

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"

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



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



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



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



5. 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



6. 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



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



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



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



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

ANSWERS

1. 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.



2. 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.



3. 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.



4. 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.



5. 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.



6. 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).



7. 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.



8. 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").



9. 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.



10. 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.

Related Topics:

• GYN Issues with Jane Harrison-Hohner, RN, RNP
• Get the Women's Health newsletter in your inbox weekly

Mysteries of Birth Control Pills Solved!

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.

Related Topics:

• WebMD Birth Control Health Center
• GYN Issues with Jane Harrison-Hohner, RN, RNP
• Get the Women's Health newsletter in your inbox weekly

Postcoital Bleeding

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

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

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:

• WebMD Video: Lollipop Breast Reduction
• WebMD Video: Breast Implants - Size Matters
• A Lifetime of Healthy Breasts
• Mastopexy or Breast Lifting Procedures
• GYN Issues with Jane Harrison-Hohner, RN, RNP
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