Women's Health

By Jane Harrison-Hohner, RN, RNP

“Driving me crazy!” “I want to tear my nipple off!” These are just a couple ways our readers have described the torment of a nipple itch. Both women and men have written to WebMD about this frustrating condition, most often with vivid descriptions of their itching agony. Yet rarely is there a documented diagnosis and treatment. The causes can include one breast and numerous skin conditions. To give you the best overview I have decided to cover the most worrisome and most common causes first, to be followed by some of the other origins of an itchy nipple.

Paget’s Disease

Paget’s Disease (PD) is a rare form of breast cancer that can involve both the nipple and the aerola (colored area that encircles the raised nipple). While it’s the least common cause of nipple symptoms, it is the most worrisome. So let’s discuss it first.

An itching or burning sensation of the nipple or aerola is a common initial symptom; it is often accompanied by a crusted appearance. Persisting soreness/itching with a scaly, eczema-like rash that does not improve despite prescription treatment is highly suspicious for Paget’s.One may also have a yellow- or blood-tinged nipple discharge from the affected side. In later stages there can be an ulcer or mass in the areola. Most often, PD involves only one breast. Thus it is not usually linked to bilateral nipple itching or rashes. PD is typically found in women between the ages of 50 and 60.

PD is diagnosed with a clinical breast exam, thorough patient history, mammogram, and an ultrasound if indicated. If there is still a suspicion, despite a normal exam and mammogram, a MRI can be utilized to identify PD. A breast biopsy of the nipple will provide tissue to be sent to pathology for a microscopic examination and conclusive diagnosis. Any coexisting lumps would be biopsied as well.

Even though you have an itchy, crusted nipple with a discharge there is a benign (non-cancerous) condition which can mimic PD. One can have a benign tumor of the breast duct tissue called “erosive adenomatosis of the nipple”. This is why a surgical biopsy is the “gold standard” for conclusively diagnosing PD.

Treatment for Paget’s disease is breast surgery, either mastectomy or a cone-shaped excision of the nipple. One study from Sweden followed women for 12 years to see if mastectomy was necessary for all women with PD. Those who just had Paget’s of the nipple (not invasive breast cancer) were selected for the cone-shaped excision. Those select patients with the breast conserving surgery had survival rates similar to those who were treated with mastectomy.

Atopic Dermatitis

From the least common cause of itchy nipple (Pagets’s Disease), let’s move to the other end of the spectrum and discuss one of the most common causes. That would be Atopic Dermatitis (AD), also known as eczema. With this condition itching is almost always present and can be severe. Itching may even precede the development of an overt rash. The rash can include small blisters with oozing or crusting. Further scratching could open the skin to bacterial infections or create thickened areas from constant inflammation and irritation.

Atopic Dermatitis can appear in persons of all ages. Since AD is thought to be due to a hypersensitivity reaction, persons may be more prone to develop AD if there is a personal or family history of allergies (e.g., asthma, hay fever).

Environmental triggers which can prompt AD to flare up can include:

• Dry skin
• Prolonged contact with water
• Dyes or scents added to skin products
• Environmental allergens such as cleaning products, wool, foam
• Stress

Atopic Dermatis is usually diagnosed by physical exam and a thorough history. If needed a skin biopsy can be done to rule out other causes of the itching and rash. When itching is severe and/or there is a known allergic trigger, antihistamine pills can be helpful. These would include both the sedating type (e.g., Benedryl®), or the non-sedating type (e.g., Clartin® or Zyrtec®).

The majority of AD remedies are topical treatments. One might be prescribed a steroid cream or ointment. A newer class of medications includes the topical immune modulators (e.g., tacrolimus or pimecrolimus).

There are also self-care and preventative strategies, which can decrease AD symptoms. Avoiding known triggers is foremost, but keeping natural moisture in the skin is an important goal. This can be achieved by decreasing use of drying soaps and prolonged hot baths. Once out of the bath or shower, a bland ointment or cream can be used to seal moisture in.

Interestingly, a number of our readers suggested treatments which fit this description. NipStick®, designed for joggers’ nipples, contains shea butter, jojoba oil, and beeswax. Another reader successfully used Kiss My Face Lip Balm® containing canola oil, beeswax, lecithin, coconut oil, and other emollients on her itchy nipples. Even Eucerin Aquaphor was found to be helpful by a reader.

Check back next week for other conditions that might be causing your itching.

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By Jane Harrison-Hohner, RN, RNP

Many of the currently menopausal women in the United States came of age during the “Swinging Sixties.”  Spurred on by very reliable contraceptives, the “sexual revolution,” and women’s right to have a satisfying sexual life, these women are less likely than their grandmothers to go off quietly into sexual retirement. Aging men with erectile problems have had several prescriptions drugs to enhance their sexual experience. Women have no FDA-approved drug to improve their sexual outcomes.  Here at Web MD, we recently posted a news story about the use of an over-the-counter hormone called DHEA, which was said to “ease menopausal symptoms and improve women’s sex lives.” When that same release showed up on the start page of my computer it seemed time to investigate these claims.

Let’s try and answer these important questions:

• Does DHEA improve sexual function?
• Is over-the-counter DHEA safe?
• What is the future for DHEA?

Does DHEA improve sexual function?

According to the just-published report from Genazzani and colleagues in Italy, it does. They state that a daily dose of a 10 mg DHEA pill worked as well as two different types of standard hormone therapy (tibolone 2.5 mg vs estradiol 1mg with dihydrogesterone 5 mg) in improving sexual function and frequency of intercourse compared to women who received nonhormonal treatment.

However, there have been other studies which do not suggest that DHEA works any better than a placebo pill. In one year-long study, 93 women with low desire were randomly assigned to take a sugar pill or DHEA 50 mg (five times more DHEA than the current study). Of the 85 women who were evaluated on satisfying sexual events and the Sabbatsberg Sexual Self-Rating Scale, the DHEA did not work any better than the sugar pill.

In an excellent review of DHEA use in postmenopausal women, the authors evaluated, then summarized the results of key studies up through 2010. They acknowledged that studies which did a single blood test for DHEA levels and a one-time questionnaire about sexual function seemed to suggest that low libido was linked to lower DHEA. However, when DHEA or a placebo/sugar pill was randomly given to study women, there was no significant benefit for DHEA pills.

Let’s say you are a postmenopausal woman and you decide to try DHEA. You have read that women’s natural DHEA levels peak while in our twenties—and most of us do not complain about libido in our twenties. So the next question would be: are DHEA pills safe?

Is over-the-counter DHEA safe?

Unlike in Europe, DHEA is available in the U.S. without a prescription. It is an active hormone, naturally produced by our adrenal glands. Our body will convert the DHEA to both estrogens (female hormones) and androgens (male hormones). I mention this as a breast cancer survivor once asked if she could take DHEA. I quoted a study by Genazzani (yes, the same scientist with the new study) published nine years ago in which postmenopausal women were given DHEA 25 mg pills for a year. Their blood levels of estradiol were 90 picograms. This is a level found in young, ovulating women.

Surprisingly, no undue stimulation of the lining of the uterus has been found in studies where menopausal women were given DHEA 25 mg or 50 mg. However, the women were followed for only 12 months. So we still do not know about long-term safety at such doses. If I had a patient using long-term DHEA I would want to be sure that their uterine lining was not being stimulated by newly created estrogen. This could be done with an ultrasound measurement of lining thickness.

What is the future for DHEA?

As noted above, DHEA can produce estrogen effects in the body. Estrogen has a very well demonstrated positive effect on sexual function. It can improve lubrication and quality of vaginal tissues. After menopause, when blood estrogen/estradiol levels drop below 20 picograms or less, vaginal dryness (“vaginal atrophy”) can make intercourse painful. In a “twenty- something” vaginal tissues will be 20-30 cells thick. After menopause when estrogen levels are low, vaginal tissues may be only 6-8 cells thick.

Currently, low-dose DHEA is undergoing testing to be an FDA-approved treatment for vaginal atrophy. Among the vaginal doses studied, blood levels of estrogen and androgens remained in the normal, postmenopausal range. Interestingly, the use of the 1% vaginal DHEA product seemed to yield not just improvements in lubrication/arousal/vaginal dryness, but also a slight stated improvement in orgasm.

The evidence continues to be mixed as to whether DHEA is the long awaited “wonder drug” for menopause. There can be so many variables involved in low libido, it is hard to believe that a single treatment will work uniformly well for all women. If readers are considering using DHEA pills  I would strongly urge you to let your healthcare provider know. It is not FDA approved, so the jury is still out.

By Laura Corio, MD

I decided to write about perimenopause not only because it’s my favorite subject, but also because a patient of mine has had an extremely rough time going through this period in her life. I wanted to share her struggles and her relief once we were able to get her to feel normal again.

Perimenopause is the four to seven years prior to menopause. It is a time in a woman’s life when her hormones are fluctuating and sometimes causing symptoms such as hot flashes, night sweats, insomnia, mood swings, anxiety and depression, joint pain, migraines, palpitations, decreased libido, vaginal dryness, weight gain, memory glitches and fatigue. There are other less common symptoms as well. Patients have come to me after they have been told by their doctors that they need to see a psychiatrist. Or they have come to me because their doctors have told them there is nothing they can to do until they’ve gone a full year without a period. This isn’t true. It is during the perimenopausal years that intervention is necessary and possible. Hormone replacement therapy is safe and effective during this time.

My patient is a 45-year-old who came to see me two years ago. During her periods she was experiencing heavy bleeding that frequently lasted two weeks at a time. Her previous gynecologist wanted her to undergo a dilation and curettage to clean her uterus. I disagreed. I felt that her issues were hormonal, that she was in perimenopause, and I asked about her other symptoms. She was experiencing anxiety, insomnia and emotional issues. She had a history of OCD (obsessive compulsive disorder), and all of her symptoms were much worse now. This is an important point. We know that women who have psychiatric disorders have a much worse perimenopausal transition.

The first thing I did was a timed uterine biopsy four days before her expected period. I wanted to make sure she did not have uterine cancer, and I also wanted to see if she was still making progesterone. I also did hormone studies on the second or third day of her cycle to see if she was close to menopause, and I did a transvaginal sonogram from day five through nine of her menstrual cycle. Everything pointed to perimenopause and I started her on progesterone oral bioidentical pills. She took them starting day 12 for 10 days to straighten out her cycle. It worked. But her other symptoms, such as anxiety and crying spells needed to be addressed as well. That’s where the psychopharmacologist came in to help. Together, we worked with antidepressants along with the progesterone.

The hot flashes followed about a year later. At this point, we decided she needed estrogen. I compounded bioidentical biEst cream, which worked for a short time, but eventually she needed pure estradiol. I switched her off the progesterone, which seemed to be making her depressed, and place her on a patch of estradiol. I followed her blood levels until we reached a good hormone level. She stayed on the estrogen patch without progesterone and her depression lifted and her moods improved. It was all right to stay on pure estrogen as long as she was getting periods at least every two months; but this was the difficult part because she would go long stretches without her period and I would add back progesterone and then she would feel terrible.

As time went on, it looked like menopause was getting closer. Her bloodwork proved that but also the fact that when we gave her a round of progesterone, she would not bleed. Finally, I put her on the estradiol patch and she is just taking estrogen. She feels great. But every three months I have to give her a round of progesterone, and that really affects her in a bad way. I am hoping that as time goes on she will get further from perimenopause and become a menopausal woman, and her symptoms will improve. We are still working with the psychopharmacologist and he has been extremely helpful.

There is no reason for a woman to suffer. It is in the perimenopausal stage that woman need to be treated. Once she goes a full year without a period, things tend to improve. Symptoms get better, there is no more bleeding, and you begin to feel like yourself again. Remember, if you see s gynecologist and he or she says there is nothing they can do, or they do not acknowledge there is something going on with you hormonally, you need to seek a new doctor.

Stay tuned for “H” for Hormone Replacement Therapy–an Update

By Jane Harrison-Hohner, RN, RNP

Women have been menstruating for as long as they’ve existed, and the products on the market are many and varied. In the last post, we covered sanitary pads and tampons. This post includes other, perhaps lesser known methods of dealing with “Aunt Flow.”

Sponges

As mentioned in the last post, sea sponges have been used from ancient times up to the present. One more modern version was advocated by Alicia Bay Laurel (she named herself after a favorite tree) in the hippie classic “Living on the Earth,” published in 1970. Here a 3 ½ x 4 ¾ inch natural kitchen sponge is cut length wise into four long strips. Usually natural sponge users are instructed to rinse used sponges in cold water and then boil to sterilize.

I found only one published study on sea sponge users. Compared to napkins and tampons, sea sponge users had higher counts of E. coli (common gut bacteria responsible for most UTIs), staph aureus and enterobacteria than tampon users.

Cups

The idea of using a cup-shaped device inside the vagina to collect menses reached a patentable form in 1867. The Hockert Catamenial Sack was attached via a string to a belt worn around the waist. Looking at the drawing submitted for patent made me wonder if the inventor was worried that the sack would “get lost” in the vagina. A more likely concern would be that it could drop into what passed for outdoor lavatories in those days. By 1937 a woman had received a patent for her design, which was a bell-shaped cup with a stem at the end.  This shape is still one of the most popular and is utilized by a variety of cups (e.g., the Keeper®, the Mooncup®, DivaCup®). It was also the shape of one of the first heavily marketed cups, the Tassaway®, in 1969. Tassaway users were advised that this cup could be reused throughout a period, but I remember disposing of some because of the mess.

All of these cups sit low in the vagina so that the stem/handle can be easily grasped to allow for removal and emptying collected flow into the toilet. They are designed to occlude the vaginal opening so intercourse would not be possible with the cup properly placed. Some of the reusable bell-shaped cups are available in different sizes to better accommodate different vaginal diameters. This could be very important to insure a good seal after a vaginal birth.

By contrast, there is another cup shape now being marketed as the Softcup®, or sometimes referred to as the Instead (manufactured by Instead, Inc. since 1996).  Readily available over the counter, these cups come in only one size. However they come in both single use and multi-use versions. The shape of these cups is more like a conventional 70mm diaphragm. Thus they sit high in the vagina, cover the cervical area, and could be used during intercourse.

A majority of menstrual cup studies have focused on acceptability and leakage and tend to be very short term. I could find only one study lasting 12 months. One recent study was a head-to-head comparison of the DivaCup to tampons. Women were randomly assigned to either sanitary product, then followed for three menstrual cycles. Eighty nine women completed the study, and results showed about equal satisfaction with both methods. Like many of the earlier cup studies there appears to be a “learning curve” for effective and comfortable use. Yet there was a calculated, clear environmental advantage for the reusable cup as it decreases the amount of waste—making it a “greener” alternative.

So what about safety issues with the menstrual cup? During the initial clinical studies for Softcup, 44 of the 406 women enrolled had detailed vaginal bacteria testing and colposcopies to look for potential problems. No safety problems were identified initially. In the over ten years of FDA postmarketing surveillance, only nine complaints were registered as serious. Two of these were about alleged TSS and neither was confirmed by the Centers for Disease Control (CDC). The materials used in the Softcup were exposed in the lab to the TSS bacteria, and there was no increase in the super-antigen producing bacterias.

Ultimately, menstrual flow control is a highly personal choice, just like choosing a method of birth control. And, like choosing a contraceptive, women may make different choices at different times in their lives. I clearly remember being instructed by a cousin how to use her Tampax-type tampons, but she wasn’t very clear about the part where you remove the cardboard applicator. I couldn’t figure out why the darn things were supposed to be so comfortable; I could feel it all the time! Later I switched to “tampon on a stick”. It was evident that the stick was to be removed after using it as an inserter. Menstrual cups, diaphragms, and even sea sponges rotated through my life. Menstrual management is just another example of adjusting oneself to time, place and circumstances.

By Jane Harrison-Hohner, RN, RNP

While menstruation has been going on since time began, the majority of menstrual products designed to deal with monthly flows have been developed within the past century or so. Others, like sea sponges and cloth pads, have been used for centuries. Have you ever wondered about changing your mode of coping with “Aunt Flow”? It seems that women often revisit this issue when some new risk is identified with their current sanitary product. For example, last month there was a recall for a specific lot of Kotex Natural Balance Security Unscented Tampons when a gram negative bacteria, Enterobacter sakazakii, was found during the manufacturing process. Thus, it seems like an apt time to review many of the newest and oldest options for “sanitary protection”.

Pads and Cloths

The first widely available, disposable sanitary pad was developed in 1921 by Kimberly-Clark. Like their other product (“Kleenex” disposable handkerchiefs), the “Kotex” pad became a noun describing other brands of cellulose-containing disposable pads. These were held in place with safety pins in underpants or used with a belt where the long ends of the pads were held snugly by small metal clips. It was not until 1970 that pads were made that incorporated a strip of adhesive so as to adhere to underwear.

Coincidentally, at around this same time, the feminist movement and back-to-the-land women revived an interest in washable cotton pads. This resurgence of interest in washable, re-usable pads has meant that one can purchase a variety of pad sizes and thicknesses, even at Walmart, which offers them online.

Previously, women made do with rags or made flannel pads or diapers for menstrual protection. These could be discretely soaked in cold water prior to adding them to the family wash. Now I have seen ads for bowls specifically designed to collect that soaking water for reuse in the garden!

Looking beyond historical interest, have there been any documented medical concerns with pad use? The few published studies have addressed the problems of “sanitary napkin contact dermatitis”.  A case series of 28 women were reported to have developed marked irritation of their vulva after using a specific type of pad (Always®). The irritation abated when this brand of pad was not used, and appeared again among the few women who decided to resume use of Always pads. A Japanese physician demonstrated dermatitis in some pad users that was curable by switching to tampons. It was postulated that a combination of wet conditions and friction could expose thin skin to normally occurring bacteria. Overall, pads seem to be safe, but the use of disposable pads (like disposable diapers) can add to landfill mass.

Tampons

Women may have been inserting absorbent materials in their vagina (e.g., sea sponges, rolls of soft wool or paper) for millennia, but the first commercially produced, disposable tampon came to market in 1933. It was called Tampax. Like Kotex or Kleenex, it then became a noun to describe other tampons. Initially, tampons contained either cotton or rayon. Rayon is made from cellulose fibers, which come from wood pulp. According to an FDA website, previous studies have not identified any differences in tampon safety between the two materials within the same absorbency rating.

A question that frequently arises is: “Will using a pad offer protection from the bacteria associated with Toxic Shock Syndrome?” Beginning around 1980, Toxic Shock Syndrome (TSS) was reported with increasing frequency in menstruating women using tampons. Its symptoms included a fever of greater than 102 degrees, vomiting/diarrhea, low blood pressure and a sun burn like rash on the palms of the hand which later peeled like a sunburn. TSS, both menstrual and that associated with pneumonia and skin infections, is caused by a super-antigen-producing strain of one of our normal skin bacteria (Staph aureus). Like many skin bacteria, Staph aureus can be found in the vaginas of between 10-30% of healthy women. But far fewer women will test positive for the super-antigen producing subtype. This might explain why only 70-100 cases of TSS (both menstrual and nonmenstrual) are reported in the USA per year.

This low incidence of women who carry the super-antigen subtype may also explain the differing results between the various studies of tampon bacteria over the past thirty years. In an early study, no difference was found in the number of women with vaginal staph aureus during menstruation whether tampons or pads were utilized.  Among women randomly assigned to either sanitary pads or tampons who then switched over to the other product, the number of “normal staph” bacteria were elevated with tampon use. Yet tampon users also had higher counts of the “good” lactobacilli vaginal bacteria. A. B. Onderdonk and colleagues found that tampon samples had decreased numbers of bacteria compared to vaginal swabs. More recently, a Czech study of 100 women concluded that there were lower levels of bacteria during tampon use, and that vaginal ecology returned to normal more quickly in tampon users compared to pad users.

Another possible explanation for the differences between studies might be the type of tampons used. Compared to the initial materials used for absorption, newer materials including polyester foam, carbomethylcellulose and polyacrylate rayon were added to dramatically increase flow capacity. Following increased reports of TSS, such materials were removed in 1984 as super-absorbent tampons were linked to TSS risk. Thereafter, increased absorption could come from increased physical size of the tampon.

After an 18% increase in TSS was noted in the Twin Cities of Minnesota from 2002-2003, Philip Tierno posited that the rise might be due to an increased usage of the much larger tampons. Since 1999, the FDA has established new, standardized guidelines for tampon absorbency:

• Light or Junior (<6 gm of fluid)
• Regular (6-9 gm)
• Super  (9-12 gm)
• Super-plus (12-15 gm)
• Ultra  (15-18 gm)

Perhaps women were using the larger tampons and were thus able to leave them in place for many more hours (e.g., overnight).

One of the most compelling studies on menstrual TSS was very recently published. Tampons used by four healthy women who had vaginal staph aureus and two women with a known history of TSS were cut into ¼-inch segments and tested. Some of the pieces had blood, others none. All women had evidence of the super-antigen subtype, and that the “supertoxins” could be found in parts of the tampon where no blood was yet present. The authors concluded, “We established that TSS T-1 [super-antigen subtype] causation of menstrual TSS is more complicated than previously thought.”

What about using tampons touted to promote natural pH balance? Eighty-one women completed a study that included testing for bacterial vaginosis (BV), yeast, pH, and a colposcopy to examine vaginal tissues. No significant differences were found between standard tampons vs. those using a pH corrected gel.

Currently the FDA recommends:

• Choose the lowest absorbency for your flow
• Change tampons at least every 4-8 hours
• Consider alternating pads with tampons
• Don’t use tampons between menstrual periods
• Know the symptoms of TSS

Fibroids are tumors of the uterus and are the most common pelvic tumors in women. They are benign and arise from the muscle layers of the uterus.

The reason I write about them is because probably 80 percent of all women will have a fibroid in their uterus by menopause. Most of the time, they will not cause any problem for the woman, but sometimes they can lead to abnormal bleeding, pelvic pain or pressure, or affect a woman’s chance to conceive.

There are different locations for fibroids in the uterus. They can be in the outer layer (subserosal); they can be within the wall of the uterus (intramural); and they can be inside the uterus (submucosal). Sometimes fibroids can be found in the cervix. The outer layer fibroids can make the uterus enlarged and distorted, and the inner fibroids can cause heavy bleeding when a woman is menstruating. The fibroids are affected by women’s hormones: estrogen and progesterone.

African-American women seem to be more susceptible to fibroids. They can also develop symptoms earlier in their lives and their symptoms can be more severe.

What are some of the risk factors for developing fibroids? Early menarche (younger than 10 years old), not having children, high blood pressure, and family history all increase the risk for developing fibroids. Eating a lot of red meat, ham, soy products or alcohol (especially beer) appear to increase the risk of developing fibroids. Consuming green vegetables and dairy products will decrease the risk of fibroid development. Birth control pills do not cause fibroids to grow. And postmenopausal  hormone replacement therapy may increase the growth of fibroids already present in a woman’s uterus, but will not cause new fibroids to grow.

When a woman has problems with fibroids, it can be debilitating. Urinary frequency, back pain and constipation can occur. Bad cramping before and during her period, along with pain with intercourse, can affect their lives. And heavy prolonged periods with passing of clots can cause anemia and social issues.

One of my patient’s shared that she was at a restaurant in white pants and started bleeding so heavily that she had to leave the restaurant in total embarrassment. This same patient went on to have surgery (hysterscopic resection of the fibroid) and told me that afterwards she used less pads in a year than she had used in each month before the surgery. Bleeding from fibroids does not occur in between your periods but rather it makes your normal periods abnormal. If a woman has a fibroid sitting inside the cavity of her uterus, it can make it difficult for her to conceive, increase her risk of miscarriage, and cause problems during her pregnancy.

Women need to see their gynecologists at least yearly, and if there are any of these symptoms, a patient should undergo a transvaginal sonogram. It is an extremely sensitive test and will be able to give results to the patient immediately.

If heavy bleeding is the problem, we put saline into the uterus and can find if the fibroid is in the cavity and the culprit. This procedure is called a saline sono HSG. It is done in the office. MRI of the pelvis also can help discover where the fibroids are in the uterus. Surgery can resect the fibroids and allow a woman to live a normal life.

The incidence of cancer in fibroids is extremely low — 3-7 per 100,000. If a woman has a fibroid in her uterus and is bleeding after menopause, a red flag should go up that this could possibly be cancer. And, if fibroids grow rapidly they should come out, because it could be cancer.

The good news is that fibroids will shrink after menopause. If a woman can hang in there, and even try birth control pills to control the abnormal bleeding, she could buy some time until menopause. If surgery needs to be performed, there are myomectomies, where only the fibroids are removed; there are hysterscopic resection of fibroids; D&C, where a fibroid in the cavity can be shaved down; there are hysterectomies, where the uterus is removed; and also embolization procedures performed by a radiologist to decrease the blood supply to the fibroids and allow them to shrink.

I hope this has been informative. I know for me as a gynecologist, it is so rewarding when I have cured a patient of their symptoms from their fibroids. Just for my patient to feel normal and have easier periods can make all the difference in the world.

Stay tuned for G  — Getting through Perimenopause– A Patient’s Story

Barbara Collura is the Executive Director of RESOLVE: The National Infertility Association, a non-profit organization with the only established, nationwide network mandated to promote reproductive health and to ensure equal access to all family-building options for men and women experiencing infertility or other reproductive disorders. RESOLVE is a member of the National Health Council. The National Health Council brings together diverse stakeholders within the health community to work for health care improvements.

Do you ever feel like you are the only person in the world struggling with infertility?  You’re not, and you don’t have to face infertility alone.  A support group, whether professionally-led or peer-led, can help you feel less isolated, empower you with knowledge and validate your emotional response to the life crisis of infertility.

Decreased Sense of Isolation
Perhaps one of the most important benefits of participating in a support group is a decreased sense of the isolation so many people feel when they are experiencing infertility. In a support group environment, feelings of anger, depression, guilt and anxiety can be expressed, validated by others and accepted as a normal response to the infertility crisis.

Support group members often experience  a special bond and sense of shared identity between group members. By sharing feelings, accomplishments, losses, and humor known only to those who experience infertility, members can develop strong emotional ties to one another.

Freedom to Express Negative Feelings
Freedom to express negative feelings and to identify with one another helps participants realize that they are not alone in their struggle with infertility. They can experience a sense of emotional relief from expressing their honest feelings and receiving support response from others. Members who may already have a highly supportive network of family and friends can find that a group provides a place to continue to share feelings without overburdening loved ones.

By offering a safe place to express and explore the feelings generated by the infertility experience, support groups help participants move toward a positive resolution of this difficult life crisis.

Learning to Develop Effective Coping Skills
Support group participants learn to regain previous levels of coping or to develop more effective coping skills. Members find assistance in coming to terms with difficult emotions and stresses inherent in the infertility experience, such as the effects on one’s personal relationships, self-image and sexuality. By sharing information and resources, learning how others’ have coped with similar problems and witnessing the coping styles of others, members can improve their own problem-solving abilities. Groups offer members realistic feedback as they try out new coping strategies, learn to be more assertive with health care professionals and share their infertility with significant people in their lives.

Couples who are having difficulty communicating with each other about their infertility can gain a better understanding of their partners’ reactions to infertility and learn how to support each other during times of stress.

Enhanced Self-Esteem
Group members benefit from enhanced self-esteem when they improve their coping abilities. A sense of emotional strength can return as one gains a sense of perspective and control during a difficult crisis such as the infertility experience. Emotional energy can be made available to address other life issues and challenges that may have been put on hold.

Find Out More

When you participate in a support group, not only are you getting emotional support, you’re also getting appropriate information about where to go to get good treatment.

If any of the following statements apply to you, you might benefit from a support group:

• I’m feeling lonely and isolated
• I have very few people to talk with about my infertility. No one understands
• Everyone I know is pregnant or has children
• My partner is the only one I have who provides emotional support
• Infertility is affecting my work and career
• I feel that my life plan is out of control. I’m having trouble navigating through my medical treatment options
• I can’t decide when “enough is enough”
• Holidays and coping with family and friends is becoming more and more difficult.

RESOLVE:  The National Infertility Association offers support groups throughout the country, making support available to people experiencing infertility who may not able to get support from their family, friends or community.  To find out about support groups in your area, visit www.resolve.org.

Endometriosis is a condition that can affect many women at different life stages. Let me give you three scenarios.

First — A young woman who has had miserable periods for several years. She gets terrible cramps during her period (and even cramping at other times of her menstrual cycle), as well as constipation and frequency of urination around the time of her period. She lives with chronic pain.

Next – An adult woman who has never had children and has been trying to conceive for over six months without any results. Her husband has been tested for fertility and is fine. She had a sonogram of her pelvis, and her doctor told her she has an ovarian mass.

Finally –  An adult woman who has very bad cramps before and during her period, pain during sex, intermittent bleeding during her menstrual cycle, back pain and lower abdominal pain.

All three of these women have endometriosis, a benign, common, chronic estrogen- dominant disease. Endometriosis affects 12  to 32 percent of menstruating women. Pain is the most common presentation — chronic pelvic pain, pain during the menstrual period or pain upon deep penetration during intercourse.

Endometriosis can also be the reason for infertility in 50 percent of women who undergo a laparoscopy, a surgery where a scope is inserted into the abdomen to visualize the pelvic organs. And 50 percent of teenage girls with chronic pain will be diagnosed with endometriosis.

So what is endometriosis?  It is when the lining of the uterus (that is shed every month during menstruation) surfaces in other places where it should not be, such as in all the reproductive organs as well as other places in the body. It can bleed just like the uterine lining and cause severe inflammation of the tissues. There seems to be a genetic component, as well. If a woman has endometriosis, a first-degree relative has a seven percent chance of developing the disease.

After a complete history and physical has been performed by the gynecologist and other conditions have been ruled out, a doctor should perform a sonogram of the pelvis. If the diagnosis seems to point to endometriosis, treatment with anti-inflammatory medication should be tried first, either alone or along with birth control pills (or other hormonal treatments).  If the patient does not respond to these treatments after three months, a laparoscopy should be performed. This procedure is the most definitive way to diagnose endometriosis because there is direct visualization of the pelvis: endometriosis looks like cigarette burns on various pelvic organs. There can be burns on the bowel and the bladder, causing these organs to develop symptoms. Also, cysts — called chocolate cysts — can present as masses in the ovaries.

Once the diagnosis is confirmed at surgery, the surgeon should try to remove all the endometriosis he or she sees. It can be lasered, cauterized and resected. The more of the endometriosis that  is removed, the more likely it is that the patient’s fertility will improve and her pain will subside.

A diet free in hormones — going organic, watching out for any hormones that are fed to animals or hormones that could be in dairy products — may help a woman who has been diagnosed with endometriosis. This is a disorder that is fed by estrogen, so any soy or phytoestrogens must be avoided. After menopause, when a woman’s hormones have declined substantially, this disease is much less of an issue.

If a woman with endometriosis is trying to conceive, she may need to consult an infertility specialist. After she is diagnosed with endometriosis and has had surgery to remove all the endometriosis, she may then, depending on the stage, try to conceive on her own for six months. If she does not conceive, she may need help from a specialist who will treat her with fertility medications or in vitro fertilization (IVF).

Last, and unfortunately, in order to control the chronic pain of this disease, a woman may need to be treated with birth control pills or other hormonal treatments until she reaches menopause. It is an ongoing problem that does not seem to leave one’s body until after menopause ceases. Sometimes, a patient can only be free of pain after undergoing a complete hysterectomy.

Once you’ve turned fifty there are several health items to focus on — including bone health, heart health, and preventive screening tests. Many women experience menopause in their early fifties. After reaching menopause, women are more prone to develop bone loss that can lead to osteoporosis. They are also at higher risk for heart disease. (more…)

According to a physician I heard at a Grand Rounds, everyone is vitamin D deficient . He deals with osteoporosis and says we are all lacking in vitamin D. We do not sit in the sun and if we do, we put on high SPF sun block. There is also a lot of confusion about how much vitamin D one should take. A recent newspaper article made people wonder if we do really need vitamin D.  Let me give you the reasons why everybody should have their vitamin D level checked in a simple blood test. (more…)