Will Zika Zap Your Pregnancy Dreams?

Zika has become a pretty big buzzkill for any woman living in a Zika-infested area who wants to get pregnant. Having a baby has pretty much become a “no go” for women who live in certain parts of the world. In fact, in some areas (cue El Salvador), women are being advised to wait two years before expanding their family. And no matter how you look at it, that’s a serious time out.

The reason that this red light won’t change to green is that Zika can cause some pretty poor pregnancy outcomes, including miscarriage, microcephaly, and brain and eye abnormalities. And unfortunately, Zika doesn’t discriminate. It is an equal-opportunity infector. Whenever you meet the Zika virus (a.k.a. your first, second, or third trimester), it can cause you problems. So in order to stay protected, here’s our advice on how to avoid getting bitten.

First things first, no matter how bad you need some beachside R&R and a tan, there are some places that women and men who are planning an upcoming pregnancy shouldn’t go. No matter how cheap those airline tickets are, now is just not the right time. If you are planning on getting pregnant, plan on looking at the Zika map before you plan your trip. And because that map is constantly changing, we not only recommend you check it before you board that plane but also be smart and buy some travel insurance! And if you live in a Zika-infested area, talk to your OB/GYN before you give the baby thing a go. Ideally, waiting (or seeking fertility assistance to preserve your fertility) is your best and safest bet.

If you must go to a Zika-infested area and you have babies on the brain, you must wear bug repellant—an Environmental Protection Agency-approved bug spray with DEET—all over. You should also cover any exposed skin, stay in air-conditioned or screened-in areas, and treat your clothing with permethrin (an insecticide). Follow these rules whether it is night or day, and make sure to reapply. What to do when you get home (a.k.a. how long must you wait before trying) depends on what happened while you were away….

Scenario A: You find yourself a victim to the mosquito and come down with Zika (a.k.a. have the symptoms and test positive). This means you will need a lot more than anti-itch cream. The American Society for Reproductive Medicine (ASRM) recommends waiting six months after the start of the symptoms to give the baby thing a go. For men who contract the Zika virus, the time-out period is no different. Your guy will be sitting on the sidelines for six months before he can try to get you pregnant. And while you are in this holding pattern, you should abstain from intimate sexual contact (vaginal, anal, or oral intercourse) or use a barrier method. Condoms are key to reducing the risk of Zika transmission. Protection is the key to prevention!

Scenario B: You may have Zika. You got bitten by something while in Puerto Rico, for example, but don’t know if it was Aedes (the Zika specific mosquito) or just an annoying mosquito. You don’t have any symptoms, but you are scared! The ASRM is recommending that you stroll on down to your local lab and get Zika testing (a viral RNA test) within two weeks of the bite/trip.

If you come back negative, while it is a relief, you are not off the hook just yet. The ASRM recommends repeat testing eight weeks later. If this test is negative, you are in the positive for attempting pregnancy. Although no test is 100% accurate (Zika can still reside in semen or bodily fluids even with a negative test), the double negatives should help you breathe a big sigh of relief. But remember, while in limbo land (arriving home and awaiting the second test eight weeks later), it’s best to use condoms or abstain. This will ensure that you protect yourself from potentially contracting or passing on the Zika virus.  

Scenario C: You don’t find yourself a victim of the big Z, but you are at risk for exposure (a.k.a. you traveled to a Zika-infected area but have no symptoms consistent with Zika). Individuals in this situation should adhere to the same guidelines as our friends in Scenario B. You should strongly consider getting Zika viral testing, even if insurance won’t pay for it, upon your arrival home and then again eight weeks later. And just like scenario B, during the eight-week waiting period, protection (condoms) is your best bet.

And while the medical world and Zika have done some serious speed dating (a.k.a. we already know a lot about Zika), there is still much that is unknown, particularly when it comes to how long Zika can remain in our systems (LINK: Buzz on Zika). As a result of the unknowns when it comes to Zika, we are uber-conservative (and we are not talking politics!)

We have read the recommendations from the three big candidates: the Centers for Disease Control (CDC), the American Congress of Obstetricians and Gynecologists (ACOG), and the ASRM. We have chosen to vote for the lattermost. If our views are too harsh and you are pulling the lever for the CDC or ACOG (they suggest women only wait eight weeks after getting Zika to start trying again rather than six months), that’s okay. Just make sure to check with your OB/GYN. His or her voice matters when it comes to your vote!

Heart Rate, Shmart Rate: Pregnancy and Exercise

There may be no greater taboo topic (other than who you voted for and what God you believe in) than pregnant women and exercise. Finger pointing, whispering, and gasps are the norm when a visibly pregnant woman hops on a treadmill. For some, it evokes the same feeling as a pregnant woman who smokes a cigarette. “How can she do that; doesn’t she know she’s hurting her baby?” No major fitness brands cater to pregnant women, and clothing lines for the pregnant athlete are scarce. It’s close to being off limits. News flash, world: the data on no exercise for pregnant women are old and no longer relevant. It’s time to turn things up and break a sweat. Here’s why.

Exercise is Excellent for Everyone. Young, old, pregnant, and postpartum, exercise is a good thing. Physical activity has a positive impact on almost every organ and organ system in your body: hearts, lungs, brains, and bones. It also is a major weapon in the war against obesity, which we are currently losing big time as a country. Additionally, those of us who move on a daily basis not only look better but also feel better. (The chemicals that bring you up are released into the brain during and after exercise. They will keep you flying high for many hours post-workout).

Exercise in pregnancy achieves all of the above benefits, plus some others. Women who get to the gym when expecting should expect a lower chance of gestational diabetes, macrosomic (large) babies, high blood pressure, and excessive weight gain. And we OB/GYNs are not the only ones endorsing exercise in pregnancy. The US Department of Health and Human Services recommends that healthy pregnant and post-partum women participate in at least 150 minutes per week of moderate-intensity aerobic activity. They are also cool with women who like to take it up a notch, which means those who engage in vigorous-intensity aerobic exercise can keep it up.

While we are not telling you to go out and achieve your PR in the marathon or train for an iron man (or woman!) in the dead of summer, we are telling you to get out, get active, and stay fit. You will have to make modifications in your regimen. You will have to share your big news with your fitness instructor. You will have to stay extra hydrated and wear loose, breathable clothing. But if given the all clear by the OB, you won’t have to sit on the sidelines.

In pregnancy, our bodies change big time (no brainer). But it’s not just that belly that we acquire; it’s also a shift in the point of gravity, laxity of the ligaments/joints, increase in blood volume, and decrease in vascular resistance. The last two are what can make you feel lightheaded and your legs swollen. Be conscious of these differences. Your awareness will keep you out on the track, in the studio, or on the mat longer.

Not every pregnant woman can bike, spin, or lift weights. Some pregnancies are more complicated, and the pregnant woman can’t exercise ad lib. For this reason, it’s important to be as open and honest with your OB/GYN about what you want to do as you would with your trainer as to what you want to build. We need to know what you’re doing so that we can tell you what is okay to do.

There are certain medical conditions (restrictive lung disease, severe anemia, heart disease) as well as specific obstetrical conditions (incompetent cervix, placenta previa after 26 weeks, premature labor) where exercise is prohibited. In addition, if you were a couch potato before pregnancy, it’s probably not the best idea to start doing boot camps once you pee on the stick. A more gradual progression into exercise is probably the way to go.

No one really knows where that magical 140 (maximum heart rate for a pregnant woman) number came from. We have searched textbooks (both online and in print) to find out why this number?? We got nothing good! And that’s because it was never based on any real data. The new recommendations from the American Congress of Obstetricians and Gynecologists on Eexercise and Pregnancy no longer stipulate that heart rate be used to assess how hard a woman is working when she is working out. We now recommend using “ratings of perceived exertion” to monitor exercise intensity (a 15-grade scale; very, very light → very, very hard).

Using the “talk test” is another way to measure exertion. (We prefer the “sing test”: can you sing the song playing on your iPhone?) Although we don’t want to hear you belting out the lyrics to “I Will Survive,” we do want to know that you will survive this workout class. If you can sing or talk, you can breathe, and if you can breathe, your baby is getting oxygen—and then you are all good.

Exercising in pregnancy has been viewed as selfish. Here’s what they say: Women who exercise care more about their bodies than their babies. Women who exercise are vain and self-centered. Women who exercise are not good mothers-to-be. This is downright bogus and simply BS. Studies show that babies actually like exercise just as much as their mothers do. While their heart rates increase, their birth weight does not decrease. In fact, babies born from mothers who exercise see benefits, from their brains to their bodies to how they are birthed (C-Section vs. vaginal delivery).

Exercise is good for both parties, mother and baby. While we may not be there to run beside you during this pregnancy, we can offer you a few parting pieces of advice:

  • Make sure to stay cool (don’t exercise in a 100-degree basement!).
  • Make sure to stay well hydrated.
  • And make sure to stay well nourished, with adequate caloric intake.

Other than that, lace up your sneakers, clip into the saddle, or roll out those yoga mats. It’s time to get moving!

No Period, No Problem?

For many of us, that time of the month is filled with moods, monster breakouts, and mounds of chocolate. We dread its arrival and plan our white pants-wearing days around it. However, if you ever or are now missing periods, this “period piece” is timely. Your period (while off hormonal contraception, remember that no period on the pill is a totally different non-alarming situation) is sort of like the sixth vital sign; it provides a lot of information about the health of your reproductive system.

The arrival of a girl’s first period is sort of a big deal. In many cultures, for many centuries, it has marked the transition from girlhood to womanhood. Historically, it indicated the promise of life, new beginnings, and the start of something. While today the pomp and circumstance around this event are much more hush hush, it is still a very intimate moment shared by mothers and daughters.

And despite the unpleasant cramps and cravings, menses does mark the culmination of puberty and the commencement of the reproductive years. So (playing off the graduation theme), when do you order your cap and gown? When will this process begin? The answer, while seemingly simple, is really somewhat complicated.

Your ethnicity, your family history, your genetics, your weight, your living environment (urban versus suburban), your fitness level, and your stress level all play a role regarding when you go through puberty. In fact, even the century that you live in plays a role in the timing of this event. (In the past 60 years, we have seen a decrease in the age at which girls get their periods.) While the arrival of a period is usually abrupt (wow, what is that?!?), the process that brought this to you actually took years. A period marks the end of the process of puberty.

Puberty encompasses many physical changes (breast development, pubic/underarm hair) as well as cognitive and psychosocial changes (sorry, Mom, for all those wild emotional tirades!). While all these things seem to occur at once, there is actually an orderly transition to this process; increases in a hormone called LH and FSH lead to the production of estrogen. Estrogen stimulates the development of breasts. Androgens from your adrenal glands stimulate the production of pubic and underarm hair (oh joy…get out the razor!). Somewhere in the midst of this, all you have a growth spurt, and then ultimately, your period arrives.

For most girls, puberty begins with the development of breasts at around 10 years (range 8–12). On average, from start to finish, the process takes between 1 and 4 years. African-American and Hispanic females, girls who live closer to the equator and in urban areas, girls who are overweight, and girls whose female family members went through puberty early are more likely to start the process at an earlier age. On the contrary, Asian and Caucasian girls, girls who are underweight, girls who are athletic, and girls whose female family members went through puberty late are more likely to start the process at a later age.

Although that first period marks the beginning of a brave new world, one period does not write the entire story. It suggests that the system has been primed but does not mean it is ready to run on autopilot. Now, while it is quite common for periods in the first two years to be irregular (many cycles during this time period occur without ovulation), after this point, they should start to follow some order. This pattern is not only good for wardrobe planning but also for demonstrating the system has matured.

Regular periods offer a visual that the following systems are a go:

1) About two weeks before the period, ovulation (egg release) has occurred (ovaries: check!)

2) A uterus with an open path for the blood to exist is present (uterus: check!)

3) The signal from the brain to the ovaries has been activated (hypothalamus / pituitary: check!)

Medically speaking, the lack of a period is called amenorrhea (for all you Latin buffs, a- in Latin means without, and menorrhea is menses). When a girl has not gotten her period by age 14 without evidence of breast development or by 16 with evidence of breast development, this is called primary amenorrhea (primary because there has never been a period). When a female has had a period(s) and then they stop for whatever reason, this is called secondary amenorrhea. While some processes can cause both, the causes of the two are usually different.

Primary amenorrhea cases require more detective work and are much less common. They are more likely to be genetic in origin, a sign of poor ovarian development, or a uterine-vaginal blockage (septum)…basically, the rarities of medicine.

Secondary amenorrhea is something that GYNs deal with almost on a daily basis. (Trivia question: what is the most common cause of secondary amenorrhea? Answer: pregnancy!) But aside from pregnancy, common causes are polycystic ovarian syndrome (PCOS), thyroid disease, over-exercise, and stress. Although a few months off from Ibuprofen and tampons feels good, you shouldn’t let this go on for very long without contacting your GYN.

Even though the arrival of Aunt Flo just in time for that weekend beach party is no one’s idea of pleasant, it isn’t all negative. Getting regular periods, while sometimes a pain, can be a plus. It shows us that the system is functioning. While there is absolutely no problem with going on some form of hormonal contraception (pill, patch, ring, IUD) and keeping your periods at bay for a vacation or big work deadline, this is VERY different than not getting period while off hormonal contraception.

Think of the reproductive system as an orchestra. The conductor is the brain, and the ovaries, the uterus, and the fallopian tubes are the instruments. So if the periods abruptly stop or never start, the conductor called off sick, or one of the instrument players have gone on strike, it is our job as GYNs to find out who is sleeping on the job and try to fix it! Although it might be easier to play over the group who’s gone, the music won’t sound or come out right. Periods mean something, and if they stop, someone needs to hear about it.

IVF Do’s and Don’ts: The Seven Best Ways to Prepare from Head to Toe

Some of the questions we are most frequently asked by women who are preparing for IVF include “What can I do to improve my chances” and “What can I do to stay safe during the process?” Women will offer to do anything, from going gluten-free to dye-free to preservative-free, to amp up their chances of seeing a smiley face on the “pee” stick. But the reality is, despite our best efforts to find some control in a frighteningly and frustratingly uncontrollable process, so much of what makes an IVF cycle a success or a failure is out of one’s control. So while we can’t tell you how to make sure it works we can tell you 7 ways to make sure you stay safe, sane and (fingers crossed) successful!

  1. Get your head in the game: Positive thinking is essential! Harping on what could go wrong or what has gone wrong in the past is not helpful; in fact, it could be detrimental. Hit up a support group; spending time with your peers can be super helpful when navigating a scary process. We also recommend engaging in any practices such as meditation, yoga, and exercise that will help keep you calm and centered. The exercise will need to be modified mid-IVF cycle but even then, walking, stretching and meditation are soothing.
  2. Breathing: Be aware of your breathing patterns. While we are fans of deep breathing and centering yourself, we are talking about shortness of breath. This can be a sign of overstimulation or in rare cases a blood clot and should be reported to your doctor during your IVF cycle.
  3. Bloating: Put your skinny jeans in the back of your closet, and say goodbye to them for about three weeks. The IVF medications will cause you to retain water. This will lead to bloating and some temporary (again, temporary) weight gain. We promise it will come off!
  4. Constipation: As your ovaries grow and your hormone levels rise, your digestive system will often slow down. This can lead to indigestion and constipation. Make an effort to increase your fiber content, and drink about one to one and a half liters of water a day from the get go, as this can help keep your system up and running!
  5. Urination: Most of us neither count how many times we urinate nor keep track of the color of our urine on a daily basis. However, when doing fertility treatments, it is important to pay attention to what’s streaming. Dehydration occurs more frequently; infrequent trips to the bathroom combined with dark urine can be signs that your tap is running dry.
  6. Ovaries: This will likely be the first time you feel your ovaries. While you always knew they were there, you probably never felt them as you walked, ran for the bus, or even lay on the couch. Be mindful of them, and note any severe abdominal pain. This could be a sign that the ovaries are twisting.
  7. Toes: Treat yourself to a pedicure! No seriously, do it! While you will definitely not find that advice in a medical textbook, being good to yourself will help you through this stressful and uncertain time.

We wish we had the magic bullet and knew the ingredients to the secret sauce, but much like the fountain of youth, the “It” action or practice simply does not exist. While we are big fans of good, healthy living, don’t beat yourself up for that can of diet soda or the glass of rosé—they aren’t the reason your IVF cycle didn’t work. Our tips may not ensure success, but they will definitely help make the journey smoother.

Achoo…F-F-F Flu! The Flu Vaccine and Pregnancy

Break out the tissues, start brewing the tea, and swallow that Echinacea, because winter is coming! No, this is not an episode of “Game of Thrones,” but a chill is in the air. When the temperatures drop, anxiety over the flu rises, as does our consumption of vitamin C. Hand washing becomes an obsession, and coughing or sneezing without covering one’s face is the biggest faux pas. Despite what may feel like a lot of hype, the flu is the real deal, especially for women who are pregnant.

Because the flu can be way more than a one-day couch-lounging event, any method to prevent catching it is of the utmost importance. In addition to good hand washing and sanitary practices, the flu vaccine can significantly reduce one’s chance of getting the flu. Given changes in the immune system and respiratory system, pregnant women are at increased risk for not only getting the flu but also getting the flu with a vengeance.

Along with the muscle aches, runny nose, and headaches, pregnant women are at a much higher risk for all the negative and serious complications that come with the flu: ER visits, hospital admissions, intensive care stays, and even mortality. Simply stated: the flu and pregnant women do not mix.

Because of this oil-and-water situation, it is crucially important to receive the flu vaccine once it becomes available, no matter what trimester or “pre” trimester you’re in. The flu vaccine in pregnancy is at the top of every OB’s list, so it should be at the top of yours as well.

Additionally, research shows that the babies whose mothers received the flu vaccine while pregnant have a lower chance of developing the flu as an infant. The flu vaccine is not approved for use in babies younger than six months; therefore, the best way for these babies to receive protection is through their mothers (antibodies against the flu will pass from mom to baby through the placenta and protect the baby for up to six months of age). Simply stated, the best way to prevent and protect both you and your baby from being sidelined in a serious fashion from the flu is to receive the flu vaccine at the outset of the flu season.

The flu vaccine USED to come in two formulations, a shot and nasal mist.  The nasal mist was NOT safe in pregnancy (it was live weakened virus).  But the CDC pulled this version from circulation as it was not found to be effective.  So currently, all formulations are safe before, during, and after pregnancy.

There has also been some controversy on the use of thimerosal, a mercury containing preservative used in some vaccines, and autism.  There is no solid scientific data to support a link with thimerosal causing autism in children born to women who used these vaccines.  Thimerosal-free formulations of the flu vaccine do exist but the ACOG and CDC do not necessarily recommend pregnant women use only these formulations.

Bottom line: if you are not getting the vaccine from your OB/GYN, make sure to share your big baby news with the healthcare provider who will be administering the vaccine.

Getting the flu while pregnant is no joke. While it’s totally normal to be extra cautious about what you eat, take, or do while pregnant, the flu vaccine gets the double thumbs up.

When a Drizzle Becomes a Downpour: Post-Partum Hemorrhage

Bleeding after baby is nothing to say “boo” about. It happens to everyone, and it’s normal. First comes baby, then comes placenta, then comes bleeding. It’s a pretty standard course of events. For most women, the bleeding is moderate and slows down pretty quickly. Although pads become our good pals in the postpartum period, we are usually ready to break up with them after about four weeks. However, for some women, bleeding after baby (a.k.a. post-partum) can be heavy, heavier, and heaviest. When it starts and is difficult to stop, we call it a post-partum hemorrhage (a.k.a. PPH).

PPH can be the real deal. In fact, post-partum hemorrhage is the number-one cause of maternal mortality worldwide. It’s estimated that about every four minutes, a woman dies from PPH somewhere in the world. It’s a very serious problem. When the excessive bleeding occurs within 24 hours of Baby’s arrival, the PPH is classified as a primary PPH.

Almost all of the primary PPHs occur because the uterus is unable to contract or clamp down. Other likely causes include a retained placenta and blood clotting problems. Secondary PPH occurs between 24 hours and 6 to 12 weeks postpartum. When you see the red faucet turning on, off, and then on again, it is usually from retained placental tissue, abnormal placental attachment, infection, or clotting disorders.

As OBs we develop a pretty strong stomach and pretty thick skin. Very few things make us nervous or make us break a sweat. However, one exception to this rule is a bad PPH, the kind that seems to have no end in sight. If you should find yourself floating down this river, this is what your OB will do:

  1. She/he will start looking and start massaging. Uterine massage is the first move in this situation—most women are bleeding because the uterus has not yet contracted. Massage will move the uterus closer to contraction.
  2. When you still feel the pain or are still bleeding despite massage, medications come next. IV infusions, IM shots, and possibly even a trip to the operating room can be in your near future.
  3. Surgical interventions are reserved for really free-flowing situations, and we only go there when we have no place else to go. However, if we need to bring out the big guns to put an end to the bleeding, we can do it.
  4. If we need to call in our peers from other parts of the hospital—radiologists, interventional radiologists, surgeons, the blood products lab, etc.—we will. As the captain of the team, we need a good offensive line to defend the blitz. We may even need to transfuse blood products to keep you safe and keep things steady.

Secondary PPH is treated in more of a sly manner. It is not as dramatic, at least initially, as primary PPH. It can happen while you are still chilling in the hospital or hanging at home. As you can imagine, the latter can be very scary. While it is very rare (about 1%) of all pregnancies, it is usually due to retained placental tissue (darn thing just won’t go away!). It can also be an expression of an underlying blood clotting disorder that you never knew existed. In most of these cases, the first person on speed dial should be your OB/GYN. They will want to see you ASAP. They will often send you for one ultrasound and possibly more. While the operating room may be in your near future, we hope to avoid it. Too many trips to the OR, particularly in the post-partum period, can lead to scar tissue.

Although we can’t always predict who will bleed heavily in the post-partum period, it is not simply a game of eenie meenie miney mo; there are some red flags. Risk factors include long labors, fast labors, assisted labors, and labors that needed Pitocin (did we leave any labors out?). They also include a history of PPH in prior pregnancies, elevated blood pressure, a big uterus that held more than one baby, and infection. The best way to treat a PPH is to be prepared. Therefore, if you fall into one or more of these categories, we may full court press you, even if it’s just an easy jump shot. We would rather overreact than under prepare.

When the drizzle turns into a pour and you have forgotten your umbrella at home, you will kick yourself for not listening to the weather report. Drizzle, we can deal with. Nothing gets ruined, and it passes quickly. A downpour is a whole different situation. The same can be said for bleeding post-partum. Minimal or moderate bleeding is normal, doable, and “deal-able.” A little massage and medication and you are on your way. The more serious stuff can be dangerous. Downpours can turn into thunderstorms and hurricanes, if you don’t act quickly. Make sure you have shared your whole medical history with your OB/GYN, as this will serve as their trusty weather app. We don’t want to leave anyone out in the storm!

The 8 Facts Every Woman Should Know About Breast Cancer

October is not a month of black and white. We definitely see lots of ghosts, goblins, witches, and skeletons, but reds, yellows, oranges, and pinks (#BreastCancerAwareness) own this time. These colors open our eyes and make us aware of our surroundings and ourselves. And while you can pretty much count on the leaves changing year after year, you want to make sure you don’t ignore any changes in your body, particularly your breasts. Here are the eight facts every woman should know about breast cancer.

  1. One in eight women will be diagnosed with breast cancer during their lifetime. And while this number as a ratio or a percentage may not seem all that impressive to you, think about it in everyday terms. Count the number of mats or bikes in your exercise class. If each row holds about 16 people and there are about three rows in the class, then about six people per class will be diagnosed with breast cancer over the course of their lifetime! And without even saying, “Boo,” those numbers are pretty scary.
  2. It’s pretty safe to say that we all know someone who has or had breast cancer. Breast cancer is the most common cancer in women and the second-leading cause of cancer death in women. Put it this way: every two minutes, a woman is diagnosed with breast cancer, and every 13 minutes, a woman will die of breast cancer.
  3. Once again, age matters. The older you are, the more likely you are to be diagnosed with breast cancer. In fact, the majority of women who are diagnosed with breast cancer are older than 50, and the median age of diagnosis in the United States is 61. However, while less than 5% of women are under the age of 40, young women get breast cancer as well. Bottom line; don’t ignore your breasts just because you haven’t reached the big 4-0.
  4. Screening saves lives. Period. Putting off your mammogram only puts you at increased risk for breast cancer. Don’t be foolish (now we sound like our mothers!). Get checked out. And for you younger ladies (less than 40), it is NEVER too early to give your breasts their own monthly exam, and make sure you see a health care provider who does so once a year. If you feel something, say something.
  5. What you eat, what you drink, and if you sweat matter. Obesity, high alcohol intake, and a sedentary lifestyle are all risk factors for breast cancer. So if you needed more motivation to move and make healthy food choices, here you go. Come on, ladies, let’s get moving!
  6. Your chromosomes dictate a whole lot more than whether you produce sperm or eggs. There are genes on those 46 chromosomes (23 from mom and 23 from dad) that increase your risk for cancer. Harboring one of these genetic mutations—think BRCA-1 and BRCA-2—does not mean you will get breast cancer, but it can significantly increase your risk. And while nearly 65% of breast cancers occur in women with no risk factors, if you know you or your family member carries the BRCA-1 or BRCA-2 mutation, you should be screened early and frequently for breast cancer. Make sure your GYN knows everything about your family history (trust us, your secrets are safe with us!).
  7. When your period first presents itself and parts ways with you (a.k.a. menarche and menopause) can alter your risk for breast cancer. Women who have an early period or a late menopause are at a slightly increased risk of breast cancer. While you shouldn’t panic if you see red early or late, it is something important to keep in mind. Additionally, women who don’t have children or who have their first child after age 30 have a slightly higher risk of breast cancer. While this statistic should not dictate when you decide to do the baby thing, it’s something we GYNs make a mental note of.
  8. Breast cancer does not equal infertility. While the diagnosis used to mark the end to one’s reproductive days, we now have ways to cryopreserve (a.k.a. freeze) eggs and embryos. This technology can safely be used prior to any chemotherapy or radiation that may harm the ovaries. With advances in diagnosis and treatment, breast cancer does not always mean the end to a woman’s reproductive road.

Breast cancer treatment is evolving every day. It is truly (#ourFAVORITEword) amazing. We take our hats off to our friends, the scientists and physicians, who have revolutionized how we diagnose, treat, and ultimately cure breast cancer. Because of their smarts and hard work, what we know now pales compared to what we knew five years ago. And while you may never meet these fantastic men and women who have dedicated their lives to making us all safer and healthier, we at Truly, MD, can make you aware of what they have found and how it can impact you.

So do us a favor and check out your breasts. While the presence of certain risk factors (particularly those listed above) increase one’s risk for breast cancer, nearly 75% of women who are diagnosed with breast cancer possess NO risk factors. Therefore take a moment to stop and feel your breasts on a monthly basis.  Although what they have won’t impress you (unlike that fall foliage that October is known for), if they do you will act quickly. Early detection of breast cancer can save your life. So think pink and make a point to do self-breast exams and get screened—it may just ensure that you see the leaves change for years and years to come.

But My FSH Is Normal…Doesn’t That Mean I Will Have a Baby?

Mirror, mirror on the wall, who is the most fertile of us all? And while we wish it would be as simple as “My Queen, you are,” it is nowhere near this clear. Although the mirror is there (in the form of hormone levels and ultrasounds), the glass is blurry. Nothing from FSH to AMH to AFC (antral follicle count) can reliably predict with certainty who will have success with IVF and who won’t. Much of what holds the answer to this age-old question is not defined by lab tests or imaging but by the most basic of numbers—age and how long you have been trying.

When interpreting the results, either with or without your doctor, you should be careful in how you let the information make you feel. Everything must be analyzed in context and assessed carefully. A high or low value can lead to instant joy or despair. And while some of this is warranted, and some of it is not—the truth usually lies somewhere in the middle. To understand how close you are to each goal post, you need to have your results reviewed rather than just Googled.

But if you are going to take to the Internet, here are a few pointers from your favorite fertility MDs:

  1. FSH must be checked on day 2 or 3 (latest day 4) of the cycle. After that, the data are nothing more than a bunch of numbers printed on a page (exception: women with very, very long cycles). If you think you might be that exception, talk to the person who sent the blood in the first place!
  2. FSH must be checked with Estradiol. An FSH in isolation is like an alto without a soprano; it may sound good but can’t really be appreciated in isolation. The brain makes FSH. The ovaries make estrogen. Although the two are produced in opposite ends of the body, they work very closely together. In terms of ovarian reserve testing, estrogen suppresses FSH levels (an elevated estrogen results in a low FSH). Therefore, a normal FSH level is only as normal as your estrogen level. Simply stated, an elevated estrogen can mask an elevated FSH. As a result of their tight relationship (#BFFs!), to have an accurate assessment of your FSH you need to know what your estrogen level was on the day the FSH was sent!
  3. AMH can be checked at any time, on any day, in any month. It is usually not impacted by the period, the pill, or pregnancy. It is a hormone made by the resting follicles, which rest, no matter what your body is doing!

Bottom line… be careful when looking into and listening to that mirror. While the words may be what you want to hear (or not—cue Snow White!), you must make sure the person speaking to you is telling you the truth. You may not want to hear it, but it will help you figure out your best next steps.

When Doctor Becomes Patient

I (Sheeva) am a breast cancer survivor. And while I have uttered those words numerous times over the past two years, it is still shocking to hear myself say it. I had no risk factors. In fact, I had all the “protective” factors and a “normal” mammogram only six months prior to the diagnosis. Nonetheless, it happened to me. And because I was a seemingly unexpected bystander, I have chosen to share my story with all of you. Truthfully and honestly. So here it goes, the unedited version.

I was 38 years old with two children, and I was “done and done.” And while “done and done” means different things to different people, for me, it meant doing something for myself. This is the part of the story that makes me somewhat uncomfortable sharing, but I decided to undergo elective breast augmentation. Prior to the surgery, I was required to undergo a mammogram. I did as I was told, and a small mass on my left breast was identified. I underwent a needle-guided biopsy, and as suspected, the mass was benign. Off I went to get my implants.

Fast-forward six months; I felt a very discreet pea-sized lump just under the surface of the skin. I didn’t remember it being there before; it immediately caught my attention. I waited it out for a menstrual cycle to see if it would go away (as a GYN I knew that some lumps and bumps come and go with our hormones). But a month later, it was still there—no change. It didn’t budge. But neither did I. I did have my gynecologist (and my colleague, fellow GYN, and best friend Jaime) feel it—we were both confident it was nothing. I mean, it was smooth and rubbery, and it moved: classic textbook description for a benign mass. Ironically, around the same time, I received a follow-up reminder to check on the benign left-sided cyst that was biopsied six months prior. Now I had two reasons to head back to the radiologist—it just seemed to make sense. One trip, two tests.

And what a trip it was. On this solo venture, I was given the most frightening news of my life. In the words of the radiologist who had performed the mammogram, “This is not normal, and it needs to be biopsied.” Despite my shock, I could piece a few words together and replied by saying, “Are you worried?” Stone-faced, she said, “I don’t know; that’s why we need to biopsy it.” Just then, the ultrasound technician joked about the size of the lump and its proximity to the implant: “The biopsy will probably burst the implant.” This was not a good experience, and it didn’t take me being a doctor to know that. I was not going back there.

I went home and did some research, and within 24 hours I had all my images transferred to a different radiologist. A couple of days later, I went in for both repeat imaging and a biopsy. Within 24 hours, my doctor called and gave me the news: “You have poorly differentiated invasive breast cancer.”  

It’s hard to put into words exactly how I felt at that minute, for the next several minutes, and for the next few days. There was so much that was unknown to me, even as a physician, and it was these unknowns that made it so incredibly frightening. How bad was it? How far had it spread? Will I recover? And through all the unknown and unanswerable questions, the pervading thought running through my head was, I have two young children who need me and who I want to see grow up.

That evening, my support team (my family, Jaime, and her husband) came to my apartment, and we mobilized. We got names of breast surgeons, we made appointments, and together, we moved forward. A few days later, I had an MRI that suggested the tumor was localized to the breast. I found out that my receptor status was positive. (Breast cancers that are positive for estrogen and progesterone receptors have a better prognosis and respond to a medication called Tamoxifen, which can be used to lower a recurrence.) I was scheduled to undergo surgery with an excellent physician at Memorial Sloan Kettering.

I was given the option for a lumpectomy, a right-sided mastectomy, or double mastectomy. Although my surgeon eloquently explained that it was a very small tumor and I could undergo a small surgery, I had already made up my mind to go for the bilateral or double mastectomy. I mean, they weren’t real to begin with! At least this way, I didn’t have to go for frequent imaging of any remaining breast tissue. The last decision came down to the nipples, to take them or to leave them. Although for cosmetic reasons, keeping them would be a plus, I decided to part with them as well. After all, I’m a doctor not a breast model…

While I felt confident about the procedure and the surgeon, hurdles still lay in front of me. Would my lymph nodes be negative or positive for the cancer, and would my oncotyping (other gene profiles related to recurrence risk) be unfavorable? If yes, I would need chemotherapy following surgery.

But I got lucky. My news was good. There had been no spread to the lymph nodes. The invasive lesion was only 7mm, exactly the pimple-sized mass that I was feeling. However, in addition to the invasive lesion I had DCIS (ductal carcinoma in situ; a.k.a. pre-cancer cells) throughout my entire right breast, including the nipple. When discussing these findings with my surgeon, she said, “Your intuition about taking the entire breast and the nipple out was right; if you would’ve opted to keep them, you would have needed another surgery.” The last piece of good news came about two weeks later, when my oncotyping returned as low risk; chemo was not needed.

Over the next three months, I went every one to two weeks to have my “tissue expanders” (the equivalent of an inflatable implant) inflated. Slowly, over time the skin stretches to accommodate the future implant. While it wasn’t necessarily painful, it was an odd sensation. I underwent the exchange surgery, in which the tissue expanders are removed and the permanent implant is placed, and I was left as I am today. The final step in this process is the third surgery to create a nipple, which I for now I will forego.

Medicine wise, I am on Tamoxifen, an anti-estrogen pill that impairs the ability of estrogen to bind to its receptors; it lowers my risk of a recurrence. My relationship with Tamoxifen won’t be short: I am scheduled to be on it for the next 10 years. And while it makes you a bit sweaty (think mild hot flashes), in my mind it is a small price to pay for lowering my cancer return risk.

It’s funny that, while I was embarrassed to undergo elective augmentation and admit it to anyone but my close friends, I truly do believe that those implants helped save my life. The implants are placed beneath the breast tissue. They pushed what little breast tissue I had (and my surgeon attested I was in the group with “lowest volume breast tissue but had cancer”) to the surface of my skin. A foreign object made me more aware of my native tissue. Ironic, huh?

According to the current guidelines and recommendations, I would not have had a mammogram for several years. I was not yet 40, I had no family history, and I was not a BRCA carrier. The American College of Obstetrics and Gynecology recommends that yearly mammogram start at age 40; a breast exam is performed by a health care provider every one to three years (from age 20–39) and yearly after 40. Furthermore, while there have also been advances in mammography (digital mammography vs. traditional film mammography), MRIs for high-risk cases and ultrasounds for women with dense breasts are not routinely used on the “regular” no-risk patient. I was that totally “random” patient who would have been missed. Except for those implants…

In reviewing my case, as both a doctor and as a patient, I have tried to understand what went wrong. How was the lesion on my right breast missed on that first mammogram? First, mammograms are not foolproof. They are pretty good, but tumors can be missed, no matter who is reading them. In retrospect, it appears that my cancer was lateral (far out wide), and perhaps the first time, they did not get adequate views. Basically, they did not go far enough out. But while we can rehash the views and the images, it won’t change my outcome. What we should stress is the benefit of breast self-awareness and self-breast exams. Without them, I am not sure when I would have found the lesion, how big it would have been, or where I would be now.

I am not alone. One in eight women will get breast cancer, and most of us are going to be the “randoms.” We won’t be BRCA carriers, we may not have a family history, and there is a chance we will have no identifiable, real risk factors. All you can do to protect yourself is to be proactive and to follow preventative screening measures. The earlier a breast cancer is identified and treated, the better the patient will do. And unfortunately, many cases are still missed, despite diligent exams and other screening.

I share my story in hopes that maybe one woman or more will be prompted to do her own breast exam, go in for her long-overdue GYN appointment, or get her first mammogram. I’m not writing this for sympathy or pity. I am not a drama queen, and honestly, I’m not too fond of attention. However, by baring it all, I hope to shed light on why it is important to know your body, particularly your breasts. It could make the difference between life and death.

I often say I was dealt the “good cancer card.” Breast cancer is one of the few cancers we can detect early, with excellent survival rates. This is why every October is deemed #BreastCancerAwarenessMonth. While medicine is evolving and our cancer colleagues are making major strides, most cancers simply do not have the same prognosis as breast. This is why I am lucky. I am grateful every day that this was the card I was dealt and by a stroke of fateful events I felt this pea-sized lump. To my sisters out there battling more extensive disease—I send you my love and support. Together, we fight and raise awareness. No cancer diagnosis is in vain. We love, live, and learn more with each life affected.

Come Out, Come Out Wherever You Are: Ectopic Pregnancy

A positive pregnancy test brings with it big-time butterflies, big, bright smiles, and a big bag of unknowns. But very rarely does it bring the big question “Wow, I wonder if this pregnancy is located in the right place.” We all just sort of assume that, when we find out we are pregnant, the pregnancy is within the uterus. Unfortunately, this is not always the case. Pregnancies located outside of the uterus, better known as ectopic pregnancies, are not uncommon (and unfortunately never viable). In fact, about 2% of all pregnancies are located outside of the uterus. Bottom line, ectopic pregnancies are a big deal, and if misdiagnosed, can cause a big problem.

While it’s hard to find anything positive to say about ectopic pregnancies (they are a serious foe for any OB/GYN), the good news is that most ectopic pregnancies pick the same hiding spot…again and again and again! The majority of ectopic pregnancies can be found within the fallopian tubes (about 97%).

The remaining spots where ectopic pregnancies like to hide include the ovaries, the cervix, the abdomen, C-Section scars, or the uterine cornua (the uterine horn). Unfortunately, even when ectopic pregnancies hide in the same place, they are not always immediately visible. When they are small, they can escape even the shrewdest of physicians. It is for this reason that we use both pregnancy levels (hCG), weeks of pregnancy, symptoms (pain and bleeding), and the ultrasound pictures to determine if there is a pregnancy hiding where it shouldn’t be. During this “come out, come out wherever you are” phase, it is important to stay close to home and be in constant communication with your OB/GYN. Keeping us posted will allow for a speedier end to this game of cat and mouse.

Another key player in the ectopic hiding game is knowing who is most likely to have an ectopic. Identifying those at risk allows us to send out the search party early (a.k.a. watch a woman who has risk factors for an ectopic the moment she tests positive for pregnancy). Such risk factors include women who have a history of an ectopic pregnancy, previous surgery on one/both of their tubes, a history of PID, STDs, infertility and/or infertility treatments, smoking, or previous pelvic/abdominal surgery. They serve as hints or flashing red lights for OB/GYNs when patients complain of vaginal bleeding and/or abdominal pain in the first weeks of pregnancy.

Knowing what might be lurking outside of the uterus allows us to keep our eyes open and our minds ready to act. Intervening early in the game (when the ectopic pregnancy is small) can minimize the damage that an ectopic pregnancy can cause.

Once an ectopic pregnancy has been discovered, we move pretty quickly to make sure it doesn’t go back into hiding. We initiate treatment immediately and act fast to put an end to this problem. Treatment can be medical, surgical, or in some cases, simple observation. Which is right for you depends on many factors: a woman’s medical and surgical history, the size of the ectopic pregnancy, the pregnancy hormone level, how far along the pregnancy is, and the symptoms one is feeling. After analyzing these factors, the decision to administer methotrexate (the medical treatment) or undergo a laparoscopy will then be determined.

Make sure you have a thorough discussion with your MD about why he or she has selected the specific treatment plan. Although your pregnancy may be hiding, you should not be kept in the dark about what’s going on inside of your body and why a certain treatment is being used.

Ectopic pregnancies are no joke. If untreated, they can lead to massive bleeding and even death (#1 cause of death in pregnant women in the first trimester). It’s because of this that we OB/GYNs get very worked up over even the possibility of one and will stop at nothing until they are found. We will send blood tests on you every two to three days, bring you in for multiple physical exams, and even ask you to undergo repeat ultrasounds to help us figure out where the pregnancy is and how to make it go away. While the follow up can be annoying, it is essential.

In this game of hide and seek, it’s important that we play together (patient + physician) on the same team. Ultimately, no hiding spot is immune from an ectopic. As a united front, we find it quicker and make sure it doesn’t go back into hiding. So let’s uncover our eyes and start searching!