Pain in the Butt: Hemorrhoids

Talking about your tush, particularly what’s coming out of it and how you feel when these things come out, is no one’s idea of a good dinner conversation. Even during a ladies’ lunch, it’s rare to hear someone say, “So, do you have pain with defecation?” And no matter what you like to call it (defecation is the medical way to say bowel movement), most of us don’t like to call attention to our bowel habits. However, after pregnancy and delivery, pooping can become a pretty big problem. Here’s why…

Pregnancy is a pressure-filled time (and we are not referring to the pressure of knowing that a baby is about to come and change your whole life). During pregnancy, your blood volume increases, you hold on to more fluid, and you usually gain a fair amount of weight. All of these pluses lead to an increase in the pressure bearing down on things like your ankles, your joints, your pelvis, and even your rectum. The local pressure on the anus can lead to varicosities (dilated/swollen blood vessels) in the anal canal (a.k.a. hemorrhoids). Additionally, constipation, a common complaint of pregnant and postpartum women, will make matters worse and will increase the pressure on an already pressured system.

Although hemorrhoids come in two “varieties” (internal and external), most of us are only aware of the external ones. The reason is that the internal ones are sort of invisible. They rarely cause pain or discomfort and only present themselves with rectal bleeding. Therefore, unless you go looking for a cause for the bleeding, you probably won’t find them.

External hemorrhoids, however, are much “flashier.” They cause a pretty good amount of pain with defecation and often move, or prolapse, to the outside of the anus after a bowel movement. On occasion, blood clots form within these prolapsed external hemorrhoids, making them doubly painful. The extra blood will not only cause extra pain but it can also turn the hemorrhoid a bluish purple color, which can cause a good amount of fear. However, the reality is that even though they look and feel bad, they are not dangerous or serious. No matter how little we may talk about hemorrhoids, they are super common, particularly in the last trimester of pregnancy (when pressure is at its peak) as well as during the post-partum period. As you can imagine, labor and all that pushing will not help the hemorrhoid situation, and most women report even more hemorrhodial discomfort (pain, bleeding, rectal itching) in the postpartum period. Not fun.

And while hemorrhoids can be a major pain in the butt, there are many treatment options available, even for pregnant women. From the most basic (anti-inflammatory, anti-itching, and pain relief creams) to the most aggressive (surgery), we have ways to take care of those hemorrhoids and those nagging symptoms. Additionally, changing your diet and increasing fluid and fiber intake can decrease constipation. Decreased constipation = less pushing = less pressure on the rectum = less hemorrhoids.

How your bottom feels can be the basis of how bad (or good) your day is. Let’s face it, we all need to sit, and we all need to have bowel movements—without pain. If you dread defecating, you need to dial up your OB/GYN. Although talking to anyone about your tush seems totally off limits, it’s a pretty standard part of an OB/GYN’s day. We hear this stuff all the time. And if we can’t help you return to the toilet without terror, we have many GI (gastroenterology) friends who can. We promise your hemorrhoids are not here to stay.

Fitting It All In: Maximizing Your Day

How do you get to work, work out, and work on your kid’s homework, all in one day? Trust us, it’s nearly impossible. We fight the same battle every day. Trying to figure out how to fit it all in is a daily struggle. And trying to fit it all in with a smile on your face and some positivity is even harder! While we don’t really have any magic bullet and, unfortunately, have not found a way to add extra hours to the clock (we’ve tried), we have figured out a way to be as efficient as possible—walking and talking, running and listening, watching and writing. Here are a few tips from two busy moms to get as much done as possible in those waking hours.

Start the day early. As much as a five AM wakeup call seems ungodly, it is a great way to get things going (that and a shot of espresso!). The early-morning wakeup call offers you some quiet time before your brood beckons you to their bedside (say that five times fast!). The “Mom” calls come early, but if you can beat them to the punch, you might be able to squeeze some you time in. While we use this time to sweat and burn some calories, it is also a way to let loose and set the cadence for the rest of our day. Exercise does way more than just burn calories; the release of endorphins improves your mental state and focuses you for the rest of the day.

Whether it’s a cycling class, a run, or a Pilates session, whatever gets your blood going will likely get your brain going as well. While we get it’s hard to get out of bed when it’s dark and cold, it may just provide you with more motivation than a Starbucks trenti (did you know they had something bigger than a venti?)! On the days that your kids are up early and you can’t go before they cock-a-doodle-doo, take them with you. Maybe invest in a jogging stroller. The car is a great place to nap, so why wouldn’t the jogging stroller do the same trick? Even if you can’t fit it in but you need your fix, play tag, lift them in the air, and clean up their toys. Although unconventional, if your kids are anything like ours you will be sweating in no time! And don’t underplay getting to and from work. Walk or run (did we really say run?) to and from the office. This is a great way to save money (and the environment) and get your blood going. Keep a mini shoe collection under your desk, an extra pair of underwear/bras, some deodorant, and even a dress (trust us, it will get some good use). You may even consider splurging on a hair dryer. It will “dry” away all the evidence!

Listen to music as much as possible—you don’t need to jam out for hours, but some good tunes on your way to and from work will reset your head and help focus you. We have found this is also a good trick when writing, studying, and even completing tasks. We all need a zone-out/Zen-out session from time to time. It gives you time to decompress and recollect your thoughts. Music has a way of doing this that is unlike any other medium. While we too love a good Bravo reality TV show, it can be a bit more distracting. Definitely get your fix of Real Housewives, but maybe not every day. Reading is also an excellent way to let your mind go; a good novel can literally transport you to another century. Book clubs with friends and even your kids are a great way to get conversations going.

Set aside email/work time. Whether you work in or out of the house, the emails are constant. They are literally non-stop. Trying to stay on top of them can be exhausting. It can also detract from your time at home, time with your kids, and time with your partner. Pick two to three times a day where you return emails, respond to text messages, and return phone calls. The worst thing we can do is be a slave to our phones (and we are culprits of this in the highest order)—it distracts us from our family, detracts from the flow of our day, and can be downright depressing. We all have to work, and we all have to take care of business. But if we are more efficient with our time, we can accomplish a whole lot more.

Make meals matter. Whether it be with your family, your friends, or with your co-workers, put your phone down, and turn the TV off. Meals can be a great time to communicate. You don’t have to make the food (we get it), but you do have to eat. Use your mealtime to make the most of your day. Go on a date with your partner. While it doesn’t have to be a big to do, it can do big things for your relationship. Kids bring with them a whole new world. The nonstop “Mommy, I need you” can wear you down. Remember that time alone with your partner is important. And while you may not make it to Bali or the Bahamas for a week’s kid-free vacation, you can make it to your local bar for a beer! Put time aside for you and your partner. It may be the necessary ingredient for a long and healthy relationship.

Write as much down as possible. As much as you think, “Yeah, I’ll remember that,” you will forget it. So become tight with your calendar. It will make sure you don’t miss a beat (or an important event)! Be it Google, Microsoft Outlook, or an old-school refrigerator door with a magnet, write things down. Whether it be your kids’ school activities, your shopping list, or when your bills are due, this will help you remember who needs to be where when and what needs to be done when. Being aware of what’s coming up will alleviate anxiety because it will allow you to plan. It will also allow you to see when you need extra help.

Don’t be a martyr. Ask for help, and let others help you. While you are almost superwoman, you still can’t fly! As women, we hate asking others for anything. We take one more, add another thing to our plate, and say yes to another task. Know your limits, and don’t be afraid to set them. Spreading yourself thin will lead to exhaustion, exasperation, and a less than ideal outcome.

Try to plan for what’s to come (and not necessarily the next five and ten years; that’s just not possible). Plan for the immediate foreseeable events. For example, lay out your clothes for both you and your kids the night before. Mornings can be stressful, and this can alleviate the “oh no, where are those shoes?” moments. Keep a good weather app on your phone; it can save you from wearing your favorite suede boots in the pouring rain! While you won’t be able to plan away every problem, conquering a few things will help alleviate some of the stress and anxieties that we all feel.

While we certainly don’t have all of the answers and most definitely lay awake at night thinking of all the things we didn’t do that day rather than all that we did do, we try to use the hours we are awake in the best way possible. Plan, plot, proceed, and prepare. But don’t forget to play; unfortunately, once we are out of school, the last “p” is often forgotten. Put it back in your day; it makes a difference in your mood and can often make you more productive. And remember that, no matter how much you accomplish, it will never feel like enough. We all feel this way. It’s a part of being a mom. Welcome to the club!

IUD: When Your Bumper Sticker Reads “Babies on Board and I Need a Break!”

You know when you are out on one of those awkward first dates that are not going well? There are endless uncomfortable silences, those pregnant pauses that are just yearning for some interesting conversation. And then someone breaks the ice and says, “What animal would you be if you could be any animal?” And in that moment, you know: we are never going on a second date! But while the relationship may be over, you probably spit out something like a dolphin, maybe a horse, or even a dog. Those animals that sort of elicit a positive emotion in all of us. Come on, who doesn’t like dogs? We highly doubt that anyone has ever said a camel. I mean they have humps, they walk in the desert, and they can shut their nostrils in a sandstorm. But if you have or have ever considered using an IUD, you may be surprised to find out that the first IUDs were used in camels. Yup, camels. Story goes that many, many years ago traders put stones into their camels’ uteri to prevent pregnancy. It worked. And that, ladies, leads us to IUDs…

Fast-forward several hundred years, and IUDs (intrauterine devices) are one of the most popular forms of long-acting reversible contraception. Given that they take almost no thought (after placement), they do a pretty good job at preventing pregnancy. They allow a pause between pregnancies or a pregnancy pause that can go on between five and ten years, depending on which type you use!

IUDs come in two basic “flavors” (think your local soft-serve shop in the summer)—the Copper T or the Mirena. Recently two more IUDs have come on the market, the Skyla and the Liletta (they are very similar to the Mirena). While the three hormonal options (Mirena, Skyla, and Liletta) differ in a few minor ways—size, the amount of progesterone they release, and the length of the time they will be good at putting baby making on hold, when it comes to the major stuff, they are pretty much the same!

The Copper T is a T-shaped device wrapped in copper. It does its job (a.k.a. no pregnancy) in a couple of different ways. First, it holds the SLOW DOWN sign to both sperm and egg. By slowing down the swimming of sperm as well as changing the speed at which the egg moves through the tubes, fertilization is delayed. However, it not only acts pre-fertilization but also post-fertilization, that is, it can damage or destroy the fertilized egg. Pretty smart, huh? It is important to remember that everything that the IUD does (both the hormonal and non-hormonal types) happens before an embryo implants. The Copper T is your steady eddy or your tortoise in the tortoise and the hare race…it is good for 10 years. But while it lasts and lasts, symptoms are not uncommon. Women often complain of irregular or heavy bleeding and occasional pain. However, the majority of women are pretty pleased with their selection and don’t even know that it’s there.

The other options on the table are the hormonal IUDs, the Mirena, the Skyla, and the Liletta (the levonorgestrel IUD). They are also T-shaped, but rather than being wrapped in copper they are wrapped in hormone: progesterone (levonorgestrel). Despite these differences, the two work in a similar fashion. Both limit egg and sperm movement and, thereby, fertilization. While the Mirena has a shorter half (five years) and the Skyla and Liletta even shorter (three years) they come with fewer side effects—primarily, less bleeding. The progesterone in these IUDs thins out the uterine lining, something that is particularly good for women who have a tendency to develop thick linings from irregular periods.

A thin lining = not so much to shed = fewer annoying bleeding episodes!

News flash: most women who use IUDs still ovulate. Therefore, when the time comes, and you get ready to pull it, pregnancy can potentially happen pretty quickly because ovulation is not suppressed.

Nobody is perfect; everyone and everything has their flaws. Trust us, we have several! The same goes for seemingly flawless medical devices and treatment plans. The IUD is pretty picture-perfect…it prevents pregnancy, you don’t have to remember to take it, and when you are ready to have a baby, you just remove it and are off to the races. What could be bad?

While IUDs are pretty easy to place (most OB/GYNS learn in their first year of residency), there are occasions where a uterine perforation (hole in the top of the uterus) can occur. The perforation rate is about 1/1000. So basically, you have about the same chance of an asteroid hitting the Earth in 2182! Bottom line, it is likely not going to happen. Additionally, there is a small risk of expelling the IUD—this happens more frequently (between 2–10% can dislodge in the first year). Last, if pregnancy should occur while an IUD is in place, calling all of you super-fertile women, you are at a slightly higher risk for an ectopic pregnancy. When things (eggs, sperms, embryos) move slowly down the tubes, they may get sidetracked and start to sightsee. This delay in transit (hello, subway system!) can increase one’s risk for an ectopic pregnancy. So while IUDs don’t cause ectopic pregnancies, if you get pregnant while an IUD is in place, the chance of an ectopic pregnancy is slightly higher. This caveat is not meant to scare you, but it is meant to have you take a pregnancy with an IUD in place seriously.

Historically, IUDs got a bad rap. When you mention, “Mom I am going to get an IUD,” she may have a visceral reaction. In the 1970s, they were blamed for everything from infertility to infection and got the “I definitely don’t want to use that” verdict from many women. However, changes in the design, particularly the string that comes off of the IUD, made them much more attractive to potential users. Now even women who have never had a baby (medically termed nulliparous) as well as adolescents are cleared for boarding. There is no good data that IUDs cause infection or infertility and as a result are “in play” for almost anyone. And bonus— routine antibiotics are no longer needed when placing an IUD.

IUDs are a great go-to for women who want an extended baby-free break. Whether these are young women who are not ready, women who have a baby and want a big-time breather, or women who are done and done, it works. Placement can be performed at any time of the cycle, although right after the period is usually preferable. While we may not have inspired you to use an IUD, we probably gave you some good dinner-party conversation (#camels) or a fighting chance when watching Jeopardy. When having kids or more kids or more and more kids feels harder than trekking across the Sahara Desert without water, think about that camel. And ask your OB/GYN about the IUD.

When the Going Gets Tough…the Tough Get Pumping!

There may be no bigger love-hate relationship than that between a breastfeeding mother and her breast pump. You love what it gives you (#foodforBABY) but loathe the process of pumping. Plugging it in, preparing the parts, putting the pump on, and processing the milk can be a pain, to say the least. For all of you who have done it or are in the process of doing it, you are likely nodding in agreement. But no matter how much angst our plus one (a.k.a. the pump) brings us, it can bring you and your baby many benefits. Here’s how to make this relationship last as successful and as long lasting as possible…

First, it’s okay to acknowledge that the breast pump/breastfeeding relationship is definitely not love at first sight. No one looks at that piece of machinery with adoring eyes and thinks, Wow, this is what I’ve been dreaming of! So before you decide to go steady (a.k.a. the baby is here and you need to make extra milk), get to know each other.

A few weeks before your baby is set to arrive, assemble the pieces, become comfortable with the parts, and set up your system. This will serve you well in the weeks and months to come. If you are unsure about this “match,” seek out a “matchmaker” (a.k.a. someone who has been there before). Don’t be afraid to ask for a tutorial. And if you are the first in your line of friends and family to do the baby thing, look online. There are several legitimate sites that can serve as a guide. Additionally, lactation consultants will not only help when it comes to breastfeeding but also when it comes to breast pumping.

After you and your pump exchange pleasantries, it’s time to solidify this relationship. While most of us like to practice the “take things slow” motto when it comes to relationships, the sooner you start making milk, the sooner you can start storing and saving. This is particularly helpful for mothers who plan to go back to work and want to continue giving breast milk.

Milk production is highest in the immediate postpartum period. Maximize what you make then by pumping after the baby feeds and setting it aside for those “rainy days.” The more you have saved up now, the more you will have to offer your little one later. By maximizing your supply now, you are in many ways matching their demands later. Frozen breast milk can last for months.

Keep track of all of your dates, even the ones that didn’t end so well. Every ounce of milk that you produce and package appropriately (#date) can be used later. Therefore, you want to clearly date each bag of milk that you produce (think black Sharpie) so that you know when it needs to be used by. Unlike the milk you buy at the grocery store, frozen breast milk can go the distance. In fact, it can last up to six months in the freezer.

Because time keeps moving on, you want to use what you made first, first and what you made last, last. And be sure to store your frozen milk in the coldest part of the freezer, not on the door! This system will ensure that you don’t let all of your hard work go to waste (making milk is not easy!)

Give your significant other some space. And while we aren’t talking about relinquishing some of that coveted closet space or clearing a spot on your bathroom counter, we are talking about rearranging your freezer. Milk that you plan to store for a later date needs to be frozen, so it’s a good idea to clean out your freezer before and free up some room before you start the milk process.

Invest in a “new outfit.” Let’s face it: getting dressed for a first date is never easy. Is that skirt too short, are those shoes too bright, is that shirt too tight? And while breast pumping seems far from glamorous, investing in a good hands-free bra can make all the difference in whether you call your pump back for a second date! Hands-free bras allow you to produce and be productive all at the same time! And when you may need to pump several times a day, a hands-free bra can make all the difference.

Be creative. It’s easy to get into a rut in your relationship. Sleep, eat, work, pump, repeat can take a toll on any new mom. It can make you forget what you are doing and why. When cleaning parts and preparing your pump bag for the next day, “wear” your baby in the carrier. While it may not be the traditional “rock-a-bye-baby,” it accomplishes that skin-to-skin closeness that we all yearn for. It also helps with bonding and brings you back to why you are busting your butt making all that milk.

Last, divide and conquer. Figuring out who and what can help you make this relationship work will help ensure that you and your pump go the distance. The pump has to be cleaned, sterilized, and cleaned again (sounds like fun, right?). This takes time, time that no new breastfeeding mother has to spare. Consider asking someone for help (partner, friend, family member, hired help). Dividing up tasks will make the process more tolerable.

There is no doubt that this relationship will have its ups and downs. No doubt you will want to break up at least once a day. And at some point, you will. Whether you get back together in the future (#anotherBABY) is up to you. But in order to make this go around as fruitful, forgiving, and far reaching as possible, it is important to remember our dating tips. While we certainly are not matchmakers, we do know a bit about how to make the breast pump/breast feeding relationship a long-lasting one—take it from us, this one is a keeper!

Sleepless Nights, Sleepless Days

There is probably nothing more exhausting than taking care of a baby (and this is from two girls who completed OB/GYN residency, working 80+ hour weeks!). A newborn trumps everything. There are no shifts, no sign out, and often no relief, which means there are many days with NO sleep. The fatigue you are feeling is like nothing else. And while we don’t have a degree in sleep therapy, or sleep training, or even come close to being baby whisperers, we do know what it feels like to be a new mom. Here, we offer a few tips on how to tackle your tiredness.

  1. Get Out of the House
    When all you want to do is lay down and close your eyes, it may seem somewhat odd that we are suggesting you do just the opposite. Take a shower, get dressed, get out and move. Getting some fresh air and boosting your heart rate a bit can make a big difference in your energy level and your mood. A short, brisk walk not only will help clear your mind but it also might help your baby go to sleep—now that’s efficiency!
  2. Remember to Eat AND Drink
    Food and drink are your friends. While you may not have time to whip up anything fancy, you do have time to chow down on a bowl of cereal or a PB&J sandwich. Additionally, invest in a water bottle, and every time you prepare to feed the baby, fill your bottle. This will help you keep your body in tip-top shape to deal with the fatigue, and for those of you who are breastfeeding, it will help keep the milk flowing.
  3. Cool it with the Caffeine
    When you can barely keep your eyes open, you might reach for liquid help. If you are a coffee, tea, or espresso girl, you go with something that is loaded with caffeine. While we certainly are cool with your ~ 2 cups of caffeine per day, anything more will most likely make you sick. Think jittery, anxious, and nauseous. Additionally, if you are breastfeeding, too much caffeine can dehydrate you, which is not good, especially when you are trying to make milk for your little one.
  4. Phone a Friend
    Ask for help from someone. Anyone. Your partner, a family member, a friend, or even a babysitter, they are there to help. Everyone needs some time off. Be it an hour, a night, or a day, we all need to walk away and take a breather for a bit. Extreme fatigue can seriously cloud your judgment, leading to accidents, injuries, or worse. Even Superwoman had buddies—ask yours for a break.
  5. Nothing is Forever
    Even the worst infant sleepers will one day catch some Z’s. While everyone talks about those babies that sleep through the night the moment they come home from the hospital, most take at least a few months to get into their slumber groove. That said, if several months have passed and you still are staying up all night, it’s probably a good idea to speak to your pediatrician. Something might be preventing your little one from lying down peacefully—your pediatrician should definitely be your go-to on this one.There are tons of books, blogs, and sleep experts out there who have made a living out of providing advice on sleep and sleep training. We certainly are not sleep experts, but we are women who have been there before and who, as doctors, know what you need to stay healthy. The words we offer come from a mixture of those two perspectives. Now, go find yourself a place to lay your head and get some rest!

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!

When Babies Are Not on the Brain: Post-Partum Contraception

Babies out. Bleeding is on. Boobs are big. Belly is still large. Sounds awesome. With all of these bothersome symptoms, “bonking” is completely out of the question. Let’s face it: when you look and feel like you have been through the wringer, intimacy is probably the last thing on your mind. But before you know it, all systems will be healed, and sex will be a go. And while those days seem further away than your first full night of sleep, it will happen. We promise! And when it does, even if you are breastfeeding, you can get pregnant without contraception. To avoid that major oops, here’s how best to prevent pregnancy postpartum.

Let’s do a quick Obstetrics 101 review. In most cases, it takes at least three weeks before ovulation resumes. Prior to this, elevations in your hormones (think hCG, progesterone, and estrogen) will keep ovulation in a holding pattern. After about one month, these levels will drop, and ovulation will resume. However, in women who are breastfeeding, prolactin (the hormone that helps you produce milk) will arrive and stay on the scene until you are ready to move on to formula or milk. In high levels, prolactin can function similar to hCG and prevent ovulation for some time.

No ovulation = no egg = no embryo = no pregnancy

The sticking point is that “some time” can be anytime; how long you can use breastfeeding as contraception depends on how frequently you are feeding/pumping, how many other “things” (a.k.a. formula or food) your baby is taking in, and your own body. Women with the exact same routines can start ovulating at very different times. Bottom line: breastfeeding is not a completely reliable source of contraception. You need a back-up mechanism.

So, what are your options? While there aren’t as many choices as for non-breastfeeding women, you do still have choices. Think about the contraceptive choices for breastfeeding women as a three-choice exam. Option A = oral contraceptive pills (a.k.a. OCPs), Option B = IUD, and Option C = barrier devices (condoms or a diaphragm).

You can go with any of the three and achieve pretty good results—if they are taken correctly! Which you select really depends on what is best for you, your medical history, and your personal needs. The first few months after bringing a baby home can be exhausting and hectic, to say the least. Remembering to take a pill daily at the same time may be harder than it sounds. The OCP prescribed to breastfeeding women, a.k.a. the “mini-pill,” only includes progesterone and must be taken at the same time daily to remain effective. While the toothbrush or shower trick may help, believe it or not, some days you might not make it into the shower (or even brush your teeth)! If you go with an Option B (IUD), you won’t have to think at all. Combined with its good contraceptive benefits, this may B the right choice for you!

If you have decided to go right to the bottle (aka formula)—and trust us, there is no judgment in that statement—you need post-partum contraception ASAP. This convo will usually commence at your six-week postpartum visit. Remember: sex before six weeks is off limits anyway! The options for women who are not breastfeeding are no different than for women who are breastfeeding. Where things diverge is in the type of oral contraceptive pills (a.k.a. hormones) that one can take.

Non-breastfeeding women can take good old-fashioned estrogen + progesterone pills as well as progesterone-only pills. Usually, the former is preferred due to slightly more flexibility in how perfect your timing when it’s taken needs to be. Because milk production is not an issue, the suppressive effect of estrogen on milk production is no big deal. If OCPs are not your speed (or medically a no go), you can also go with the patch, the ring, implantable devices, Depo-Provera, the IUD, condoms, or diaphragms.

Basically, barring any underlying medical issues, the sky is the limit. Pick what’s best for you and your busy lifestyle. Just remember: fatigue will be an issue, so the less you have to think, the better. Whatever you choose, be sure to commit; otherwise you may find yourself expecting way before you were expecting!

Let’s Get the Screening Started

If your little ones have finally started to sleep through the night, eat real food, and maybe even venture onto the potty, you are probably feeling pretty good. Major milestones for your kids mean a lot to you not only as a mom (#ProudMom) but also as an individual (#HiWorldIamBack). While your schedule still somewhat revolves around your little ones’ naptime (which, let’s face it, none of us really likes to give up), the bonds of babyhood are slowly being released. (See you later, diapers and bottles!) As things settle, you are ready to get not only your house back into order but also your health. This includes sleeping, eating, exercising, and screening. While screening may conjure up an image of TSA and airport security, what we are referring to may include an X-ray machine and takes a whole lot more than 3 seconds.

The screening we are talking about includes visiting your MD for a good, old-fashioned chat, a physical exam, and probably some tests. Although most of us can barely find time to get a haircut, a checkup is kind of essential. While this meeting may include nothing more than a quick conversation along with a height, weight, and blood pressure check and focused physical (think heart, lungs, breasts, abdomen, and pelvis), if something looks or sounds off, we recommend a more detailed follow-up exam with blood tests and imaging studies (X-ray, MRI, or CT scan).

Depending on where you are in life (a.k.a., your age) and what your family’s history is like, you are probably getting teed up for a mammogram and maybe a colonoscopy. Although you should already be doing breast self-exams and clinical breast exams (by a healthcare specialist), most of us welcome the big 4-0 with our first mammograms. While there is a lot of fear and anxiety over entering the world of mammograms, for most of us (no matter what your breast size is), it’s nothing more than a few minutes of discomfort. You have endured endless sleepless nights, changed innumerable dirty diapers, and sat with a breast pump on for hours—you can tolerate a mammogram!

Although admitting this is hard (it is for us too), as our kids age, so do we. With age comes not only maturity and perspective but also disease and illness. As a result, your body needs to be “looked at” more frequently than it was in your 20s. Prevention is the key to your body’s prosperity and longevity. So, while we don’t doubt that you are a woman with a loud roar, even the strongest among us can get sick. Having a good doctor who knows you and your body is crucial. Get checked up and checked out on a regular basis (not just when you are sick). Screening may not be as “sexy” as getting your hair colored or your skin cleansed, but it will likely help you keep looking and feeling sexy.

The bottom line is that you should get a mammogram, get a Pap smear (or at the least have your OB/GYN review your cervical cancer screening history), and share your past and your family’s past with your doctor. While your kids may no longer be babies, there will be several bumps in the road for which they will need you by their side. Screening will help you stay strong!

Milk Maid: Are the Benefits of Breastfeeding Bogus or a True Bonus for Your Baby?

Ah, breastfeeding. What can we say? Just the word, the thought, and the image can engender emotions as variable as night and day, north and south, love and hate. People are very passionate (on both sides of the aisle) about this topic. Remember how much flak that lady took who was breastfeeding her 3-year-old son on the cover of Time magazine? She almost got as much press as Caitlyn Jenner!

For those who have danced the dance before, some recall the experience with fondness and affection, while others remember it with frustration and fury. For those who have not yet even tried, the thought can create both anxiety and excitement, nervousness, and anticipation. Wherever you fall on the breastfeeding spectrum, it is worth a discussion. Why is there so much buzz around this subject, including if you do it, where you do it (who knew a woman breastfeeding her baby would make its way to the floor of Congress!), and how long you do it?

The tides on breastfeeding have changed more than the Atlantic Ocean in hurricane season. In the 1950s, women were given medications that put them in a twilight state for delivery (no memory of the pain, the pushing, and the other glories of childbirth) and given formula to feed their babies when they woke up.

Today, hospitals are jockeying to receive the prestigious “Baby Friendly” recognition where Baby and Mom are never separated (the newborn nursery no longer exists). Lactation consultants occupy the hallway. Breastfeeding classes happen twice daily, and formula is hardly even mentioned. In 1971 only, about 25% of mothers left the hospital breastfeeding. In 2005, this number had risen to 72%. The change has come on the heels of extensive research, which has demonstrated the numerous benefits of breastfeeding for both Mom and Baby.

So what is so magical about that milk? Why is it liquid gold? Breast milk offers numerous benefits for both babies and mothers. The list is long, and at the top is the protection it offers against infection. Buried within the milk are antibodies that strengthen your baby’s immune system. While women are breastfeeding, their babies have a lower chance of infections, including stomach bugs, respiratory illnesses (colds and coughs), ear infections, and urinary tract infections. Additionally, breast milk has been shown to help stimulate the growth and motility of a baby’s GI tract.

And as if the carats of this gold were not high enough, breastfeeding does not just offer short-term gains but also major long-term benefits for your child. The pluses seem to persist for years after the last drop is released; a mother’s milk provides protection against illnesses for the first several years of a child’s life. Fast-forward into your child’s adolescent and adult years, and there is evidence that suggests breastfed babies have a lower incidence of chronic diseases, including obesity, cancers, allergies, diabetes, and even adult cardiovascular disease.

And if you think that’s it, think again. Select studies have shown that breastfed babies may have better vision, hearing, cognitive development, childhood behavior, and stress reduction. But while the list is long, some points deserve more press than others. While the early benefits are clear, the later ones are controversial. Don’t let the fear of what might happen to your child ten years into their life if you put the pump away after six months keep you going. Whatever you have done or will do is better than nothing! And remember, many of us have gotten to the top of the professional ladder and never consumed even one ounce of breast milk. Your child’s success is not solely based on their first diet.

Breastmilk doesn’t just do a baby’s body good; it also does your body good! Breastfeeding hastens your recovery post-delivery (the hormone that produces milk also helps the uterus to shrink back down to its normal size). It helps the weight come off faster (a magic diet pill—we’ll take that!), and it can serve as a form of birth control (at least in the first few months after your delivery).

Some data suggest that women who breastfed have a lower incidence of breast and ovarian cancer as well as a lower risk of heart disease. Lastly, it’s basically free! Formula is not cheap, and babies drink a lot of it! Take the money you saved, and buy yourself something special. You deserve it. Breastfeeding is hard work!

But while breastfeeding may not be right for every woman, it is medically not advised for some women. These include women who are HIV+, HTLV type I or type II, have active untreated tuberculosis or varicella (chicken pox), or have active herpes with breast lesions. Women who are advised to take certain chronic medications that they briefly stop during the pregnancy may also be advised to resume postpartum and not breastfeed. Additionally, women who use illicit drugs or consume excessive alcohol should not breastfeed. Lastly, babies with a condition called galactosemia (inability to break down a milk byproduct) should not be breastfed.

Let’s face it, even the best milk producers amongst us need a break every now and again. An afternoon to pamper yourself or an evening out with friends is important for your mental state and can actually help with your milk production. Making milk is hard work. You need to eat well, drink lots of fluid, take your vitamins, and try your best to get some rest (we understand how hard this is!) Continue to watch your fish intake (like you did during pregnancy), as some are loaded with mercury  (Link: A Fishy Situation). Bottom line: in order to keep the milk flowing, you need to maintain your health.

You’re not a machine, but even machines don’t work without maintenance! In fact, it is estimated that you need an extra 500kcal per day when breastfeeding. And although infant demand (how much your baby wants and needs) is the major factor determining how much milk you produce (some women breastfeed twins, triplets, plus!), maternal stress, anxiety, fatigue, illness, and smoking can all lead to a tapping out of your supply. A little pumping and dumping now and again never hurt anyone or left any baby hungry.

While we are not here to tell you not to try or to stop prematurely, we are here to say, cut yourself some slack. You are not a failure if you didn’t make milk, if you couldn’t get your baby to latch, or if you simply could not do it. Breastfeeding does offer many benefits, but it’s not right, easy, or appropriate for every mother. And that’s ok. No baby was rejected from Harvard because his or her mother did not breastfeed, quit after a few months, or didn’t make the recommended six-month mark.

In an ideal world, we would have an extended paid maternity leave—this time together would be more conducive to continued breastfeeding. But most women don’t get this; shortly after delivery, they must return to work. So we recommend you use all the resources available to you: lactation consultants, breast feeding organizations/stores, websites, and your friends. Many of them will have walked in your footsteps only months before and can be your cheering squad pushing you forward. Their knowledge can benefit you and offer you solutions to a problem that, despite the loneliness you feel, millions of women before you have faced.

It’s likely not a day will go by that you don’t blame yourself for something, feel guilty about something, or think that someone else would have done it better. It’s par for the course. Parenting is a big responsibility. We get it; the thought is overwhelming. But on this journey of motherhood, you will bogey, you will eagle, and sometimes you will even par. We all do. Breastfeeding is only the first putt on the course. Do your best, and the rest will likely take care of itself.

Got the All Clear, But Can I Really Re-Consummate This Relationship? Sex after Baby

The first six weeks after your baby is born are a major blur. Let’s be real: while there are magical moments, most of your days are filled with spit up, dirty diapers, milk stains, and sweats (don’t think we changed out of our workout clothes once!). Your home becomes a welcoming ground for friends, family, and all of those well-wishers who can’t wait to meet your little one.

And while you welcome a break from the routine (feed, burp, diaper, sleep), their presence can be beyond overwhelming. It’s not only the germs you see them bringing into your Purel-ed place or the gift that now requires a thank-you note (you could write a thank-you note for that cute onesie in your sleep!), but your energy level for entertaining is at an all-time low. It is not easy.

And to top it all off, your body still does not feel like your own. You’re still bleeding, your boobs are now enormous, and your belly still looks pregnant. (We have all been there. It is not fun one month after delivering, when that friendly neighbor says, “Any day now: you must be so excited!”). Additionally, you are now on pelvic rest—a.k.a. nothing in the vagina for six weeks post-delivery (whether or not your kid came out from below or through your belly). That includes no tampons and no sex.

So you make it through the first six weeks sleepless and sexless and go to your OB for the famous post-partum visit. She or he chats about life, how you are feeling, and how you are adjusting. They weigh you (ugh, still have 15 pounds to go) and examine your incisions (both abdominally and/or vaginally). Then they begin the discussion about birth control—pills versus patch, condoms versus IUD, or for those at the end of the baby line, tying your tubes versus tying his tubes (a.k.a. a vasectomy).

This subject transitions into “YOU are all good to go”; basically, you have the green light to have sex again. At this moment, you are probably thinking, Am I really ready to turn in my postpartum hospital-grade underwear? (Gotta admit, those are the best!) for my Hanky Pankys? Given your current state, sleepless and shaveless, it’s hard to imagine being intimate again.

Let us give you a quick preview… It’s as dry as the desert in summer down there, and no matter how much lubricant you use, you will still feel like you are being set on fire. We are here to say not to worry; while completely unpleasant, it is totally normal. In a large study of post-partum women, nearly 85% of women reported sexual problems at three months’ postpartum (See, you are not alone).

Your mind and body have gone through some pretty serious changes, and it will take time for things to go back to normal. And the good news is that for most it will go back to normal. Research shows that about 50% of women reported dyspareunia (medical way to say pain with sex) at two months post-partum. By 18 months postpartum, this number decreased to 24% (See, time does heal all wounds!).

Post-delivery, your estrogen levels plummet. This drop is not only caused by the delivery of your baby and placenta, but also by the rise in prolactin (the hormone that produces breast milk). Prolactin levels remain elevated post-partum to allow for the continued production of milk. With this high comes the persistent low of estrogen.

In addition to the mood changes, the hair changes, the skin changes, and the headaches that come with low estrogen, you can also welcome vaginal dryness. And not just the mild “Oh, KY Jelly or Astroglide can fix that” vaginal dryness…it’s a dryness that requires an army of products. Medically, we call it “atrophy” or “friable.” Due to “atrophy,” you can often see bleeding post-sex. Again, we are here to say that this is not uncommon.

In addition to the discomfort experienced with sex post-partum, a significant number of women report decreased libido. Nearly 60% of women reported a decreased libido at three months post-partum. Not surprisingly, they cited fatigue, discomfort, and fear of making a bad situation worse. Women who breastfeed were even more likely to report a decrease in libido than non-breastfeeding women; this is likely because those who don’t breastfeed have a faster return of their hormones to baseline. However, the difference did not persist for the long term (again, nothing lasts forever!).

Ways to combat this problem include lubricants and vaginal estrogen creams. So even without a major makeover, in most cases, things will get better. Now, if you sustained a serious tear or had a complication with your laceration or episiotomy, the situation might be a bit more complex. It may require you to sit out on the bench for a bit longer and apply a more comprehensive armamentarium of medications and products. But don’t worry. Even in the most serious cases, with the help of an OB/GYN, a pelvic surgeon, and in most cases, physical therapists, this team can help restore the situation back to normal (although you may need to consider having a C Section for your next child to avoid a repeat event if the situation was really bad).

Bottom line is that your bottom will heal—it just takes time. If you don’t feel like you, physically and emotionally, it is totally normal. Don’t be afraid to give your body and your brain time to rest; the postpartum period is no joke! But rest assured, with a little rest and assurance, you will be back in the game in no time.