Does Breast Pain Always Mean Something Bad?

Although there isn’t a moment in our lives that “the girls” aren’t by our side (or rather on our front), on most days we are unaware of their presence. Sure, we have the daily AM bra conversation with ourselves…what color, what material, strapless vs. racer-back, but in reality we spend a very modest amount of time paying attention to our breasts. This is except when one or both starts to hurt.

Breast pain makes us say, hmm, what could that be? And while most of the time our mind goes to that scary place, the majority of breast pain is totally benign. Let us unveil the A, B, C, and Ds (and maybe even the double A or double Ds) of breast pain with these basic facts.

A: Breast pain is one of the most common reasons women visit their GYNs.

B: The medical term for breast pain is mastalgia.

C: The easiest way to figure out what is bothering your breasts is to break out your calendar. Pain that moves with your menses (a.k.a. changes throughout the menstrual cycle) is considered cyclic. Cyclic breast pain is almost always caused by hormonal changes. Pain that comes on any calendar day (a.k.a. is constant) is considered noncyclic. Noncyclic breast pain is almost never caused by hormonal changes.

D: There are other structures (think of your muscles and your ribs) that are “roomies” with your breasts. Their close proximity to the breast can often masquerade as breast pain. So problems such as trauma to the chest, a fracture of the ribs, herpes, reflux, inflammation of the cartilage connecting the ribs, and angina make one think one’s breasts are in big-time trouble—when in reality they are nothing more than innocent bystanders!

Getting into the nitty gritty of it (or the double As and Ds as we like to say), hormonal or cyclic breast pain can occur from any medication that is either made from or modifies your hormones. Think OCPs (or any form of hormonal contraception), fertility medications, and medications used to treat abnormal vaginal bleeding.

When it comes to noncyclic breast pain, hormones are not the issue. While the breast is involved, the pain has nothing to do with your period. Think of things like trauma, infection, cysts, tumors, and cancers. Therefore, non-cyclic breast pain, specifically when it is in one breast, is intense, and is getting worse, makes us a bit more nervous. It definitely needs to be checked out.

In most cases, pain prompts a physical exam and an in-person chat: when did the pain start, what makes it better or worse, how often does it occur, and what where you doing when you felt it first? Depending on what these initial evaluations show, your doctor may decide to send you for a mammogram, a breast ultrasound, and/or an MRI. But because most breast pain winds up being no big deal (not cancer), the best thing to do is take a deep breath: it will very likely be okay. After this, it is not a bad idea to consider changing your bra (more supportive, better fitting) and changing your diet (less salt, caffeine, and fat). These modifications might just do the trick.

When nothing works, you may need to move on to medications. Starting an OCP or changing your OCP can help alleviate cyclic breast pain. Additionally, lowering the dose of a hormonal medication can also be helpful. Last, if the pain is non-cyclic and related to the muscles of the chest, an anti-inflammatory like Ibuprofen or Advil can certainly do the trick.  

Your breasts are sort of a big deal, no matter what size you are. And when they don’t feel right, you want to look into what’s making them hurt. While the pain is most likely from normal hormonal ebbs and flows, this is not a tide you should just watch roll in and roll out. Go looking for the lifeguard (your GYN) to make sure you weather this storm safely. It may be a pain (no pun intended), but it will keep you and your breasts protected.

The 10 Questions Everyone Should Ask When a Fertility Cycle Fails

A negative pregnancy test can be hard for anyone to bear, particularly individuals and couples who are going through fertility treatment. It’s like studying for weeks and weeks for an exam, thinking you know the material, and then getting an F. “Disappointing” doesn’t even begin to describe how you feel. And while the first place you usually go is your significant other’s shoulders for a good cry (and for a glass of wine and a bite of unpasteurized cheese), the second should be to your fertility doctor to break down why this cycle didn’t = baby.

Here are our suggestions on what should be on your list:

  1. Why didn’t it work?

Hands down, this is the most frequently asked question when a fertility cycle is not successful. And while it is a good place to start, in order to get concrete answers, it’s better to break it down into little pieces (a.k.a. your reproductive parts). When you chat with your doctor, make sure to be specific in your line of questioning; the narrower the question, the more useful the answer. And bring a pen and paper!

  1. Did I make a bad egg?

While we are never fans of finger pointing, in many cases the culprit is an abnormal egg, which resulted in an abnormal embryo, which = no pregnancy (especially if this was an IVF cycle where the embryo did not undergo genetic screening). Unfortunately, barring genetic testing of the embryo, there is not much that we can do to predict if the egg you ovulated or we extracted was normal. While we use hormonal assays (think FSH and AMH) and female age to help guide our treatment plans and analysis of the outcome, they are limited in their abilities to predict the future. This is why we are huge advocates of embryo screening. While it can’t tell us if the extra chromosomes came from the egg or the sperm, it gives us a lot of data about where the “damage” may have started. And while it is nearly impossible to change egg quality, by analyzing the embryos that are produced by those eggs, we can find the good egg (s).

  1. Was my partner’s sperm only so so?

Although men are often sperm-making machines for years longer than we are egg-making machines, as time ticks away, so does sperm quality and quantity. Furthermore, certain medical conditions or recreational habits can hamper your other half’s sperm production. Make sure that your partner has had a semen analysis, and if the results were only so so, your fertility doctor should refer your partner to a urologist. There are procedures, techniques, and medications that can help improve sperm quantity and quality.

  1. Are things not flowing freely through my tubes?

Think of the tubes like any major New York City tunnel—they can get blocked up anytime and for any reason. And while there are certain things in one’s medical and gynecologic history that would predict a tubal closure (a.k.a. a history of pelvic inflammatory disease or multiple abdominal surgeries), in many cases they are just closed for no clear reason. Therefore, before any fertility treatment is initiated, it’s a good idea to have your “tunnels” checked. If there is a problem, you will need to take an alternate route to achieve a pregnancy—and learning this before you set out on your fertility journey will save you a lot of time!

  1. Was my uterus not ready for a guest?

Although the uterus is infrequently the primary or solo cause of infertility or a failed fertility cycle, it should be looked at from a few angles. Routine ultrasounds depict the uterus in two dimensions. And while it can look good in this mirror, it’s important to have a 3D study or a test (HSG or hysteroscopy) that shows the inside of the uterus. Unwanted guests (e.g., fibroids, polyps, or scar tissue) that can interfere with implantation can be lurking!

  1. Should I repeat the same treatment, and if I do, what is the chance it will work?

Yes and no and maybe. (Well, that was helpful advice!) But all kidding aside, the reality is that most fertility treatments doesn’t work the first time you try them. You often must try a few attempts before you see success. However, you should 1,000% speak with your doctor between every attempt and ensure he or she breaks down what happened and how he or she can make things happen next time. Additionally, make sure you have an end point. While this road can be long, it shouldn’t be endless. Make sure there is a stop and you know where and when that will be.

  1. When is it time to move on to the next step?

Unfortunately, this one doesn’t have an easy answer. However, we added it to the list to make sure you ask it. And to ensure that you know that there are options, both in what you do and where you do it. You aren’t tied to one type of treatment or one treatment center. Ask, look, and listen. There are many good resources out there with lots of information (#trulyMD).

  1. Do you have paper and pen?

Write things down! Whether it be the questions you want to ask or the questions that you had answered, remembering everything can be hard. Jotting down what you want to say and what has been said will serve you well in the future.

  1. Can I have my records?

You are your best advocate (and your best record keeper). Asking for your records and speaking up on your behalf does not make you annoying. It makes you smart. And while you don’t need to become a bookkeeper, keep track of what goes into and out of your body. It can ensure that you stay balanced!

  1. What’s next?

We love plans. Just check out our calendars! But we especially love plans when it comes to our patients. Knowing what you are going to do if your day 1, that is, your period, comes can make dealing with D day somewhat easier. Simply stated, plan for the worst (#period), but hope for the best. That way, you won’t waste any time.

Getting pregnant and having a baby are not easy. Contrary to what we thought in college, you don’t get pregnant every time you have sex! Although people use the word “fails” liberally, remember that you are so not a failure. Doing fertility treatment is hard: emotionally, physically, and financially. Staying in the game when things get hard makes you a success—no matter what that pregnancy test shows.

Ten Tips for First-Time Moms: What to Do in That Last Month!

Take everything we say in this post with a grain of salt. Most of it has minimal medical basis and maximal learn on the job-type tips. Pregnancy can be amazing and awful all at the same time—yes, we just said awful and pregnancy out loud together!

When you head into the home stretch, the physical pain usually gets worse, as does the anticipation and anxiety, especially if it’s your first time at the rodeo. First, all the emotions you are feeling are totally NORMAL. We totally give it up to Brooke Shields, who broke barriers by sharing her postpartum experiences. It’s important to know that joy is not the only emotion you’ll be feeling at the end of pregnancy and the beginning of mommyhood…

Here are our top 10 pre-delivery tips.

  1. Get groomed.
    While we are not telling you to run from the nail place to the waxing place and back to the hair salon, we are telling you to treat yourself! Make time for you before the baby arrives. A spa visit and some good R&R is the best way to do it. Besides, who doesn’t like to be pampered?
  2. Make a delivery playlist.
    Labor is not called labor because it comes and goes in the blink of an eye! Much to the chagrin of the family members camped out in the waiting room, it can be a LONG process—especially for your first! We recommend bringing along some good music, downloading some good movies, and maybe even packing a good book. Nothing takes your mind off things like laughter and light tunes.
  3. Plan a dress rehearsal.
    It’s never a bad idea to map out the best route to the hospital. Know where you are going and how to get to the labor and delivery floor. While it may seem silly to make a dry run, it will likely ease anxiety when game time comes. On that note, it’s also not a bad idea to have your “costume” (a.k.a. overnight bag) ready to go. The last thing you need when those contractions start is to be searching for your favorite sweatpants!
  4. Breast milk vs. formula.
    We are NOT here to pass judgment or tell you which is better for you or the baby. In our opinion, what works best for you will work best for your baby. But if you do think that you want to give this breastfeeding thing a whirl, make friends with a good breast pump, and a find a good lactation consultant (or someone in the know). This will help you prepare for what’s to come and increase your chances of getting the milk flowing.
  5. Bag the birth plan?
    We get it…you know exactly what music you want to be playing, exactly where you want your partner to be sitting, and where the baby should be placed right after delivery. And while having a birth plan is important, be FLEXIBLE with your bullet points. For sure know if you want an epidural, if you want a doula, and if you want a vaginal delivery or a C-Section—but unfortunately, labor and delivery don’t follow a plan. Be prepared for things to deviate from the script…the show will still go on!
  6. Know who you want to be there at the final push!
    Who you want to hold your legs and wipe your forehead is a very personal decision. Don’t be bullied by parents, your in-laws, or your friends—only people you want in the room should be there. It’s okay to want privacy during your special moment.
  7. Eat your heart out!
    While we want you to be careful about how many pounds you add during your pregnancy the night before you go into the hospital (if being induced, having a C-Section or as labor is starting), we recommend going all out in the food department. Treat yourself to a decadent dinner with your significant other. You will not only need the energy to push, but you will also want to enjoy the last moments of being kid free.
  8. Be mindful of unsolicited advice.
    Everyone is an expert when it comes to all things pregnant, and they are not afraid to share it. While most mean well, the advice can become moderately annoying. Listen to what you want to, and shut out what you don’t want to hear. Your doctor and medical team have probably done this several hundred times; they have got you covered and know what’s best.
  9. Accept the unacceptable.
    So many times, we hear women saying through tears and sobs, “This is not how I planned it. I feel like such a failure.” Unfortunately, no matter how hard you try to control what happens on D-day, you can’t. Nature doesn’t care if you dreamed of delivering in a bathtub in the dark with classical music in the background—if your baby’s heart rate drops, you’re having an emergency C-Section under the bright lights, no questions asked. The number-one priority is your and your baby’s safety; trust us, when you hold that baby in your arms, the plan will be nothing more than a moment in the past.
  10. It’s ok to want to quit—at least several times a day.
    Motherhood is the only job you don’t get to call in sick to, you don’t get to resign from, and you don’t get fired from. You can’t clock out, and you don’t get a paycheck. But even with all the exhaustion, the frustration, and the anxiety, it is the most amazing experience you will ever have. Labor is TIRING. Pushing is HARD. But quitting is not an option—you are stronger than you know.

Feeling More Than Blue: The Reality of Postpartum Depression

There is no easy way to say this…the postpartum period can suck. It can be awesome and awful, exhilarating and exhausting, and precious and painful all at the same time. You will find strength you never knew you had to get through those long days and even longer nights. But while nearly 40 to 80% of women feel postpartum blues, about 10 to 15% actually suffer from postpartum depression. It is a serious illness that requires serious attention. We want to address it with all the gravity that it deserves.

The emotions following the birth of a baby are as labile as the weather in the tropics. In minutes, you can go from elated to dejected. While it is quite common for women to experience what is called postpartum blues (a.k.a. the baby blues), the symptoms of depression are usually mild and short lived. Why it happens is not clear; most of the research points towards those crazy hormones that are flooding your system post-delivery. Women report sadness, tearfulness, irritability, anxiety, insomnia, and decreased concentration.

In the first two to three days following delivery, about 40 to 80% of women report feeling blue. In most cases, the symptoms of being “blah” (medical term = dysphoria) will peak over the next few days and then resolve within two weeks, basically, like a blip on the radar. So while some moments—and days—will be harder than others, all in all your mood and emotions should be stable.

Postpartum depression is in many ways the baby blues magnified by 100. Unfortunately, because the symptoms often overlap with the typical postpartum pleasantries, many women are misdiagnosed or undiagnosed and suffer in silence. Fatigue, difficulty sleeping, change in appetite/weight, and low libido (to name a few) are often seen in both processes. Again, what fuels postpartum depression is largely unknown; however, much like the blues, hormonal changes are thought to be the culprit (although here genetics is also thought to play a role).

While we are all at risk, there are specific risk factors that make us more likely to develop this disease: a history of depression, history of abuse, stressful life events, lack of a partner or social/financial support, family history of psychiatric illness, and childcare stressors (inconsolable infant crying). If postpartum depression is left untreated, it can often develop into chronic depression. It can also have a major impact on our ability to bond with the baby and can impact the development and mental health of infants and children.

To minimize the negative domino effect for both mother and baby, we as OBs need to ask the right questions and encourage you as moms to share your emotions. While we can’t definitively prevent who develops postpartum depression and how it affects them, we can identify women who are at significant risk and start treatment early. For example, if you have a history of major depression and were successfully treated with antidepressants in the past, you may be a candidate for immediate medical treatment postpartum. Bottom line, don’t be afraid to share your past history (physical and mental) with your doctor; this sort of information may make a big difference on how you weather the postpartum storm.

The “fourth trimester” (aka the postpartum period) is largely dominated by breastfeeding. Therefore, taking medications for both depression and anxiety while breastfeeding has become a hot topic. As moms we don’t want to take anything or do anything that could affect the health or development of our baby. We martyr ourselves to the umpteenth degree for our children; what we ingest, be it food or medicine, while breastfeeding is no different. But the reality is an unhappy mom makes for an unhappy baby. While medications may not be the first or only step (cognitive behavioral therapy is recommended initially) they are a close second. And in cases of severe major depression or mild/moderate depression that is not treated with psychotherapy alone, medication should be initiated. In general, for women who are breastfeeding SSRIs (selective serotonin-norepinephrine reuptake inhibitor) are the preferred class of medications as they present the lowest risk to your baby.

Everything in medicine (and in life) has a risk-benefit ratio. It’s like a seesaw; sometimes you are up, and sometimes you are down. Our goal when prescribing treatment is to find a balance. For example, while breastfeeding on an antidepressant may pose a small risk to your baby, the benefits of breastfeeding appear to outweigh the small risk of the antidepressant on the baby. All medications will make their way into your breast milk, but the amount can vary.

Here are some pointers to reduce the exposure:

  • Select medications that are in your system for a shorter amount of time.
  • Take medications immediately after you nurse (so that the levels in your milk are the lowest).
  • Work with your OB, your mental health provider, and your pediatrician and see what is best for you and your baby. You wouldn’t stop taking medicine for your blood pressure if it was high. Your brain is no different!

The problem with post-partum blues, depression, and the feelings of being down and out is that we are afraid to admit things are not perfect and that maybe motherhood is not all that we imagined. We feel guilty for wanting to scream when the baby won’t stop screaming or drink a bottle of wine when the baby won’t take the bottle. We feel guilty about not loving every second of what is supposed to be the most precious moments of our lives.

But the reality is, we all feel like this. For some of us, they are transient, and we quickly return to our baseline. But for others, the feelings remain and can worsen. Don’t be afraid to share your feelings; help is available. You are not a bad mother for feeling this way. In fact, admitting there is a problem and getting help makes you bold, courageous, and actually a pretty badass mom!

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.

When Doctor Becomes Patient

I (Sheeva) am a breast cancer survivor. And while I have uttered those words numerous times over the past three 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 and Jaime) 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.

Does Everything That Itches Equal Yeast? Vaginal Infections

When anything feels off down there, our mind usually goes to one place: yeast infection. No matter what the actual symptoms are, any discomfort seems to signal yeast. For whatever reason, for most of us vaginal discomfort reflexively equals yeast. And while some of us will call our GYN to get their take on what’s going on down there, most of us simply head over to the local Duane Reade or CVS for some sort of topical relief.

Whether you pick the one-day, the three-day, or the extended seven-day course, you leave with something to stop the itch, the burn, and the overall discomfort. It isn’t until your symptoms outlast the one-, three-, or seven-day regimen that you pick up the phone and call your doctor. It is usually here that you find out that not all burning, discharge, or itching is yeast—a.k.a. Monistat works, just not on a bacterial or urinary tract infection.

Here are some tips on how to know if yeast is really the culprit…

  1. Discharge: While most of us associate vaginal discharge with some sort of problem or infection, news flash: a healthy vagina also secretes vaginal discharge. However, the latter is usually odorless, fairly clear, and doesn’t make you think or wipe twice! An infection, be it yeast, bacteria, or something else, will cause the discharge to change color, content, and quantity. While yeast is routinely associated with white, clumped (cottage cheese-like) discharge, discharge that is green or yellow is more commonly seen in bacterial infections (e.g., bacterial vaginosis or Trichomoniasis). And taking it one step further, urinary tract infections (which are often misdiagnosed as a yeast infection) will likely cause no change in the quantity or quality of the vaginal discharge. Bottom line, what the discharge looks like may “color” our diagnosis of what is causing your vaginal discomfort.
  2. Odor: Nobody wants to smell bad…especially down there! So, when something smells off, it should signal you that something is not right. However, that “not right” does not mean a yeast infection. Here’s the deal. A normal vaginal pH is about 3.8 to 4.5. Infections can alter the pH and change the vaginal odor. Select bacteria (think bacterial vaginosis, a.k.a. BV) can result in foul-smelling vaginal discharge. And although yeast can alter the pH, it doesn’t usually have a significant impact on vaginal odor. Therefore, when the odor seems way off you are likely dealing with something else.
  3. Itching: Vaginal itching and yeast infections sort of go hand in hand. In fact, this is the symptom that sends most of us straight to the drugstore. But while yeast is the infection that is most likely to cause an itching sensation, the vaginal mucosa, just like your skin, is sensitive to changes in body washes, soaps, and detergents. The same sort of itching that can occur on your arms, legs, stomach, and face when you change detergent or add a new skin care product can happen to your vagina. Before prescribing yourself Monistat, think about what has changed in your hygiene routine, and make sure that it is not what’s making you itch!
  4. Abdominal Pain: Most vaginal infections are limited to the vulva and the vagina. They rarely make their way to the cervix, the uterus, the tubes, and into the pelvis/abdomen. However, some sexually transmitted diseases (think chlamydia and gonorrhea) can move. They are frequent trespassers in the pelvis and pelvic organs. Therefore, when abdominal pain is accompanying your vaginal discharge the culprit is more likely to be a bug that can do damage on the inside as well as the outside rather than your garden-variety yeast. However, the pathogens that can move can do some major damage (e.g., infertility) if they are not treated.
  5. Fever: While most vaginal infections are super annoying, that won’t make you super sick. Therefore, when a woman reports a fever as well as vaginal discharge we start to think of things like gonorrhea, chlamydia, and even an infection in the kidneys. If your temperature goes up, you should get up and go right to your doctor!
  6. Pain with Urination: Although vaginal discomfort can make urinating super uncomfortable, pain with urination is usually the tell-tale sign of a urinary tract infection. Add to that urinary frequency and urgency (a.k.a. I have to go right now!), and urinary discomfort is more likely to be from a urinary tract infection rather than a vaginal infection.

So, while we all love to play Dr. Google not everything can be solved without a visit to a doctor. Not everything that itches, burns, or makes you feel uncomfortable is a yeast infection. Make sure you take note of everything that you are feeling. If your discharge comes with any one of the above, Monistat is not going to make it go away. Go and see your GYN!

 

“Judgey” Eyes: What Are Embryologists Really Looking At?

How do I look in this dress? What do you think of these shoes? Is red a good color for me? Let’s face it: even the most down-to-earth among us has an inner diva. Who doesn’t want to look good and turn some heads? Furthermore, how we look on the outside can impact the way we feel on the inside. While we’re certainly not saying that looks matter, we are saying that how you think you look often impacts the way you feel. The same can be said for your embryos. How they look to the embryologist in the lab can tell us a lot about their health, their genetics, and their ability to make a baby.

While different labs use different grading systems, most that perform day 5 or 6 embryo transfers use the Gardner and Schoolcraft embryo scoring system. This dynamic duo introduced their scoring system in 1999 to determine blastocyst (day 5 or 6 embryo) quality.

And while it’s certainly not the Miss USA competition, embryologists are grading the embryos in three ways: development and morphology (don’t worry; we can count). Morphology is assessed for both inner cell mass and the trophectoderm, bringing the total to three!

Embryologists are looking for things like embryo expansion, cell compaction/tightness, and cohesiveness. Years of experience and tons of training have trained their eyes to be really judge-y and label these areas with letters and numbers. We don’t give an overall number; it’s more of a general impression! The cumulative score determines which embryos have the potential to wear the crown. The scoring system not only helps embryologists and fertility doctors decide which embryos to transfer but also how many embryos to transfer. Those with straight As should have a limited number of embryos transferred to avoid an octo-mom situation.

Remember, just like undergrad universities, some grade inflation may go on. An A at Harvard may be a B at Yale—grading is subjective. (Just sayin’. And no, neither of us went to Harvard or Yale). Therefore, while a patient may make all A+ embryos in lab #1, when they come to lab #2, the report card can be totally different. Usually, this is not because your eggs or your partner’s sperm went over the cliff, but because the scoring was skewed. Skewed scoring doesn’t decrease one’s chances; it just messes with one’s expectations. If you have an A+ embryo, you’ll think this is a slam dunk. If it’s really a C, you won’t expect to win the science prize.

Unfortunately, even those with the “judgiest” of eyes can’t discern a trisomy 21 from a 46XY. Visually, they look pretty much the same. Aneuploid (genetically abnormal embryos) clean up well; they can look just as handsome when it’s time for their big date. Cue modern day PGS (pre-genetic screening). PGS has allowed us to distinguish between those who have natural beauty and those who are caking on the makeup. By subjecting the embryo to genetic screening, we can take embryo selection and success rates to the next level. We know a lot more about their abilities to make a healthy baby and the reasons why IVF cycles work or don’t work.

For the type As among us (we’re both raising our hands, so you’re not alone!) we lived and died by our grades. We burned the midnight oil to get the coveted A in Chemistry and logged many sleepless nights for the Honors on our English paper. However, grades don’t mean everything. In the same regard, there are several modest-quality embryos that make the most beautiful, smartest, and kick-butt kids.

So, while we totally get your hangup with the grade, don’t obsess. It won’t change the outcome and will only increase your anxiety. You’ve studied as hard as you can; the rest is in our hands!

Wine = Whine

We’ve all been there. The incessant instances of “No,” “I don’t wanna go,” and “Mama…,” whether it’s at the 5 o’clock witching hour or the 1 o’clock I don’t want to take a nap, these sounds are less than pleasant. Like nails on a chalkboard, the longer it goes on, the more it drives you insane. It drives your blood pressure up and takes you to a place that can only be made better by some time alone and a sizeable glass of rosé! Let’s face it: they whine, you want wine.

Motherhood isn’t easy. It’s non-stop, 24-hours-a-day, seven-days-a-week work. And unlike any other job, you can’t clock out, you don’t get paid, and there’s no such thing as overtime. And no matter how badly you wanted this “job” or how long you took to perfect your “resume” (a.k.a. did whatever it took to have a baby), there are many times when you want to quit. We know…we feel it too.

Although we can’t offer you a break room, we can offer you a few words of advice. When you’re all whined out, take a moment and step away. Whether it’s for some deep breaths, a quick workout, or a glass of wine, do something that will help you reset. Stepping out of the moment rather than stepping into the drama will let you come back to the scene in a whole different headspace.  

But when all else fails and your self-inflicted time out doesn’t do the trick, pick up the phone. Call your BFF, and let it all out. The more you share, the less isolated you’ll feel. Community and camaraderie can be more powerful than any cocktail you concoct. Verbalizing your feelings to a peer can prevent you from loudly vocalizing (a.k.a. yelling) your frustration to your kids. So, while a phone call may seem second best to a glass of wine, “pouring” out your emotions can be pretty powerful.

Cheers!

Take a Bite Out of This: What Your Teeth Could Be Doing to the Rest of the Body

There may be no bigger hassle than a dental problem. A root canal, an implant, a denture, or a chipped tooth: it’s all a big pain and a big hit to your bank account. And unfortunately, as we age so do our teeth. Just like your ovaries, they have been present for all your bad decisions. The sweets, the “oops, I forget to brush and floss,” and the endless packs of gum have taken their toll. (Trust us, we know, we do it too!) And while it may come as a shock to you, what’s going on your mouth may be a barometer for what’s going on in the rest of your body.

Oral health disorders like periodontal disease (a medical way of saying “gum disease”) have been associated with problems like cardiovascular disease, diabetes, Alzheimer’s, respiratory infections, and even preterm labor. Inflammation in the gums can lead to inflammation in other parts of the body. Picture this—bacteria make their way into the body through the gums. The gums have lots of blood vessels. Blood vessels act like a shuttle transporting bacteria throughout the body. Wherever they land, they bring inflammation. Inflammation in the blood vessels can cause the blood vessels to narrow. Narrow blood vessels cause blood flow to slow down and clots to form. Such clots increase the risk for heart attack and stroke. Because women post-menopause are already at increased risk for heart disease due to age and other medical risk factors, you don’t want to add to it by introducing gum disease and inflammation.

But there is more to the teeth’s story than gum inflammation and bacteria. After menopause, estrogen levels drop. This drop not only causes hot flashes and vaginal dryness but also the loss of bone in the jaw. Bone loss can lead to loose teeth and tooth loss. And unfortunately, when you lose a tooth at 55, there is no tooth fairy—just a lot of dental bills and inconvenience!

On top of the age and decreased estrogen part, medications that are used for osteoporosis have been linked to osteonecrosis (a.k.a. bone decay). And while this is very rare and most often seen in women with cancer who are on high-dose bisphosphonates, it is important to give your dentist frequent updates on your medication list so that your dental work is scheduled appropriately.

To make matters a little more distasteful, menopause and its hormonal fluctuations can also bring oral discomfort. Post-menopausal women report changes in their taste perceptions and dry mouth. And your gums feel it, too. Receding gums and sensitive gums are not uncommon.

Age gets us all over. From your hair and skin to your bones and toes, time takes a toll. Your teeth didn’t want to be left out! To decrease damage, the American Dental Association recommends that you make a trip to see your dentist twice a year. And for your homework, they suggest daily brushing and flossing. Also, limiting sugary foods and things that stick is a sure-fire way to improve your dental health.

So, don’t follow the nearly 35% of US women who did not see a dentist last year. Make an appointment to get those pearly whites (or at this point, some shade of white) checked out. You will be doing your whole body good.