No Period, No Problem?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What Happens in the OR Stays in the OR!

No matter how excited you are to get your eggs out (#retrievalday), the OR is no one’s idea of a good time. It’s cold, it’s sterile, and everyone is wearing a mask. To make matters worse, your backside is usually baring itself to a roomful of strangers (gotta love those hospital gowns)! And although you won’t remember a whole lot about what happens on that day (thank you, anesthesiologist!), here are the four things you can pretty much count on as you count yourself to sleep!

  1. Identification: We want to make sure you are who we think you are— repeatedly. When it comes to anything medical, particularly egg- or sperm-related, we’re super strict about identification. Plan on us asking you your name, your date of birth, your partner’s name, and their date of birth MANY, MANY times. This is one place that less is not more. Before you have any of the good stuff flowing through your veins, you want to make sure that you’ve been identified by the operating room team, the physician, and the embryologist. No shortcuts here! You want everyone to know who you are, why you’re there, and what you want done with your eggs.
  2. Recognition: You’ll see lots of familiar faces: The staff in the Operating Room generally includes a nurse, a surgical technician, an anesthesiologist, and a doctor (likely your doctor!). Given the amount of time you’ve spent getting your blood drawn and your ovaries checked, you’re probably on a first-name basis with almost everyone in the clinic. But if you’re not and these faces are somewhat foreign, they should introduce themselves. You should feel comfortable (although a bit cold) with the people around you!
  3. Reposition: While you’ll enjoy some Zzzs (again, thanks to your friend the anesthesiologist), we’ll ask you to do some exercise beforehand. And while we’re not talking about Soul Cycle, we do need to position your body so your bottom is aligned with the operating room table. Where you’re positioned on the operating room table will ensure that we can safely extract your eggs and that you can walk out of the office without any aches and pains.
  4. Relaxation: After the formalities have been exchanged (identification, recognition, and reposition) it’s time to go off to your “happy place” of choice. And whether you’re a beach or mountain girl, get ready to be there for the entire 15 minutes it takes your doctor to retrieve your eggs!

MDs love the operating room. It’s part of why we do what we do. But we get that, to most folks, it’s a scary place. And while we’re not likely to convert you into a surgery fan, we can help alleviate some of your anxiety surrounding the procedure by sharing some of our tips. So, take a deep breath, and know that most likely your doctor has done this MANY, MANY times. He or she has this covered. And don’t worry; whatever secrets you share are safe with us. What happens in the operating room stays in the operating room!

A Fishy Situation: Safe Seafood for Expecting Moms

Eating when you are pregnant can be a tricky situation. What you want and what you can have don’t always jive. Menu choices can become a bit complicated, particularly when it comes to fish and seafood. While we want you to get the good stuff fish has (think Omega-3s, protein, and vitamins), we don’t want you to take in too much mercury. For those of us who are sushi addicts or fish fanatics, you may have to modify what you eat and how often you eat it to make it ok during pregnancy. Here’s how to modify the menu to make fish, sushi, and seafood acceptable during pregnancy.

Simply stated, mercury is not a mother-to-be’s best friend. While you may be close to it after or before pregnancy, during pregnancy (and while breastfeeding), you need to put your relationship on hold. The reason for this temporary breakup is the potential negative impact high levels of mercury can have on your growing baby. Mercury turns into methylmercury, which is a toxin to the developing brain/neurologic system of a fetus as well as the future vision and hearing of a child.

While you can be exposed to mercury in many ways, it is most frequently found in fish, particularly large fish. For this reason, swordfish, shark, king mackerel, and tilefish are totally off limits during pregnancy and while breastfeeding. Fish that is low in mercury (think shrimp, wild salmon, trout, catfish, cod, tilapia, canned light tuna) should be on your table at least once a week. In general, about 8 to 12 ounces (2–3 servings) of low mercury fish/week is recommended. White albacore tuna can be added to the list above, but consumption should be limited to 6 ounces a week.

Fish caught in local waters are a slippery situation. You can check with your state or local health and environmental agencies to find out what the mercury content is, but if there is no answer, you should probably limit your intake to 6 ounces/week.

A discussion about seafood would not be complete without the temperature situation (a.k.a. raw vs. cooked). And while the CDC and the FDA say no to raw fish, this is one area in which we have set sail in a slightly different direction. Although undercooked, seared, or raw fish has a higher chance of harboring a parasite, a bacteria, or a virus, women from other parts of the world have been consuming raw fish for centuries without a problem (think Japan).

Additionally, because most of the fish used in sushi in the United States has been flash frozen before it makes its way to your local jaunt, the majority of parasites and bacteria have already been eliminated. However, while we may let raw fish slide (or swim!), what we don’t deviate on is where you consume this raw or undercooked food AND the type of raw fish you choose to eat.

Make sure you are getting your food from a reputable establishment that not only handles and stores food properly but also serves it soon after purchasing it. Last, choose the low mercury menu choices (a.k.a. fresh or wild salmon) rather than the high mercury options (farmed salmon and the like).

Your taste buds will change faster than your body. One week, you will be obsessed with shrimp, and the next, just the sight of it will make you want to vomit. It’s totally normal. The tides of eating and cravings move fast in pregnancy. Make sure to chat with your captain (a.k.a. your OB/GYN) before you embark on a new food journey. Safety is first no matter where you choose to set sail.

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.

Done and Done! Permanent Contraception

Most mothers could probably recall the day they found out they were pregnant like it was yesterday: where you were standing (or sitting if it involved peeing on a stick), what you were doing, maybe even what you were wearing. There truly is no other feeling like that of becoming a parent. But when you decide that you are done, there may be no other fear like finding out you are going to be a parent again. How can we afford another child? Where will we live? Can I take those sleepless nights again? And while we definitely don’t have the answers to these questions (trust us, we live in New York City and get the space thing!), we do have suggestions on how to avoid having such things happen. Simply stated, we offer: permanent contraception.

It’s funny, women ask each other the question “Are you done?” all the time. And without more than those three little words, we know exactly what the question means. Are you having more kids? Cutting, tying, blocking, or clogging are common ways to permanently turn the system off. Both women and men can undergo procedures that will make getting pregnant without any fertility assistance nearly impossible (nothing is impossible because all methods, even the forms discussed below, have a failure rate).

The options available to women all center on blocking an egg from meeting a sperm, a.k.a. tying, cutting, or blocking the fallopian tubes. Tubal sterilizations can be done immediately after a woman has a baby, a few weeks after a baby, or years after a baby. When the former is done, a small incision is made below the belly button, and the tubes are found and subsequently cut/tied. When done weeks or years later, the procedure is most commonly performed through a camera (medically termed a laparoscope). The laparoscope is inserted through the belly button, and the surgery is performed through three tiny holes (one in the belly button and two above the hipbone). When done this way, the tubes are most frequently burned and cut (although a clip can also be placed).

Last, GYNs now have the ability to place a spring-like device (think a Slinky) into the fallopian tubes through the vagina. Again, a camera is inserted, but rather than placing it into the belly button, it travels through the vagina, past the cervix, and into the uterus. Under direct visualization, these springs are deployed into the tube; in the months following their insertion, the body forms scar tissue around them. Together, a serious roadblock is formed and it becomes nearly impossible for anything (including those swimmers) to get through. The caveat here is that you need to make sure all systems are a no go before having unprotected intercourse. Therefore, a hysterosalpingogram (a.k.a. HSG or dye test) must be performed approximately three months after the device is placed to confirm that the tubes have become a steel trap. Once the red light is seen, you get the green light for unprotected intercourse.

While women often find themselves in the driver’s seat for permanent contraception, the number of men electing to undergo a vasectomy is rising. Similar to what happens to a woman’s tube, a man’s vas deferens is “interrupted.” The vas deferens (like the fallopian tube) also serves as a tunnel, transporting sperm from the testes to the urethra. So while the path out may be closed after a vasectomy, men who have had a vasectomy are still producing sperm. The testicles go on as usual, producing both sperm and testosterone, ignorant that their hard work is for naught!

The procedure has no impact on a man’s ability to achieve an erection or to ejaculate. The prostate, the ejaculatory duct, the seminal vesicles, and the glands are all functioning as is, and while the ejaculate is devoid of sperm, it is chock full of other products. While post-operatively there is some pain, in most cases a little Advil and Tylenol should do the trick. It’s quick (usually no more than 15 minutes) and can be performed in the office. The biggest point to stress is that, similar to female sterilization, in which spring-like devices are placed into the tubes, a three-month wait period is required before it’s safe to use this as reliable contraception.

If you should have a major change of heart, there are ways to undo the undoable. Fertility treatment has found a way around tubes that have been tied or sperm that has been stopped. Although it requires in-vitro fertilization, IVF allows women a second (or third or fourth) chance if they should want it. In reality, both men and women who have undergone a tubal sterilization or a vasectomy are still producing both eggs and sperm. They are just no longer able to meet up with each other (think being grounded and stuck in your room).

Fertility doctors have the ability to go right to the source (ovary or testes) and get the goods (egg or sperm). So while we recommend you be certain about your decision before taking the leap, remember there is always a back-up plan should you change your mind.


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.


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.