1. Pads – these come in many sizes and shapes promising to help with light days, modium days and for those heavy or overnight flows that can even wrap around your undergarments to prevent soiling your clothing. However, patients will feel the moisture against their skin and it can be uncomfortable and not necessarily the best choice if you lead an active lifestyle, especially for women who use swimming or pools as a part of their exercise regimen. Pads can overflow and cause soiling of clothing, leading to embarrassing situations. And remember, the best way to clean blood from clothing is to use 0.9% salt water which lifts the red blood cells from your clothing vs water which breaks the red blood cells and leaves a ‘ghost’ of the cell or a stain that will not go away. Bleach doesn’t work as well either because the red blood cell breaks open, again leaving a ‘ghost’.
2. Tampons are an internal absorbent option that is also graded for light, regular, super and super-plus flow options. Patients can even walk 2 tampons up together at a time if you experience a super heavy flow if you are involved in a situation or a timing that has you unable to change your tampon supply in a 2hr period. Tampons are usually comfortable to wear as long as there is enough flow to absorb through 50% of the tampon; otherwise, insertion or removal can be ‘catchy’ or a little uncomfortable as it pulls against dry vaginal tissues. Tampons are only meant to be in place for approx. 4hr during the day and many experts will advise against overnight use until you know you are not sensitive to the absorbent materials used in tampons. There is a small subset of patients who have had an allergic reaction to the absorbent materials used in tampons so always use for only a 2-4hr window when you are first trialing tampons to be certain you don’t have a tissue reaction with swelling, redness or warmth to your outer vulvar tissues; if you do, remove the tampon immediately, take some oral Benadryl and see a professional for an exam. There are also patients who may already have a bacterial vaginal infection occurring; that is not the time to put in a tampon which will hold blood product and infection in a tampon in your vaginal vault for at least 4hour vs allowing it to drain, also causing vaginal irritation; you may require an antibiotic if the infection is on-going. However, the vast majority of patients will safely be able to wear internal tampon protection without risking injury or infection.
3. A third option is a vaginal cup which is reusable and is also sized for the amount of flow it can hold; using this type of protection allow for a reusable option and you are not adding to a landfill as you are not using a disposable product.
4. A fourth option is an absorbent wicking undergarment called Thinx; it can absorb the equivalent of a super tampon into the undergarment without the patient feeling moisture against their skin and without staining to the clothing that you are wearing, even if you are wearing white. This is an option for the very active outdoors woman or anyone not wishing to risk the tampon string that may travel outside of their undergarment or secondary overflow pad. This garment is approx. $35 per pair but they can be washed and are reusable so they are environmentally friendly and will not add to the landfill.
1. Are you under stress? Any type of stress; work stress, financial stress, emotional stress or physical stress can all contribute to an imbalance in your hormones and cause decreased natural lubrication causing vaginal dryness, this then ‘catches’ dry penile skin on dry vaginal vault tissues doesn’t glide, it rubs and can irritate.
2. Are you in the swings of hormone ups and downs that occur with perimenopause? Hormone levels in your 1yr or more before menopause can cause good lubrication one month and poor lubrication the next month, all based on female hormone swings; these levels can be easily checked by your health care provider so ask for these levels, they are a simple blood test.
3. Are you in menopause or post-menopausal? The female body stops making female hormones with menopause and this means poor or no lubrication. The vaginal vault is meant to be elastic which means it will stretch without tearing and it is meant to have lubrication to allow for appropriate glide and pleasure with intercourse. Taking female hormone away at menopause can be very distressing to many of our body systems, but it is particularly distressing when it negatively impacts our sexual part of our lives and our marriage. And you don’t want to feel responsible but realize that it ISN”T YOUR FAULT!!! Ask your doctor to have your female hormone levels checked; there are some simple solutions that work: vaginal Estradiol cream can be used locally without changing a blood level of Estradiol in your bloodstream. You can also have a combination Estradiol + Testosterone or an Estriol + Testosterone compounded vaginal cream custom made for you if your bladder is also misbehaving with urgency (wanting to void every 30min) or with symptoms that mimic a bladder infection with painful urination but no evidence of a bladder infection. Don’t be embarrassed to talk to your healthcare provider about using an Estradiol based hormone cream vaginally to help; it’s not your fault that your body stops making female hormone.
4. Another less common reason for painful intercourse, especially if it is painful with deep thrust only is if your pelvic organs are starting to ‘fall’ or prolapse; the uterus wants to relax and fall down the vaginal toward your vaginal opening so that with intercourse, the uterus is pushed back in further than it is used to and that ‘stretch’ on it’s support ligaments is now painful; and that pain can go all the way to your groin because that’s where the round ligament attaches.
5. Lastly, make certain that you don’t have any type of vaginal infection such as a yeast infection; if you are taking an antibiotic for any reason, it can affect the balance of the normal bacterial that reside in a woman’s vaginal vault and cause yeast overgrowth that you may not even be aware of. Over the counter treatment with yeast creams designed for a woman’s vagina are perfectly safe to try at home; if you don’t get results, then get checked by your healthcare provider.
Blood clotting disorder work-up includes Factor V Leiden, Antiphospholipid antibody, Anticardiolipin antibody, Protime, Prothrombin time, Methyltetrohydrate Folate Reductase deficiency (MTHFR deficiency), Factor VIII and CBC for platelet count. This testing can be very expensive so be certain that your healthcare provider checks with your insurance regarding correct ICD-10 coding as ‘recurrent miscarriage’ which means 3 miscarriage in a row during 1st 12 weeks or a 2nd trimester miscarriage. If any of this testing above is positive, it may mean that the mom needs to be given treatment to prevent blood clotting throughout the pregnancy; this may mean shots of blood thinner injected subcutaneously or into the abdominal skin daily. In addition, a lesser known cause of recurrent miscarriage which can occur in the 1st or 2nd trimester is a low Progesterone level which leads to a poor uterine lining that is not healthy enough to support continued growth of the fetus. Progesterone can be easily tested by blood test, is relatively inexpensive and is pharmaceutically available as a vaginal gel or as an oral pill. Progesterone is also prescribed in preterm labor to help stop preterm labor.
For those couples who need to seek this level of counselling and healthcare help, seek a high risk obstetrician who will do the work-up with you ahead of time so that when pregnancy does occur, you have many of your health concerns already addressed; finding out at the beginning of a pregnancy that there is a potential concern is not the time to find out this type of information.
So ask your doctor to check your bloodwork: you need day 21 of your cycle bloodwork if you wish to tie your Estradiol, Progesterone, Total Testosterone and Free Testosterone levels to your fasting glucose and insulin levels (4hr fasting). Only by knowing where your levels are can you know if your Metformin is helping not only your blood sugar but also your female cycles.
And remember, if you have an elevated glucose and require Metformin, you are at increased risk for diabetes in pregnancy that may even require insulin and you are at increased risk for type 2 diabetes later in life. So learn as much as you can about how your body responds to Metformin now, how it impacts your female/male hormone levels now so you can help protect your health in the future.
One last tidbit; folic acid is also recommended when patients have an abnormal Pap smear as it is involved in cellular turnover and the cervix is certainly turning over cells on a regular basis. So if you have an ASCUS (Atypical Squamous Cells of Undetermined Significance) or even a mild dysplasia/CIN-1 (Cellular Intraepithelial Neoplasia-1), then taking Folic acid daily can help you reverse your Pap smear back to negative!
If you are not showing an 0.8 degree increase in your temp or if your temperature never rises at all, then you are not ovulating; this can occur for up to 3 to 6months coming off of birth control pills and can occur for up to 12months coming off of the Depo Provera shot.
Approx 10-15% of patients may actually make a higher Testosterone amount than they should (average is a Free Testosterone value of >15th% of the female range). If you make higher Free Testosterone than 10-15%, you may actually not ovulate due to a condition called Polycystic Ovarian Syndrome or PCO disease. The PCO syndrome can have associated symptoms like facial acne, abnormal weight gain, male pattern hair loss to upper forehead or even top of crown of head and/or excess hair to upper lip/sideburns chin; some patients will even be shaving this excess hair. However, you may have PCO disease vs syndrome and may have elevated Free Testosterone levels but not enough to have the other symptoms mentioned above so you go undiagnosed by your doctor. Medicine will not diagnose a patient with infertility until you have tried for 12months and are still not pregnant. However, more and more patients are waiting longer to start their family and do not have the luxury of waiting an entire year to then find out there is a medical issue that needs to be addressed. In addition, once you are labeled with ‘infertility’, you may not have certain tests covered by your insurance because you may require a prior authorization; this means that your insurance company is already thinking you may cost them a lot of money for a work-up and they want to keep tabs on all aspects of the medical work-up and they may approve some testing but not other testing, making those unapproved tests an out of pocket cost to you. I always recommend knowing as much about your cycles and your hormone levels before you even think about trying, you are then being proactive and can work with more simple bio-identical hormone replacement if your levels return low or imbalanced before you feel rushed for time or face testing that you may suddenly have to pay for and may not have budgeted for.
Once you have appropriate hormone levels and whether or not you need additional Progesterone or not, you may still require fertility medication to help you ovulate; this medication is called Clomid and can usually be prescribed at low to medium dose by your GYN but must be carefully followed to be certain that you do not have ovarian hyperstimulation. Hyperstimulation may cause more than one follicle to ovulate; if 2 ovulate, you may experience twins, or if 3 ovulate, you may experience triplets; this sounds exciting but places you in a high risk pregnancy situation which a high risk of premature labor or even hypertension or toxemia with pregnancy which can put both you and your babies at risk and almost always results in early hospitalization with time off work and additional costs that again you may not have budgeted for. Clomid should always be under the supervision of an experienced GYN as a very small percentage of patients may even have abdominal ascities or extra abdominal fluid that can cause respiratory and GI issues. As well, Clomid may not be enough to stimulate ovulation; these patients then may require more intensive infertility work-up or in-vitro fertilization which is rarely covered by insurance and entails surgery to harvest eggs and surgery to put sperm and eggs or fertilized embryos into your uterus. Lastly, your male partner may also need a semen analysis to make certain he is ‘shooting good swimmers’ as he may have a low sperm count or a high percentage of abnormal looking sperm; this also needs further medical evaluation or work-up with a Urologist.
Common reasons for 1st trimester miscarriage:
1. Genetics of the fetus are just not destined to make a healthy fetus, either from the woman’s egg or the man’s sperm.
2. Low Progesterone <20 that doesn’t make for a lush uterine lining for the fetus to implant into. Low Progesterone can also lead to pre-term labor later in a pregnancy.
3. Poor control of known medical conditions such as thyroid dz, poorly controlled diabetes, severe ulcerative colitis with diarrhea and GI bleeding as well as others, esp if strong medication with category C, D, or higher is being taken by the mom.
4. Clotting disorders that may not manifest until a pregnancy occurs; these can cause microclotting in the placenta, which cuts off blood supply to the fetus (see the list in #5 of the 2nd trimester miscarriage list below).
5. Certain viruses such as the virus that causes 5ths disease can only give mild symptoms to the mom, but catastrophic to the fetus.
6. Abdominal trauma such as a motor vehicle accident with an intact lap belt as well as a missing lap belt.
7. A significant fall on your bottom which jars or may even fracture the pelvic bone structure or tailbone.
8. A fever of 102.5 or greater from any reason.
9. A maternal diagnosis of anovulation (not ovulating) or irregular ovulating per menstrual cycle such as polycystic ovary, or PCO; this diagnosis may only have a patient ovulating once every couple of months or, in a severe case, ovulation may be so irregular as to require fertility medication or an infertility specialist.
However, there are less common reasons for a 2nd trimester miscarriage, or from 12-24wks:
1. Abnormal genetics that allow the fetus to grow to this stage of pregnancy, but will not support life outside the womb; doing genetics on the "products of conception" are important to perform.
2. Low Progesterone <20 can still be responsible and an easy issue to "fix," but difficult if your healthcare provider doesn’t feel this may be a cause.
3. Poor blood pressure control or a variant of pre-eclampsia (severe high blood pressure in pregnancy) can occur that causes dangerous blood pressures before 20wks pregnancy that can cause damage to the blood vessels of the placenta or even cause a stroke in the fetus. If this condition occurs before 20wks, it is also dangerous to the mother and can also cause stroke or even rupture of internal organs such as rupture of liver or spleen, which can cause internal bleeding or even death.
4. Abnormalities to the uterus such as fibroids or a prior uterine scar from a prior C-section or myomectomy can cause altered blood flow to that internal section of the uterus where the placenta may grow over; this causes poor blood flow interaction that can also cause painless and sometimes painful bleeding and cramping that can lead to miscarriage. This chain of events with abnormal bleeding can also cause premature rupture of the bag of waters; in that case, the fetal lungs are unable to properly develop and the usual outcome is miscarriage.
5. Again, clotting disorders such as Factor V Leiden, Antiphospholipid antibody syndrome or anticardiolipin antibody syndrome or Methyltetrahydrofolate reductase deficiency (MTHFR) need to be tested.
Because these reasons for 2nd trimester miscarriage are more serious, it’s possible that these reasons may still have the underlying cause remaining to cause a repeat miscarriage in the event of a 2nd pregnancy. So, getting pregnant may not be the problem, staying pregnant may be the bigger problem; check with your healthcare provider as the work-up for a 2nd trimester miscarriage is similar to that for recurrent miscarriage or 3 or more 1st trimester miscarriages.
I realize this is a longer answer than you might have been expecting, but it’s a more complex question with a more complex answer than a 1st trimester miscarriage. Be certain that your healthcare provider has you see an OB-GYN who can do the work-up for you. You can even have a lot of the work-up done remote from the miscarriage in case this testing was missed.
Dr. Victoria J. Mondloch
If you are getting recurrent vaginal pruritis without malodor, then this may actually be an indicator of hormone imbalance. Many women may make more male hormone than the normal range (approx. 15% of a normal laboratory range for Free Testosterone is my rule of thumb), and that can cause a decrease in the amount of female hormone (Estradiol + Progesterone) that your ovary would otherwise make. This imbalance does not always cause abnormal periods or spotting between periods, but it can. If intercourse is uncomfortable, it may also be a sign that your vaginal vault has decreased elasticity or stretchability, and that is also a sign of "low E." The best way to know what your hormone levels are is to have your blood tested by labdraw on d21 of your cycle on a conventional 28-day cycle; this is the day that your body makes its peak of Progesterone and Estradiol (2 days on either side of d21 is also okay or d19-23 of your cycle). Ask your healthcare provider to do bloodwork on you. They would use the ICD-10 code for abnormal menstruation of N62.5 or painful intercourse (Dyspareunia) with IC-10 code R68.82. If you have acne, use L70.0 for ICD-10 code.
If your Free Testosterone comes back higher than 15% of the normal laboratory range, then you may need further evaluation to rule out PCO, or polycystic ovary. PCO is also associated with other Excess Testosterone symptoms such as hair loss to your head, acne, mid-abdominal weight gain, and excess hair to your upper lip or chin. Or you may not have any other symptoms, but still have an elevated Free Testosterone, those are the silent sufferers of Excess Testosterone who are usually never diagnosed or diagnosed late; it can even lead to infertility or late fertility with its increased risks.
Lastly, another hormone that can also cause changes in your female/male hormone balance is your AM Cortisol. Cortisol is made in your adrenals and helps you to manage stress, "WHO HAS STRESS?" When your cortisol levels are too high (stress) or too low (distress), that can also interfere with your female/male hormone balance. Ask your healthcare provider to add AM Cortisol to your laboratory requisition form along with your hormone levels above. This needs to be drawn before 9:00AM to best capture the peak production of Cortisol in your body; the ICD-10 code is F43.0.
In summary, your lab requisition should be for Estradiol, Progesterone, Total Testosterone, Free Testosterone, and AM Cortisol with the ICD-10 codes listed above, drawing before 9:00AM. It’s okay to eat and definitely drink fluids before you go in so your blooddraw goes easily for you.
If none of the above answer your concerns, then you may need to see a GYN specialist who deals in bio-identical hormone replacement as they have a very good understanding of how hormone balance works and how to best rebalance you. Or, contact my office through my website, victoriajmondlochmdsc.com, and we will try to help.