Dr. Victoria J. Mondloch, M.D.

Stomach pain could mean many things: in the world of women’s health, ‘stomach pain’ can actually be your stomach, which is usually associated with acid reflux, a hiatal hernia (not usual for a 17yo), a high acid concentration that is irritating to the stomach lining that can lead to ulcers over time or a stomach that is not emptying so it ‘back-fires’ and you then ‘throw-up’. Abdominal pain that is associated with your period is usually associated with your female hormones which can impact your entire GI tract from your stomach, to your small intestine and your large intestine, usually as rapid transit time resulting in diarrhea or as slow transit time resulting in bloating which can also trigger burping. Slow transit time goes along with low Progesterone; this can happen once in awhile or it can happen a lot which means you may be bloated a lot. Low Progesterone can also result in a thicker lining inside your uterus that needs to get bled out with your period; if your uterus is trying to pass a lot more blood than it usually does, you may not pass it all as a liquid form and you may form some blood clots; these are harder to push out and your uterus, which is a muscle, will work harder and contract stronger to push out those clots, this is another reason for ‘bad cramps’.

Over time, low Progesterone can lead to a condition called endometriosis when you have some of your menstrual blood and bits of lining pass backwards through your fallopian tubes landing in your pelvic tissues; this blood is extremely irritating and causes cramps by itself. Then any of the tissue can start to grow outside of your uterus and you then bleed inside your abdomen EVERY MONTH, causing stronger and stronger cramps each month. This condition called endometriosis can cause scar tissue and your bowels become irritated with inflammation and that can cause your bowels to ‘stick’ to the bleeding and now it’s not free to move as it normally would and this can cause abdominal pain.

Sometimes women will build a cyst on their ovary from too much Estradiol and too little Progesterone; this cyst pushes against your bowels and can irritate them causing them to slow down and contribute to bloating. And some stronger pain medication can slow down your GI tract so that it stops moving; if that goes on for too long, then it may require a doctor to intervene.

So as you can see, abdominal pain can be a once in awhile type of occurrence, or it can happen on a monthly basis. If it happens regularly, then seek a doctor’s advice as endometriosis needs to be found early and reversed by treating it properly with replacing natural progesterone at the right levels or by overriding your cycles with the Estrogen and Progesterone artificial hormones that are in birth control pills. Do NOT use a Mirena IUD or an implant in your arm as these options are only using artificial progesterone which is not a healthy option for you.

Feeling uncomfortable and a ‘burning pain’ with intercourse are more indicative of low vaginal Estradiol and loss of elasticity. Quite likely, you were sexually active before your hip replacement and then you naturally had a break with your surgery and recovery. Your vaginal tissues have the ability to continue to self-lubricate ‘to a point’ when there is regular sexual activity. However, once there is a significant break in time, then those same vaginal tissues are no longer as active so they stop lubricating. But adding a lubricant isn’t always the answer; many times you need to get back the elasticity that was also lost; this is best done with a vaginal estradiol treatment. There are many Estradiol only vaginal creams or rings or vaginal pills or vaginal suppositories; ask your doctor which one is best for you and which one is covered by your insurance. Make certain that you get the ‘real deal’; get Estrace 0.1% or Estradiol 0.1% cream; do NOT settle for Premarin cream as this is Pregnant Mare’s Urine (where Premarin gets its name from). You can place the cream daily at night for several nights in a row to regain your vaginal tissue elasticity and vaginal health; then resume relations as before. You may only require the cream once or twice a week to maintain your elasticity but ‘prime the vagina’ for a week every night to get the tissues healthy again. If your partner is exposed to the cream, don’t panic and think he will suddenly grow man-boobs; simply have him wash off before falling asleep to avoid a prolonged exposure. Having your cream on different days from days of sexual relations is usually the better plan.

VZV is Varicella Zoster Virus; Varicella is Chicken pox, not herpes. Chicken pox is a virus that your body continues to harbor in nerve roots; when you are under physical or emotional stress, the virus can be reactivated and it can then manifest as shingles along the distribution of the nerve that it travels down. Shingles can be very painful and it can also be contagious as it has clear vesicles that will break open with active virus in the clear fluid. There is a shingles vaccine but many patient can simply have their antibody titer checked by a blood test to see if your body has a high enough antibody defense already within you, then you wouldn’t need the vaccine.

The bigger question is your PCOS; this condition leads to higher infertility as you make more Testosterone/male hormone than female hormone and you may not ovulate every cycle. Patients with PCOS many times require fertility pills like Clomid to help them get pregnant; start working early with your doctor due to your maternal age 36 which gives you a higher risk of Down’s Syndrome. PCOS patients also have an increased risk of Gestational Diabetes and Hypertension during their pregnancy so knowing your underlying health before trying for pregnancy is very important.

I am hopeful that whomever started you on birth control pills also told you that taking continuous birth control, skipping the fake pills during your bleed for 3 months is perfectly safe, but then you need to take the fake pills and have a pill period every 3months. As long as the pill pack is a 30mcg dose and does not change colors or dose every week, you are able to run 3 packs together, then it is recommended to take the fake pills and have your pill period.

My first question is did you have your hormone levels checked, male and female before you were started on birth control pills? Many times, patients are just ‘put on the pill’ before any investigation is ever done to see if there is a reason for the abnormal bleeding pattern. Granted, there are many patients who have abnormal periods and no pattern to their bleeding that birth control or oral contraception pills (OCP’s) can control. However, approx. 15-20% of women begin to manifest a condition of excess male hormone production called Polycystic Ovary (PCO) syndrome (PCOS) in their early years of their menstrual career with this male dominance in hormone becoming a stronger and more dominant pattern as patients progress out of adolescence into their 20’s and 30’s. It’s highly important to know if you may actually have PCO or PCOS because excess male hormone leads to mid abdominal weight gain (similar to what men have in their 50’s, 60’s and beyond), to excess facial hair to upper lip and chin, acne and sometimes cystic acne not only to their face but to their back (back-ne) or shoulders and excess hair loss, similar to male pattern baldness. In addition patients with PCO or PCOS have higher infertility rates as their female hormone levels are typically low and age inappropriate more often than their levels will be higher and age appropriate, showing the hormone swings that are more typical of a women in her mid to late 40’s in perimenopause before menopause. The bet way to know if you may have PCO or PCOS, which is genetic, is to have your hormone levels checked, even while you are on OCP’s. Ask your doctor to check your Estradiol, Progesterone, Total Testosterone and Free Testosterone levels; if your Free Testosterone levels are greater than 15th percentile of the normal range, then you may actually have PCO or PCOS and you need further work-up. PCO and PCOS patients usually require a higher dose of OCP’s (30, 35 and sometimes even 50mcg dose OCP’s) as the lower dose pills are not strong enough to override the male influence. Also, any hormone containing implant or hormone containing IUD is going to exacerbate the male pattern symptoms, especially weight gain and acne so these options are also not appropriate. If your doctor is not comfortable checking your hormone levels or doesn’t know how to interpret those values once you’ve had them drawn, then contact my office and I will help you.

In addition, you may be having undue stress (who doesn’t have stress these days) with anxiety; stress can also trick your body and uterus, causing nuisance bleeding that has no rhyme or reason; taking Vitamin B Complex with METHYL Folate and METHYL B12 is key to helping manage your stress.

Dr. Victoria J. Mondloch

Office: 262-524-9116

The emergency birth control pill has a good track record in preventing pregnancy but it’s not 100%. If you aren’t sure, then the best way to truly answer your question is to have a blood test for a quantitative HCG pregnancy test; then repeat it again in 2-3days if your symptoms persist. If the test remains negative, then have your doctor also check your female hormone levels so that’s the best way to really know what’s happening. If you aren’t sure which hormone levels to check, check out my book Blossoming, Becoming a Woman and there’s a section on how to talk to your healthcare provider.

What most women are never made aware of: how our ovaries that make both our female hormones and our male hormones are highly influenced by STRESS! COVID-19 stress, emotional stress, physical stress (from sleep deprivation) are all potential reasons why your ovaries aren’t working the way they’re supposed to. The usual menstrual cycle is every 28days and is triggered by the drop in your progesterone level that starts the release of the lining inside your uterus. When you are under stress, you may not ovulate or make your progesterone; so there’s no trigger to tell your uterus when it’s time to bleed. So you can miss the usual timing of when your period should happen; and the longer you miss a period, the thicker a lining can be which can cause heavier bleeds. But if stress shuts your ovaries down, then both of your female hormone levels can drop quite low and your body can give you symptoms like menopause if those levels stay down too long. How do you know which scenario may be yours? You need to ask your doctor to check your hormone levels; only then can you know what your body is doing. I also recommend that you check out my book, Blossoming, Becoming a Woman (on Amazon); it explains how periods should work, it explains symptoms and it has a section about how to talk to your doctor.

But handling your stress is important; take Vitamin B Complex with methyl Vitamin B12 and get your 8hours of sleep at night!

Whenever you have a positive pregnancy test followed by a negative with pain in your pelvis, ALWAYS follow with a blood pregnancy test called a quantitative HCG which gives you a number of the HCG protein in your bloodstream. This number should double every 48hours, with a fetus able to be seen by ultrasound with an HCG that reaches a level of 5,000. But this increase in HCG doesn’t always mean the pregnancy is in the right place; the correct place is inside the uterus. But another place could be inside the Fallopian tube; this location may still show a doubling of HCG but at a certain point it cannot continue to safely grow and it will rupture the tube because it blows the tube past a safe size. If this happens, you may or may not have pain on the side where the pregnancy is in the tube; but if it ruptures, it can be life-threatening as you may bleed or hemorrhage into your abdomen; this is called an ectopic pregnancy because it occurs where it shouldn’t be.

However, another option is that you were able to start the process of implantation in the uterus with an initial positive pregnancy test; however, the negative test that follows usually means your progesterone levels is too low and cannot maintain a rich enough uterine lining for a pregnancy to grow in. If this continues to happen, that’s called recurrent miscarriage; please check with your doctor as this means you need to supplement with Progesterone and maintain a level of 20; NOT taking progesterone can result in miscarriage but not all doctors believe this to be true so advocate for your health and get your levels done.

Herpes is a resilient and tough little virus; once it’s in your body, it’s smart enough to hide out in your nerve roots and only ‘comes out to play’ when you are stressed or have UV sun exposure. This is usually going to have a ‘prodrome’ or warning up to 12-36hours ahead of the outbreak with a skin sensitivity or tingling of the skin where the outbreak will occur; usually to the peri-oral area/mouth or to the vulvar/perineal area or penile shaft. These lesions are contagious from the time you feel the warning or the tingling of the tissues through the open outbreak; once the lesions heal over, they are no longer contagious but I usually tell people to wait an additional 24-48hrs to be certain. There are over the counter topical creams that help but usually taking the anti-viral medical Zovirax or Valtrex can help shorten the course by 1-2days of the infection and help with the discomfort. If you are prone to having more than 3 outbreaks in a 12month timeframe or more than 2 in a 6month timeframe, you should qualify for daily suppression therapy with a lower dose of antiviral medication daily as suppression. Hope this helps.

Limited access to bio-identical hormone replacement is truly a challenge; but KNOWING that you have low Estradiol or age inappropriate Estradiol also means that you have the ability to check your blood levels of Estradiol (and Progesterone) to be able to know that your levels are low. Age inappropriate Estradiol (E) is associated with multiple organ system symptoms including: Short term memory loss, Difficulty cocentrating, Forgetfulness, Insomnia, Early awakening, Dry skin/Dry eyes, Brittle hair, Migraines, Heart palpitations, Muscle aches, Joint pain, Acid reflux/GERD, Shortness of breath with Dry AM cough, Urinary urgency/frequency, voiding middle of night, Urinary incontinence, low libido and painful intercourse. So as you can see, low Estradiol impacts EVERY ORGAN SYSTEM IN THE BODY. Also, realize that low Estradiol levels over several years of menopause is known to lead to calcium loss to a patient’s bones; meaning osteopenia and osteoporosis, another common diagnosis that occurs in menopausal patients.

Estradiol is a generic bio-identical medication that is cost effective and likely available by mail order anywhere in the world; it is the generic of the name brand Estrace. Estradiol is a tablet, and not overly susceptible to temperature extremes; thus it is amenable to shipping that may encounter a time delay in delivery and that a 3 or 6month supply would be stable, even in a tropical environment. However, it is also imperative to know what your Progesterone levels are in relation to your Estradiol levels in order to have a Progesterone/Estradiol dominance; this is important to be proactive in the prevention of thick lining, uterine polyps, uterine fibroids, endometriosis, ovarian cysts and even fibrocystic breast disease. I recommend that you have your healthcare provider check your Estradiol + Progesterone levels every 6months; check on day 21 of your cycle (1wk before your period in a 28day cycle or 3wks from the 1st day of your last cycle). Both Estradiol + Progesterone are available as prescription and in Europe, Estradiol is available without a prescription; Progesterone is yam based and usually prescription only, and usually made in a peanut oil suspension that can go rancid in hot climates. Progesterone caps can also be a powder only cap that is compounded; this would take a little more effort to obtain but would be very stable to ship and would last for months in storage, just take it with 1 teaspoon oil.

I encourage anyone having low Estradiol or low Progesterone to work with their healthcare provider; I also encourage you to order my books: Blossoming, Becoming a Woman (from puberty to approx. mid-late 20years old) or Full Bloom: Perimenopause, Menopause, Postmenopause and Beyond. Both books are available on Amazon as printed book or as Kindle version and then you have a resource to refer to and work with your healthcare provider based on the information in the books.

Having a UTI in pregnancy, especially in the final trimester of last 3months can actually trigger uterine irritability and cause bladder contractions that then cause the pregnant uterus that sits on top of it to also get irritable and may trigger false labor or preterm labor where the cervix actually starts to prematurely soften, thin and dilate. Regardless, UTI’s are not comfortable and can actually lead to a kidney infection, travelling from the bladder up to the kidneys; this will usually trigger a fever of 101 or greater and require IV antibiotics. Kidney infections can also trigger preterm labor and dehydration; and can sometimes end up with a tendency to recurrent UTI’s, repeat kidney infections or even kidney damage. You need to call your doctor’s office and request a sterile urine cup with the antiseptic wipe that is labeled with your name and the lab requisition slip; someone needs to pick that up for you from their office (that can be handed off in a bag with ‘no contact’ or minimal contact and that specimen then needs to be a clean catch middle of your urine stream urine sample (clean front to back with the wipe, start to urinate in the toilet and then catch only the middle part of the urine stream in the cup, place the cover back on WITHOUT TOUCHING THE INSIDE OF THE CAP OR THE CUP ITSELF). Then the urine specimen that has your name on it and the requisition can be dropped off at a lab or back at the doctor’s office, whatever instructions they give you so that you can get the urine cultured. If there is indeed a UTI, then you will need antibiotics more than 95% of the time to get rid of it. Meanwhile, drink a lot of oral fluids; water, milk, tea, weak coffee but NOT FRUIT JUICES as they contain sugar and NOT SODA as that contains chemicals that irritate a bladder and are not good for babies. You CAN drink pure cranberry juice (no sugar) or take cranberry pills (available at Walgreens, CVS or any pharmacy) and then continue to drink water; cranberry helps an irritable bladder. The medication you mentioned is not a bad option but you need to know if you indeed have a bladder infection or not… There are also pills that can help take the sting out of urinating called Azothiaprine but I would check with your OB or midwife before taking anything like that; you really need the urine culture first.

Your questions are all good ones; let’s break it down. Breast tenderness with lumps/masses or nipple discharge usually signals hormone imbalance; specifically, an Estradiol dominance. Women make both Estradiol + Progesterone during their monthly menstrual cycle. Once the decade of your 40’s begins, most women start to experience perimenopausal symptoms of ‘swinging hormones’ that includes larger and larger swings in Estradiol (E) levels and many months when ovulation doesn’t occur so there is no Progesterone (P4) production. Even if both E+P4 levels swing, they may not swing together with wilder swings in E levels and usually a drop out of P4 levels, aggravating the E dominance. E dominance will then hyperstimulate the organs that have larger numbers of E receptors: breast (fibrocystic changes), uterus (fibroids, polyps, thick and heavy lining with heavy periods), endometriosis and its cousin, adenomyosis and even ovaries (large and possibly recurrent ovarian cysts). The longer and the larger E dominance there is, the stronger the hyperstimulation to the breast which can lead to increased breast density (fibrocystic change), bad mammograms, cysts, breast biopsies, breast enlargement which may not be equal L vs R side and sometimes even underarm tenderness if there is a tail of breast tissue that you may have in your armpit or axilla. If you build a cyst in the breast (an enlargement of a duct which is usually E dominance), then the larger the cyst, the more it may change the direction of the duct that it is in and then change the direction of the nipple. Breast surveillance by self-breast exam can help determine if your breast feels more ‘cystic’ or overall more ‘lumpy-bumpy’; you may feel a generalized ‘fullness’ and not a lump if these changes are deeper in the base or inside of the breast; that’s where having your doctor do a breast exam or having a screening mammogram (X-ray or radiation) vs a thermogram (heat-distinction/no radiation) can be helpful. I also recommend closely following your female hormone levels throughout your decade of your 40’s so you are better prepared to rebalance your hormones and keep yourself in best female health. I highly encourage you to get more information about hormone balancing by checking out my book, Full Bloom: Perimenopause, Menopause, Postmenopause and Beyond. Full Bloom is available on Amazon and is written for the everyday patient to help debunk the myths and put forth the truths about this challenging time that we all need to go through and how to best help ourselves navigate the many changes that our body will go through. The hormone imbalances that occur happen to us all; some of us more gracefully than others, but knowing what your body is doing and how to keep your female health as balanced as it can be is your best approach to optimal health. Family history may not be in your favor if there is a direct family history of breast cancer in your maternal side of the family, but that may also mean that there was hormone imbalance in your maternal family members as well. Talk with your doctor; managing your female health in your early 40’s can make the decade of your 40’s more manageable and put you back in control of your physical and emotional health. There is a chapter at the back of Full Bloom that tells you how to talk to your doctor and which lab tests you should have done; use that as a guide to help you get the right blood tests done. Become a partner with your doctor in your healthcare.

Best way to answer this question is by doing it the old fashioned way: check you basal body temperature and chart it every morning on a BBT chart. BBT charts are available online, so find one that expands the temperature range from 97.0 to 100.0 in 0.1 degree increments with each graph as long as 35-40 days and graph each cycle out. It’s important to take your temp every morning at the same time of morning, BEFORE YOU GET OUT OF BED and then record the temp on the graph. Your body temp will rise approx. 0.8degrees with ovulation (after LH surge) and will remain elevated until it either drops with your period or remains elevated which may mean you are pregnant. So, if your temp goes up and stays up, then you are ovulating. Remember, sperm can remain active in your female tract up to 7 days pre-ovulation, but will only be active up to 36hr post-ovulation so you are ‘dangerous’ before you even think you are.

Another technique is to ‘pee on a stick’; this means an over-the-counter ovulation stick similar to a urine pregnancy test. They are available at the dollar store, but your dollar store may be out of stock during the COVID-19 lockdown or not open, so call around and get the best price. It also means that you need to start checking a few days before mid-cycle until you see a definite change or + ovulation on the stick.

Both of these techniques can be done at home without the guidance of your doctor. However, if you have any questions, send a picture on your phone or upload to an e-mail to your doctor’s office and ask the expert.
Hope this helps.

Your questions is a good one. First of all, an abnormal Pap with LSIL or low grade abnormality should ALWAYS have the HPV typing done, that should be an automatic reflex test done on that level of abnormal Pap. If the HPV typing was NOT done, then ask your provider to add that testing on, it should still be able to be read as a part of that Pap test even though it’s 2 months old (most labs hang onto the test for a period of time); they may be an extra charge for that service but your insurance should pick that up. If it is too late, then get it the next go around. Why would the test then go back to normal? Realize that despite being on birth control pills, your own underlying female hormone levels are still a part of your chemical health of your female tract. However, the longer you are on birth control pills, the stronger the influence on your ovaries to ‘go on vacation’ and not make enough female hormone. The higher the dose of birth control pill and the longer you are on birth control, the less your ovaries make of their own female hormone.

Also, are you a smoker? Smoking actually helps contribute to abnormal Pap smears so the quick answer is to quit if you are indeed a smoker.

What can you do to help yourself? What most patients are never told is that they can help themselves get healthy tissue on their cervix by taking METHYLFOLATE 1gm or 1,000mg daily. The methyl is just as important as the Folate or Folic Acid; sometimes I will tell my patients to just take a prenatal vitamin but not all prenatals have the METHYLfolate. Look for the METHYLfolate or METHYLFolic acid which is the best that you can take.

Does having a LSIL Pap now mean it will always progress? As you just found out, NO. Progression to a higher form of abnormality doesn’t always occur, you can reverse it back to normal all on your own with the proper supplements like METHYLfolate and cutting out nicotine as cigarettes, cigars, chewing tobacco or other products with nicotine. However, once a cervix progresses to a severe or in situ abnormal Pap, then it usually requires a surgical removal of this abnormal tissue; even then, the cervix will regenerate new tissue but it may be weakened and show up as a cervix that fails to remain closed during a pregnancy, resulting in premature delivery of a baby.

Pain in your L lower abdomen, L thigh and L back may all mean the same thing or they can actually mean 3 different things; it depends if they happen in a certain sequence or if they all happen together. Has the timing of which one happens first changed? Or has the intensity of how the 3 different areas manifest their pain changed? Does the pain get better or worse with eating? With movement? With walking? With emptying your bowels or your bladder? Are you able to sleep at night? Or does it awaken you at night? Do you have a fever? Are your bowel habits regular? Are your periods regular? How does this relate to the timing of your period? Does your pain increase with exercise? Are you nauseated? As you can tell from the many questions that I am asking, this could represent muscular pain from the low back/pelvic brim; this pain can start in your back, include your hip/lateral low back, your buttocks and even your upper thigh. Or it could represent your bladder/kidneys with a kidney stone or endometriosis to your bladder/ureter. Or it could represent your GI tract with constipation/diverticulosis/pelvic-abdominal adhesions (scar tissue) from prior surgery? Or it could represent your female trace with a L ovarian cyst that may or may not have ruptured putting pressure on the lower L abdominal wall and surrounding structures; this could be a simple cyst with clear fluid or a complex cyst like a dermoid or an endometrioma which causes terrible pain and scar tissue if they rupture. To map out each of the above possibilities would not be helpful until more information can be given as it relates to your L abdominal pain, Sorry to not be more helpful.

What you’re not being told by your Gynecologist is that despite being on a Nuvaring, your body still makes a small amount of its own baseline levels of female hormone that your Nuvaring will override. In addition, the longer you are on Nuvaring, the longer your body only makes a small and thin amount of lining inside the uterus that you may not completely bleed out with each cycle. Old brown blood is internal bleeding that takes a little time for your uterus to pass, that’s why it’s brown. That may be coming from bleeding from a very thin surface of lining inside the uterus and that lining doesn’t protect the muscle of the uterus well, so it’s like bleeding after a rug burn, or bleeding from the purely muscular inside surface of the uterus, sometimes assoc with cramps but many times no cramping is involved. The job of the artificial progesterone or progestin is to NOT build a thick lining so that you don’t bleed a lot; that has good and not so good implications over time. Sometimes what I recommend is to switch from the Nuvaring to a birth control pill for a month or so to give your uterus a different exposure from both the artificial estrogen and progesterone that are in the Nuvaring to the artificial estrogen and progesterone that in a birth control pill. I usually choose an Ortho Novum birth control pill or a 35mcg dose due to both of their artificial hormones seem to be the best tolerated by the largest number of women. This shows your uterus a little higher amount of hormone to build a little more lining that yes, you will have to bleed out. However, that little more lining will then act to stabilize the inside of your uterus and after a 1month, 2month or even 3month ‘vacation’, then switch back to your Nuvaring. You don’t lose any contraception as you are continuing a birth control pill but you have to remember to take it every day. The alternative is to stop the Nuvaring and let your body come back with its own natural hormones but then you are not covered by any contraception and you cannot trust the 1st month that you are back on the Nuvaring.

This is a very simple question but not such a simple answer. It totally depends on whether or not the pregnancy was truly 4wks along and it was really a ‘chemical pregnancy’, meaning that you miscarried at about the time you would’ve had your period. Or if the pregnancy was 6wks along or ‘1month after ovulation’ which is about the time that many patients will feel their first sign of morning sickness or GI upset and realize that they are more than just ‘late’ for their period; a positive home urine pregnancy test at this timing would’ve registered a ‘Yes’ or a ‘+’ on the stick. Or if the pregnancy was 8wks along or ‘1monthat after missing your period’ which would be the timing of most patients noting breast tenderness and GI upset along with increased urination from an enlarging uterus putting pressure on the bladder; for sure a urine pregnancy test would show positive at this point.

Now the question becomes did the pregnancy end in a spontaneous miscarriage or was it an induced miscarriage by taking a pill to cause miscarriage or was it an induced miscarriage by having a D&C or suction abortion at a clinic? Regardless of the way the miscarriage occurred, as long as there are no signs of persistent bleeding or fever which may actually signal that not all of the pregnancy tissue was passed (placenta, amniotic sac with or without a fetus inside), then it is likely but not confirmed that all of the tissue has passed. There are instances of delayed bleeding or infection up to a few days to a few weeks later if retained pregnancy tissue occurs; then do a urine pregnancy test to help confirm. If the test is still positive, then consult a physician. One of the circumstances that can occur is an ectopic pregnancy; that’s when the pregnancy is outside of the uterus, most commonly in the tube. All of the signs and symptoms of pregnancy occur but you may not be aware that it is tubal until it cannot grow any further without rupturing the tube; this this a medical emergency THAT CAN KILL YOU; it is imperative if you have a higher risk of tubal pregnancy that you seek immediate and early pregnancy care as you may require serial HCG blood testing and probable ultrasound to prove that your pregnancy is actually inside the uterus. Patients at high risk of this happening are patients with a history of pelvic infection, endometriosis, anovulation, prior abdominal or pelvic surgery, uterine abnormalities such as fibroids and recurrent ovarian cyst rupture which causes scar tissue around the tubes and can impair the conceptus (the developing fetus) from finishing it’s trip from the tube, where conception occurs to the inside of the uterus where it will implant.

Patients who are at increased risk for not passing all of the products of conception include patients with a prior C-section or prior uterine surgery such as a myomectomy or polyp removal. Patients with an IUD in place are at especially high risk if they become pregnant with an IUD in place as this can cause disruption of the pregnancy as the IUD arms may puncture the amniotic sac, the IUD may be pushed by the growing pregnancy into the wall of the uterus causing it to embed in the muscle and perhaps even puncture partially or fully through the wall of the uterus into the abdominal cavity; both can cause hemorrhage, severe pelvic/abdominal cramping, fever and that combination will end up as an emergency admission to the hospital and probable emergency surgery to retrieve the ‘lost IUD’; and IT CAN KILL YOU if it punctures the bowel and spills fecal content into the abdomen; this would mimic an appendicitis that isn’t an appendicitis at all with normal CT of the appendix perhaps causing a delay in diagnosis.

So as you can see, it’s a simple question, but not a simple answer.

BV or Bacterial vaginosis is an overgrowth of a common organism that is part of the ‘normal flora’ of every woman’s vaginal vault; it is part of the pH ‘balance’ that needs to be there to keep our vaginal vault secretions and tissues healthy. BV will usually not be a problem. However, when there is a more alkaline pH (semen) or if there is spotting and breakdown of blood (more alkaline), then overgrowth of BV occurs because it has more to ‘feed on’. This overgrowth will usually reset by itself with return to normal; not having any spotting/bleeding and having a regular timing of relations. Even having an increase in timing of relations can trigger BV; if relations were twice/wk and they go to every day can be a trigger for BV as it is an alkaline ‘overload’ or change. I have even had patients who changed to a heavily alkaline diet who noted a change in frequency of BV.



For those patients that have suffered with recurrent BV and are having breakdown of vaginal and vulvar tissues from wearing pads that are rubbing external tissues raw like a rug burn or just constant alkaline pH to a vaginal vault, there needs to be a ‘pH vacation’ from anything alkaline. That may mean relations can only happen with your partner wearing a condom and soaking AM and PM in Epsom salt baths to cleanse the vulvar tissues and allow them to heal. I tell my patients to go ‘commando’ and wear no underwear, wear cotton, breathable flowing clothing with good airflow, use a hairdryer on ‘cool’ setting after an Epsom salt soak and above all NO SOAP OF ANY KIND to the very sensitive tissues of your bottom. That means even squirt bottle hygiene vs dry toilet tissue with emptying your bladder and dab dry. BV is debilitating for some patients and you feel you are in this alone; but take heart, you have all of the tools to combat this, it just takes time and understanding the things that WILL HELP and the behaviors that WILL NOT HELP.

‘Lumps’ on the labia majora or ‘lips’ are quite commonly noted by many patients of all ages, causing consideration consternation and concern. ‘Are these STD related?’ ‘Are they contagious?’ ‘Did I cause this?’



Most of the time these ‘lumps’ are actually blocked glands that collect the usual secretions that a skin gland will normally secrete and that build up of liquid enlarges the gland, then the liquid leaves the blocked duct leaving behind the cellular debris that is more solid in nature or a ‘lump’. This process can take place over a few days to a few weeks; most of the time, usual physical activity of sitting, standing, walking and cleansing prevents these glands from blocking closed. However, sometimes these glands will appear and are usually not painful, are not trapping bacteria so they do not get infected. Exposing these ‘lumps’ to a warm soak of Epsom salts can help to open stubborn glands that will not open on their own without significant risk of injuring these sensitive tissues. What should NOT ever be done is to try to ‘pop’ these cysts as it usually causes injury to the labial tissue and can actually CAUSE an infection or bleeding.

One of the etiologies for these blocked glands occurring in the first place can be traced back to using soap which is quite drying and irritating to the very sensitive tissues of the labia. PLEASE do not use soap directly to these tissues as you hope to ‘clean’ this area; please soak in warm or hot water, with or without Epsom salts and these glands will self-resolve. Occasionally these glands blocking can be the result of hormone imbalance, but this is actually not a common etiology. If you have any concerns, please have an exam with a GYN as they are the most qualified to check and diagnose these ‘lumps’.

This is a simple question but such a simple answer. The quick answer is ‘yes’ but the better answer has a few questions that must be asked first:

1. Was the miscarriage a ‘chemical pregnancy’; meaning that you had a positive pregnancy test but your period was only a few days late and there was not any products of conception or ‘tissue’ seen, only menstrual flow? What this usually represents is a low Progesterone (P4) level that was so low that it did not make a rich enough secretory lining for a healthy fetus to properly implant and it would not properly establish a healthy implantation for a healthy placenta to form. A healthy placenta is the ‘filter’ through which maternal bloodflow, nutrition and oxygen will exchange with the returning blood and waste from the fetus for the mother to exchange out, allowing for a healthy pregnancy. Patients who are prone to recurrent multiple ‘chemical pregnancies’ need to have their Progesterone (P4) levels checked and bio-identical P4 replaced to help maintain that pregnancy until the placenta is big enough to make enough P4 on its own at around 14weeks pregnant.
2. Was the miscarriage associated with a fetus? As crazy as this sounds, some pregnancies will have a placenta and an amniotic sac filled with fluid but the cells destined to make the fetus never develop into a fetus; this is called a blighted ovum and has no real cause as to why it happens; those cells destined to become the fetus simply do not start growing. Once the body figures out that it is doing all of this work to have a healthy pregnancy but there is no fetus there to support, then the body will ‘figure it out’ and will initiate the miscarriage process on its own. Although sometimes the body doesn’t figure it out and you may wish to have your doctor set up a scheduled D&C to end the process and allow your body to ‘reset’.
3. Was the miscarriage associated with a fetus that had a heartbeat? At the time of miscarriage or perhaps spotting that prompted you to see your doctor, did an ultrasound demonstrate a fetus that measured to be as far along as you thought you were pregnant? Sometimes, a fetus will have a chromosomal problem that the body knows will not survive if it develops to term and delivers. Sometimes a fetus will have a heartbeat that will then lose its heartbeat before 12wks pregnant. This can represent the low P4 level as in #1 above; it can also be associated with multiple small blood clots to the placental blood vessels that compromise bloodflow in the placenta and cut off blood and nutrition to the fetus.
4. Was the miscarriage with a fetus not the first miscarriage but was it the 2nd or 3rd recurrent miscarriage of a pregnancy with a fetus? In this case it may represent autoimmune disease and a recurrent miscarriage to rule out autoimmune disease is needed. This work-up includes a clotting work-up to rule-out multiple blood clots in the placenta and includes: antiphospholipid antibodies, anticardiolipin antibodies, lupus anticoagulant, MTHFR deficiency, Factor VIII, platelet antibodies. Unfortunately, recurrent miscarriage may be the first sign of autoimmune disease and deserves a work-up.
5. Was the miscarriage after the first trimester ended (post 12weeks)? This timing would be much more dangerous to the mother as it may mean a maternal medical issue that is causing the miscarriage or it may not occur until the middle to end of the 2nd trimester which may not be at a timing when the fetus could survive outside of the womb.

Usually, a miscarriage at any stage in the pregnancy is a very physically and emotionally traumatic incident. Emotionally, you have given this child a name and a place in your heart and in your family; and now you’ve suffered a death that is NOT OF YOUR MAKING!!! Too many times, the woman is ‘blamed’ by her partner for ‘doing something wrong’ or ‘doing something that caused the miscarriage’ or ‘eating or drinking something’ that caused the miscarriage; these are hurtful and non-productive statements that can cause depression in the mom, feeling that she in deed is ‘at fault’ or ‘did something’ when indeed it was not within her control.

From a physically traumatic aspect, too many women are told that it is best to go through a miscarriage ‘the natural way’ by allowing the body to spontaneously miscarry. The natural process may occur and may completely evacuate the contents of the pregnancy and placenta but sometimes it doesn’t; this may result in retained placental pieces that may trigger an intrauterine infection which can be serious and even fatal if not recognized early in the process. Or it may result in significant blood loss and hemorrhage which can take weeks to months for the patient to recover from.

Regardless of which of the above have been the actual situation that you may have had happen to you, the uterus actually needs to recover, to get back to its normal size and be healthy enough to accept another pregnancy and not reject a healthy pregnancy because a patient got pregnant too soon before the uterus was prepared to properly handle the rigors of a healthy pregnancy. I usually tell my patients to allow the body and the mind/heart to heal over the next 2 cycles, then it’s okay and you are psychologically ready to try again; usually this timing will allow a proper reset of your body and you will have no increased risk of miscarriage simply because you got pregnant too soon.

Remember, chromosomal abnormalities are usually NOT going to cause a 2nd or 3rd trimester miscarriage; so doing a chorionic villous sampling of placental cells by 10wks pregnant or an amniocentesis sampling of sloughed fetal cells in the amniotic fluid between 14-17 wks pregnant can determine the exact genetics of the fetus. These tools are most commonly employed when the mom is ‘advanced maternal age’ or AMA with conception occurring after age 35years old.

Hope this helps answer a very simple question but it doesn’t have anything but a complicated answer.