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FAQs: Women's Health

I am a 27-year-old female. I had my first child in May '95, and in Sept '95 I started taking Depo-Provera injections as a method for contraception. I have gained weight since then, and also started having pain in my knees. I feel giddy if I try to go on a diet. Can you give me a reason for this? Also, if I plan to have a second child, when should I stop taking this injection? And are there any side effects when stopping?

My fiancee has used Depo-Provera for almost a year, and we are considering having a child now. We are wondering how long it takes for the medicine to fully leave her system and her fertility to return. She has been off the medicine for about four months now, and we have had intercourse regularly in that time frame. Planned parenthood has told her that it would probably take six months to a year for her to be able to conceive again. Is this true, and if so, what can we do in the interim to increase our chances of conception?

The Depo-Provera injection is a form of contraception that involves getting shots of a progesterone-type hormone (medroxyprogesterone) into the arm or buttock once every three months. It is very effective; almost as good as sterilization, assuming that the shots are taken on time. In contrast to the pill, or condoms, it has the great advantage of requiring no day-to-day thought, and it allows complete freedom for spontaneous love-making. Like the pill, it works by suppressing ovulation and thickening cervical secretions, thereby inhibiting the movement of sperm into the uterus. It does nothing to prevent STDs.

Weight gain is a common, but not universal, side-effect. The drug company quotes an average weight gain of five and a half pounds after the first year of use. Weight gain appears to continue over time, increasing to an average of eight pounds in two years, and nearly 14 pounds after four years. Another common side-effect is irregular periods: there may be light spotting that continues off and on for months at a time, or menstrual flow may stop altogether.

Pain in the knees and giddiness when trying to diet do not sound like typical side-effects of Depo-Provera. Those are good questions to discuss with your regular doctor.

The shots are effective for about three months at a time. Once you have decided to stop using this form of birth control, it is safe to simply discontinue the shots and begin unprotected intercourse. There will generally be no noticeable side-effects from stopping. It may, indeed, take up to a year to become pregnant. The company quotes a median time to conception of ten months. According to Tripod's Dr. Yates, there is nothing specific that can be done to increase the odds of becoming pregnant once Depo-Provera is stopped. Have patience, and enjoy the process. (Incidentally, if a women becomes pregnant at the time she first starts on the shots, there is a higher incidence of birth defects, as well as babies who are underweight for their age. Therefore, the shots are usually initiated within the first five days of the menstrual cycle.)

It is also worth noting that there is a similar type of contraception available called Norplant. Norplant is another way of providing long-term contraception by delivering a type of progesterone into the body for five years at a time. It is surgically implanted beneath the skin. Although the surgical procedure is minor, it costs hundreds of dollars. Both Depo-Provera and Norplant are useful for women who want long-term birth control. Depo-Provera has the advantage of being easier to start (no surgical procedure) and easier to stop (no second procedure required to take it out); but it does mean having the discomfort of a shot every three months.

-- R. Jandl, 11/13/96, Category: Women's Health

I was just wondering...I have very irregular menstrual cycles and even though I might not have a cycle could I be ovulating? Because I have a medium flow of vaginal discharge from month to month. It is thin, milky, and white in color, sometimes with a light foul smell if I eat sweets only. The doctors I have seen say it is normal discharge, but can't figure out why I have so much of it from month to month. Can you give me some possible reasons?

I consistently have some sort of slight vaginal discharge. There are no other side-symptoms, typically -- though I do detect an occasional odor. The "usual" discharge is clear, or faintly yellowish. This has occurred since I began menstruating.

My question is this: at the beginning of my cycle, the vaginal discharge becomes thick and brown, and often does have an unpleasant odor -- rather like the "normal" smell, only stronger. It will then pass into the red "lining" discharge before turning brown again before the cycle stops. I experience no pain or discomfort, and I am a virgin and not in any way sexually active. The one time I've had a Gyn exam, nothing unusual was detected... but that was some few years ago. I'm mildly concerned here... should my monthly discharge be ONLY red?

Vaginal discharge is a subject many people would rather avoid talking about, or even reading about. Nonetheless, it is a concern to just about all women at one time or another.

If you were to design a part of the body with an eye towards maximizing the chances of infection, the vagina would be an award winner. It is warm, moist, often undisturbed, and doesn't get much air. Micro-organisms love that. The fact that there isn't a continuous infection is a tribute to bio-diversity. The balance of growth among many different micro-organisms acts as a system of checks and balances so that one or another of the organisms can't take over. If you take antibiotics that selectively kill off one portion of the "flora" (amoxicillin is a familiar example), the yeast may have a field day.

Normally, clear to yellow, or milky appearing mucous is produced by cells that line the internal canal of the cervix. Some women produce more than others, but most women have some sort of discharge. Having no other place to go, it sometimes passes out the vaginal opening. The mucous is important to help ease the passage of sperm from the vagina into the uterus, and also acts as a barrier against infections of the uterus and fallopian tubes. There may be some variation in the amount, consistency, color, or smell of the discharge from one menstrual period to the next, or after going through a pregnancy. Foods are not generally recognized for being a cause of variation in discharge, but you will know your body better than anyone and may observe just such a variation. A brownish discoloration just before and after your menstrual flow can be a normal sign that sloughing of the lining of the endometrium is about to occur or has just ended.

How would you know if there were a more serious problem? If you experience irritation, intense itching, or burning; if there is any pelvic pain associated with it; or if, indeed, there is any change from your usual discharge, that would be a good reason to get it checked out. See a previous Ask the Doctor question for more on this.

More careful questioning or an examination wouldn't be a bad idea, but the symptoms you both describe sound normal.

-- R. Jandl, 10/30/96, Category: women's health

I recently had a pap smear and found that I have a mild case of human papilloma virus. I had a child two months ago and I'm wondering if the baby can also be infected. It was a vaginal delivery. I have no noticeable signs and I need to know more about the virus. I know that there is no cure and I am seeing a doctor and wish to keep from getting cervical cancer. Is surgery necessary? I am scared to death what this will lead to.

I recently had an abnormal pap smear. I then had a procedure to check my cervix and a small biopsy was taken. I was then called back to have the Leep Method procedure to remove the bad tissue. The nurse mentioned to me that on my file she noticed it read I had the HPV wart virus. No one had ever told me this before, and the doctor said this virus would stay with me forever, and also was the probable cause of my dysplasia. I'm interested in finding out what the HPV wart virus is. And also I found somewhere that dysplasia is the first stage of cervical cancer. My doctor says everything we are dealing with is pre-cancerous. I'm still waiting for my results of the tissue removal. I'm just interested in educating myself on my condition and its seriousness.
-- KM

Pap smears were developed as a technique for screening for cervical cancer by the pathologist G. N. Papanicolaou. Pap smears are about the most effective cancer screening technique ever developed. With the exception of the expertise required to interpret pap smears, it is low tech, low cost, and without side-effects. It is so effective that it is very rare for a woman to die of advanced cervical cancer. (It generally means she did not have regular pap smears.)

During a pelvic exam, a pap smear is obtained by rubbing a brush and a wooden stick over the surface, and in the opening, of the cervix, in order to obtain a sampling of cells. These scrapings are placed on a microscope slide and examined for abnormalities. If the cells look normal, than your pap smear report comes back "normal." If the cells look abnormal, that is usually (but not always) because there is some dysplasia. Dysplasia is a pre-cancerous condition. There is mild dysplasia, and severe dysplasia. The worse the dysplasia, the higher the risk of developing cervical cancer. Left alone, dysplasia can result in cervical cancer, although mild cases often disappear spontaneously. So what a pap smear does is to pick up these early dysplastic changes so that they can be treated and normalized.

What is the association with HPV? HPV stands for human papilloma virus. That is the virus that is sexually transmitted, and that can result in warts involving the genitals. HPV is one cause of cervical dysplasia.

Dysplasia does not occur in every woman who has been infected with HPV. According to Tripod's Dr. Susan Yates, women with HPV should be extra careful to get annual pap smears done. If warts are seen, they can usually be treated chemically (although, of course, you are never cured of the virus). If dysplasia is found, that too can be treated in a variety of ways such as cauterization with heat, electricity, or chemicals, cryosurgery (freezing the tissues), laser therapy (burning the tissue), or a cone biopsy which surgically removes a portion of the cervix in more severe cases.

Woman who are pregnant are examined for signs of "venereal warts," or HPV. If found, these warts can be treated during pregnancy. This helps to prevent excessive bleeding or physical interference in a vaginal birth. Babies, happily, are very unlikely to pick up HPV during vaginal delivery -- even if there are visible warts. Rare babies have polyps of the larynx, but this does not appear to be a major concern.

-- R. Jandl, 10/9/96, Category: women's health

I am a female, 36 years old. I am terribly concerned about hair growing on my face. This is new growth. It is only noticeable to me at this point. But I believe that in the next couple of years it will be terribly noticeable to others. What should I do? I have been told the following:
1. End my five year celibacy, and have sex.
2. Start taking birth control.
3. Start taking hormone treatments.
Coincidentally, I am not in a position to end my five year celibacy so easily. What can I do about slowing down the hair from growing?
-- JH

Excessive facial hair growth is traumatic for many women. In the US, women with noticeable body hair are often thought to be less attractive. In other cultures, body hair on women is seen as attractive and linked to sexuality. There are racial patterns to hair growth. Black women have more body hair than Asian women. And white women have more body hair than black women. There are ethnic trends too -- eastern European women have more hair than, say, Scandinavian women. So the question as to how much facial hair is too much is relative.

All women have some degree of facial hair. Some have more than others, but the presence of hair on a woman's face is normal. So let's say yours is becoming more noticeable. You hate it and find it unattractive. What is the cause? Assuming you are not on any medications that cause hair growth as a side-effect (ask your doctor), the most important question is whether or not your periods are normal. If they are abnormal -- maybe they are irregular, infrequent, or don't occur at all -- then testing for one of a number of hormonal problems may be warranted. Infertility, too, is a possible clue to an underlying hormonal problem.

In most cases involving women who are in good health, whose periods are normal, and who are not known to be infertile, excessive hair growth just seems to be a normal variation. Interestingly, all women have a small amount of the "male" hormone called testosterone in their bodies. An enzyme within their hair follicles converts testosterone into a hair growth stimulating compound at a more rapid rate than women who do not have excessive hair. The reason for this is unknown, but the change does seem to explain the extra hair growth.

Will ending celibacy and beginning an active sex life change the balance of hormones or reverse extra hair growth? As far as I know, the answer is no. How about the pill? Oral contraceptive pills, or other types of medication, can help some women who have specific glandular problems (such as the ovary or adrenal gland) by blocking or preventing some of the effects of excess male hormone activity. This would likely take some testing to find out whether you have one of these problems and whether or not it would work for you. It's not something you just take as an antidote to hair growth.

The only other treatments for unwanted hair are probably well known to you, and involve treating hair by bleaching, shaving, waxing, chemicals, or electrolysis.

Finally, getting through some of the physical changes of getting older (more hair in unwelcome places being one of them) isn't fun. But fighting it is often a losing battle. In our culture, superficial beauty is held to what I think is an unreasonable, even undesirable, standard. What will make you beautiful or attractive to those around you will have a lot to do with your spirit, your attitude about life, even your acceptance of physical changes. Your uniqueness, physically and in other ways, will be of value to those who care most about you. I suspect a little facial hair will not turn any of them away.

-- R. Jandl, 10/9/96, Category: women's health

: I am a DES daughter. Is hormone replacement therapy possible for me as I advance toward menopause? Is it safe?

DES stands for diethylstilbesterol. This is a drug that was used during the fifties and sixties by women who were having difficulties with repeat miscarriages, in the hope that it would help carry the fetus to term. It was later discovered that the daughters of women who took DES during pregnancy later had an increased risk of vaginal cancer.

Hormone (i.e. estrogen) replacement therapy is now being advocated for all women after menopause unless there are contraindications. Since concerns have been raised as to whether or not estrogen replacement therapy increases the risk of cancers of the breast or endometrium, your question is a good one.

However, the risk of vaginal cancer is not affected by estrogen replacement. Barring other considerations, or other medical concerns, the use of estrogen replacement in a woman who has been exposed to DES should not be a problem.

-- R. Jandl, 9/25/96, Category: women's health

Can you list some of the symptoms of a urinary tract infection? Could it cause pain during and/or after sexual intercourse?

The typical symptoms of a urinary tract infection include burning during or immediately after urination, a need to urinate frequently and in small amounts, blood or cloudiness to the urine, a lower mid-abdominal discomfort, and sometimes a fever. In more severe cases, when the infection ascends from the bladder up to the kidneys, you may also experience flank pain and shaking chills.

Urinary tract infections are distinctly uncommon in men, and often prompt one or more tests to see if there are any "plumbing problems" that might block, slow down, or reverse the normal flow of urine. Most women know that urinary tract infections are very common for them. Various pseudo-scientific theories relating to the length of a women's urethra (the passage from the bladder to the vaginal opening), the act of sexual intercourse, the direction of wiping after bowel movements, and others, have been proposed to explain this predisposition. However, none of them provide a satisfactory explanation.

Pain during or after sexual intercourse suggests other potential problems, and is not really a sign of a urinary tract infection. There may be simple physical explanations for the pain, such as inadequate lubrication or overly forceful penetration. Depending on the exact nature of your symptoms there could be other considerations as well, ranging from a pelvic infection to endometriosis, or adhesions from a prior pelvic surgery.

It is also worth mentioning that for some women it may be difficult to know whether or not burning and frequency are due to a urinary tract infection versus a vaginal infection. Some detailed questions, a urine specimen, and occasionally a pelvic exam will usually sort this out.

-- R. Jandl, 9/16/96, Category: common ailments

I have fibrocystic disease of the breasts and am on hormone (estrogen) replacement therapy. I am concerned about breast cancer. Can you offer any information?
--PP

I have been experiencing milk secretion from my breasts for a couple of months and am definitely not pregnant. What could be some causes of this?

Recently, one of my breasts has been cycling through a painful swelling and then returning to normal size. I am 32 years old. The mammogram came back negative. However, the cycle continues, and I recently noticed a slight discharge that I think is pus. Could this be mastitis and how is it treated?

Having received all of these questions recently, it seemed to make sense to try and address them together. With symptoms such as these, the biggest worry for most women is whether or not they might have cancer of the breast.

After puberty, any woman who has a painful area in a breast, a lump that can be felt or seen (especially one that doesn't go away with the passing of a menstrual cycle), changes in the appearance of the breast skin or nipple, or discharge or milk from the nipple, should be examined and screened for the possibility of breast cancer.

Having said that, there are many conditions that can cause all of these symptoms, but which are not cancerous, three of which are brought up in these questions. Before talking about them, a little background is helpful.

Women now have greater reproductive control than ever, and often delay getting pregnant until well into their thirties or forties. It is worth remembering, therefore, that women's breasts exist primarily for the sustenance of a baby. Every month, the hormonal changes responsible for the menstrual cycle also affect the breasts, preparing them for potential pregnancy. In fact, the lining cells of glands within the breasts have their own cycle of growth and shedding, much like the lining of the uterus. Most women experience this as premenstrual swelling and tenderness of the breasts. Sometimes the cycle is imperfect. For example, abnormal amounts of fluid may collect within a gland, resulting in a cyst. This is often felt as a painful lump and usually goes away with the next menstrual cycle.

As the first question suggests, many women's breasts go through "fibrocystic changes." This is simply an accentuation of the lumpiness found in all women's breasts and represents an exaggerated response to hormonal stimulation. It has been called "fibrocystic breast disease," but it is not a disease -- it is just an unfortunate choice of phrase that clinicians use to describe their examinations. Do fibrocystic changes increase the risk of breast cancer? There does not seem to be a simple answer. If you look under the microscope at tissue from breasts with fibrocystic changes, a small minority will have changes in the cells that look "atypical." Atypical cells are not cancerous, and by themselves, they are not cause for alarm. In certain cases, however, they become more atypical with time, and may one day become cancerous. When found in a biopsy they are associated with a several-fold increased risk of breast cancer. However, the great majority of women who have worrisome enough fibrocystic changes to warrant a biopsy do not have atypical changes and are not at increased risk for breast cancer.

On a practical note, fibrocystic changes do make the physical examination and detection of a cancerous growth within the breast more difficult. Whether or not estrogen replacement therapy in post-menopausal women increases the risk of breast cancer is controversial. If any increased risk exists, it is probably small.

What about discharges from the nipple? Well, if it looks like pus, and the breast is painful, there may be mastitis present (an infection of the breast) in which case antibiotics should be used. If the discharge looks like breast milk, it may simply be the effects of excessive hormonal stimulation (but could also indicate other glandular problems). With any new nipple discharge, a clinician's examination is advised. Depending on their findings, he or she may suggest simply watching things for a while. Or, they may want to order a mammogram, an ultrasound, a biopsy, or other tests to follow.

-- R. Jandl,8/30/96, Category: women's health

I am currently taking the birth control pill Ortho-Cept, and have gained some weight. I am interested in finding a listing of pills with low levels of progesterone, as I was told they reduce weight gain. Do you have a list, and can you let me know if this is myth or fact?

First, a little background may be helpful. Birth control pills are made up of two components, the estrogen component and the progesterone component. Today, the estrogen component is most often ethinyl estradiol. The dose used in the pill is kept at a minimum in order to avoid the blood clotting complications seen in older, higher dose pills. In practice, this usually means between 30 and 35 micrograms of ethinyl estradiol per pill. (The actual dose used for a particular woman may end up being higher or lower than this according to her tendency to get side-effects, the presence of other problems such as endometriosis, painful heavy periods, acne, etc.)

Since the estrogen component is now fairly standard, it is often on the basis of the progesterone, or progestin, component that one particular contraceptive pill is chosen. There are many different progestins. One useful way of differentiating among them is according to their tendency to cause a cluster of side-effects that include weight gain, acne, increased hair growth, mood changes, nervousness, changes in blood fat (lipoprotein) constituents and carbohydrate metabolism. This cluster is referred to as "androgenic activity." Obviously, for most women, the use of a birth control pill with low androgenic activity is desired.

A partial list of low androgenic progesterone contraceptives follows. You'll note that Ortho-Cept is one of them.

These contraceptives all contain an older, low dose progestin:

Modicon
Brevicon
Nelova 0.5/35
NEE 0.5/35

These contraceptives contain newer low dose progestins (their effects are more specific to the reproductive cycle):

Ovcon 35
Ortho-Cyclen
Ortho-Cept
Desogen
Ortho Tri-Cyclen

Just a final note about weight gain. Many women will complain about weight gain while taking birth control pills. But when studies are done looking at large numbers of women, no more than half a pound of weight gain distinguishes the contraceptive users from the others, suggesting that the problem is not as bad as generally perceived. Nonetheless, for a woman who does gain weight, or who already has a weight problem, lowering the amount of progesterone in the pill may help.

-- R. Jandl, 8/19/96, Category: women's health

I have been off the pill for six months now and have not yet had a menstrual cycle. I am worried about infertility. What should I do?

According to our obstetrician/gynecologist consultant Dr. Susan Yates, any woman who has not had a period in six months should see her doctor. It is common to go up to three or four months after stopping the pill before normal menstrual cycles resume, but it should not be longer than that. Infertility is a concern only in as much as normal periods and normal ovulation are needed in order to become pregnant. Neither of these seem to be occurring. Because there are so many different reasons (often very treatable) why your periods may have stopped it is really not possible to say whether or not this will result in infertility.

Incidentally, it does not matter how long you have been taking the pill in terms of whether or not you experience a couple of months of missed periods. Being on the pill even 10 or 15 years does not make it any more likely.

-- R. Jandl,7/29/96, Category: women's health

My nipples are inverted. I would like to have children in the next year or so. Can I still breast-feed normally? I have never asked my doctors any questions because they never seemed surprised by the abnormality. How common are inverted nipples and are there any known reasons for why they occur?

Many women's nipples, one or both, are inverted. They fold inward rather than point outward. This is just a normal variation and does not cause any health concerns. However, it is something to think about if anticipating breast feeding. The baby needs something to latch onto. Otherwise, the baby will have a difficult time nursing.

Usually this is easily dealt with. Your obstetrician/gynecologist may be able to provide you with exercises to help reverse the inversion, or can recommend a "lactation consultant" who will take the time necessary to help you work on this. You should not need to do anything until you become pregnant, as there will be plenty of time then to do the exercises.

An inverted nipple will not affect the amount of milk made by the breast. As to why inverted nipples occur in the first place, I have no idea.

If you're not sure whether your nipples are flat, inverted or stick out, here's a test.

-- R. Jandl,7/29/96, Category: women's health

Please help! I am having a terrible problem that probably is very common. The thing is that I have such awful pains during my menstruations that I sometimes almost pass out. What am I to do? Thanks in advance!

When thinking about the causes of pelvic pain during menstruation, a problem referred to as "dysmenorrhea," it is helpful to break it down into two types. Primary dysmenorrhea means that the pain occurs without any underlying disease or physical abnormality. It's more like an accentuation of normal menstruation. Secondary dysmenorrhea just means that the pain occurs due to some other factor.

What are some other factors? The most common, perhaps, is endometriosis. In this condition, islands of endometrial tissue (the tissue that normally lines the uterus) occur outside of the uterus and may be found attached to almost any pelvic or abdominal organ. Pain occurs when these islands of endometrium go through menstrual cycles the same way your normal endometrium does. Besides causing pain, endometriosis may be associated with infertility, pain with intercourse, or heavy menstrual bleeding. Endometriosis occurs as a result of events in fetal development.

Other causes of unusually bad menstrual pain include an intrauterine device, or IUD, used for birth control; chronic pelvic inflammatory disease (PID); and numerous other less likely possibilities.

If none of these problems exist, you would be said to have primary dysmenorrhea. This is very common. Generally, the pain lasts two to three days, beginning each month at the time menstrual blood begins to flow. Research has shown that women with this type of dysmenorrhea have increased levels of hormones such as prostaglandins, leukotrienes, and vasopressin. These hormones act to increase the intensity of uterine contractions and reduce the blood supply to the endometrial lining, both of which are necessary for normal shedding of the endometrium each month. Excess production of these hormones can thereby result in increased pain. Medicines called nonsteroidal anti-inflammatory agents (ibuprofen is one common example) reduce prostaglandin synthesis, and may dramatically relieve the pain.

-- R. Jandl,5/29/96, Category: women's health

I am 23 years old and have not had a baby or a significant loss of weight. However, I have BAD stretch marks on my inner-thighs from the tops down to my knees! Is there anyway to get rid of these unsightly monsters? Is there any way to prevent more from forming? Thanks in advance!
-- RT

I wish I had a good answer for you. Unfortunately, there are no easy solutions to stretch marks. They seem to come about due to weakness or excess strain on the elastic tissues within the deeper layers of the skin. As you suggest, stretch marks often occur from pregnancy, where they are commonly seen in the abdominal wall and breast areas. There are also certain glandular problems wherein excess steroid hormones are made by the body ("Cushing's syndrome") resulting in wide-spread stretch marks, or striae. I've also recently learned that weight training may be associated with stretch marks.

Although it seems attractive and desirable to lubricate the skin to avoid stretch marks, there is no reliable evidence that this works. That's because the problem is in the deeper layers of the skin, well below anything that moisturizers or other creams might reach. You might consider having a dermatologist take a quick look to make sure there are no other problems.

-- R. Jandl,5/23/96, Category: women's health

Is it true that cranberry juice will help fight urinary infection, or is it just an "ole-wives tale?"
-- JK

There is a long standing controversy over whether or not cranberry juice helps to fight urinary tract infections. For example, it is often recommended that women who experience burning and frequency with urination should drink lots of cranberry juice. Burning and frequency can be signs of a urinary tract infection, or cystitis. Studies that have looked for an effect have noted that cranberry juice will increase the acidification of urine, potentially inhibiting the growth of bacteria. An effect of cranberry juice on reducing the adherence of bacteria to the lining cells of the bladder have also been noted. Bacterial adherence is one of the factors that promotes infection.

However, there does not appear to be any solid data to indicate that drinking lots of cranberry juice actually prevents or cures urinary tract infections. To recommend its use, we should really be able to show that it works. Keep in mind, that burning and frequency of urination are not specific for cystitis. (Vaginal infections can cause similar symptoms.) Other women with these symptoms are difficult to diagnose. Their symptoms may lack a clear explanation in spite of careful examinations and testing. So there is not necessarily a direct connection between the symptoms, a urinary tract infection, and the effectiveness of cranberry juice. Perhaps some women with these symptoms are helped; there just does not seem to be sufficient information to make it a recommendation.

-- R. Jandl, 5/8/96, Category: women's health

I read here that doctors can't tell if a woman has had a miscarriage or an abortion, but I know that it's possible to tell if a woman's been pregnant before. Apparently, there's a line running vertically from a woman's belly button to her nether regions, and this line gets darker as a woman progresses in her pregnancy, and even if she has an abortion or miscarriage, the line does not fade. Am I wrong about this?

You may be right. The line you refer to is a little curiosity of pregnancy. Doctors refer to it as the linea nigra. One of the things that happens in pregnancy is a darkening pigmentation of certain parts of the body. It is most noticeable in the nipples, and in this line of pigmentation that extends from the navel to the pubic region. The hormonal changes of pregnancy appear to increase melanin, the substance that causes darkening of the skin (and naturally blocks UV radiation).

This coloration varies from one woman to another. In some woman it is very striking. In others it is barely noticeable. It slowly increases over the course of pregnancy, and generally will not be noticeable if pregnancy ends early (say within a couple of months). After full-term delivery the darkening will fade to a certain extent, but will always be present.

Could this line be used to determine whether or not a woman has ever been pregnant? Well, I wouldn't stake much on it -- there is just too much variability. But I suppose if I saw a woman with a very dark linea nigra I might think that she had been pregnant before. This conclusion wouldn't exactly stand up to scrutiny in a courtroom forensic science debate, but it does provide somewhat of a clue.

-- R. Jandl, 5/6/96, Category: women's health

My mother developed breast cancer when she was thirty-four and died when she was forty-two; my grandmother also developed breast cancer in her late sixties. I was given an option by my step-mother's doctor to have all of my breast tissue removed and have implants put in. He says this will drastically reduce my risk of developing breast cancer. Is this something that you would recommend doing? What can you tell me about the procedure? Any info would be appreciated.

Can it really be true that having both breasts surgically removed at a young age is a good thing to do? Does prudence require that you cut your losses now? Or has the fear and stigma of breast cancer overwhelmed all rational considerations?

There are no easy answers, and every woman in your position has to make this choice for herself. For whatever it is worth, here are some of my thoughts:

The average woman in the United States has a 10% lifetime risk of getting breast cancer. A history of breast cancer in a woman's family increases her risk two to three-fold; and if those relatives had breast cancer in both breasts, the risk is even higher. Generally speaking, that's a pretty high risk. But on the other hand, if you turn it around, it means that the average woman's lifetime chances of not getting breast cancer is about 90%.

A family history of breast cancer is not the only risk factor to consider. Age is a factor too. If a woman is in her twenties or thirties, her risk of breast cancer is much lower than if she were in her sixties or seventies. Does it make sense to hold off awhile on a "prophylactic mastectomy?" Also, a woman who starts to menstruate at an older age, whose natural menopause occurs at a younger age, or who was young at the time of her first full-term pregnancy, is less likely to get cancer. How do these risks apply to you?

Most importantly, what are your values? Of course, most of us would assume that cancer is a bad thing to get, and most would agree that having both breasts removed is a bad thing. But is one of these outcomes more troubling than the other, to you? If you had to choose, which could you live with best? Some people are terrified of surgery, and would rather take their chances on getting cancer. Others would want to have any risk of cancer reduced to the lowest level possible, no matter what the costs.

This is your decision. Take your time with it. Consider speaking to an oncologist, or other trusted doctors and friends. Think about talking to women who have had this surgery done, as well as to women who have had breast cancer. Their insights may be invaluable. What you learn will undoubtedly help you to feel more confident about your ultimate decision.

-- R. Jandl, 4/16/96, Category: women's health

After being diagnosed with in-situ breast cancer and receiving a mastectomy, I have been informed that I can no longer donate blood or be an organ donor. Why is this?
-- JL

The reason is quite simple, although in your case largely theoretical. It is to avoid giving cancer to another person.

Cancers, of all types, if left untreated will spread by various means to other parts of the body. For example, when a cancer grows by direct extension, it is simply spreading into adjacent tissues as it enlarges. However, when it metastasizes, it spreads to remote parts of the body. It does this via cells that break off from the original cancer and move either through the lymph system, or through the blood stream to distant sites. Some cancers metastasize early, when the original cancer is quite small (melanomas of the skin are notorious for this) while others don't metastasize until the original cancer is very large and advanced.

If you have had any type of cancer, an "in-situ" one is the most advantageous because it can usually be readily cured. The implication is that it has been caught quite early, and has not even invaded the surrounding tissues, never mind metastasized. Nonetheless, there is a theoretical risk that microscopic cancer cells did spread to other parts of the body through the blood stream prior to the mastectomy. Therefore, donating blood, or an organ, would put the recipient at risk.

-- R. Jandl, 3/11/96, Category: women's health

I have a lot of shoulder, neck and upper back pain, in addition to having considerable difficulty getting physically comfortable enough to fall asleep. I'm quite certain this is due to having breasts which are just too large and heavy for my body. I'd give anything to have a reduction, but am unsure of what's involved. Is it necessary for me to be at my ideal weight? What are the risks? What questions should I ask my doctor, and what should I tell my doctor to convince him or her that something needs to be done? I'm tired of being in pain!
-- CM

It is certainly possible that the symptoms you describe are caused by very large breasts, a condition called "breast hypertrophy." Other symptoms often seen include shoulder pain, headaches, breast pain, and numbness in the arms due to traction and pressure on a particular nerve. Needless to say, women with this problem may also have difficulties with some of the physical activities involved in sports and in some vocations.

In defining whether a woman has true breast hypertrophy, a plastic surgeon will compare her overall body stature with her breast size, and will also measure the nipple position. One criterion which would suggest the presence of excessive breast size, would be a distance of more than 21 centimeters from the notch above the breastbone to the nipple.

Most plastic surgeons would suggest a trial of weight reduction in women who are at greater than 50% above their ideal body weight, as in some cases this may reduce breast size enough to improve symptoms. If it does not, it will at least lower the risks of breast reduction surgery, also referred to as "reduction mammoplasty."

There are other surgical risk factors to consider such as a history of serious heart or lung disease, insulin dependent diabetes, a past history of blood clots (thromboembolism), ongoing cigarette smoking, or a history of prior radiation therapy to the breast or chest wall area.

The surgery itself may be done using one of several techniques, each of which will result in a different type of scar. Ah yes, the scars. This is really the major trade-off which a woman needs to consider when deciding whether or not to undergo one of these procedures. All of them will leave visible, possibly prominent surgical scars. Depending on the individual, with time, these scars may become less noticeable to one's eyes and hands. Or, they may not. Sometimes there may be permanent loss of sensation of the nipple, or inversion of the nipple (so that it goes into your body instead of sticking out), or there may be mispositioning of the nipple and areola with need for a second surgical procedure to reposition it.

A small number of women will have difficulty breast feeding after surgery. The standard surgical and anesthetic risks apply as well, of course, including such things as wound infections, blood clots, a potential need for blood transfusions, and reactions to the anesthesia and other medications, including the rare fatal event. Nevertheless, the majority of women who, after careful consideration of all the options and trade-offs involved, choose to undergo this surgery are happy with the end result and the improvement in the symptoms which led them to it in the first place.

As far as how you should go about discussing this with your doctor, you are already off to a good start. Your question already contains all the relevant factors which you need to start that conversation. The only unanswered element which you may need to explore is the question of who is going to pay for it. Some insurance companies, unfortunately, completely exclude coverage for this kind of surgery, regardless of whether it is causing physical symptoms or not. You might want to read through your contract to avoid an unanticipated surprise. Good luck!

-- B. Kopynec, 2/18/96, Category: women's health

I am a woman of 29 years. My breasts are very under-developed. Besides trying to gain overall body weight, what are some natural methods to increase my breast size? I am not willing to consider implants... Will being on the pill help ?

It is unlikely that any exercise or medicine will change breast size significantly. Birth control pills often increase breast size to some extent, but not for all women. Gaining weight will also often increase the size of the breasts, since women store more fat in their breasts than men do, but the rest of your figure may suffer as a result!

I would avoid the "miracle cures" that you see in some magazines since they have generally not been proven to work and are often expensive. You may want to consider some of the newer bras available to enhance your figure. Many of these garments may create the image that you desire, without the risks of cosmetic surgery.
-- S. Yates, 2/4/96, Category: Women's Health

I heard a recommendation about pregnant woman, who should keep away from cats as she might get infected by bacteria in the cat, and then get an abnormal baby. How come? Is that true?

The reason that pregnant women should avoid changing cat litter boxes is because cats can be infected with a disease called toxoplasmosis. This often happens when cats hunt and eat other animals. Therefore, it is rare in house-bound cats. A pregnant woman can catch the infection through touching or breathing particles (such as dust) from cat feces. If a woman gets the infection during pregnancy it can affect the developing baby and cause birth defects, particularly in brain development. Therefore it is generally advised that women who are pregnant ask to have someone else change the cat litter boxes. It is safe to hold and pet your cat however, so feel free to give your pet all the affection it deserves.
-- S. Yates, 12/6/95; Category: Women's Health

Generally when should a woman have her first gynecological examination?

I would advise a woman to get her first gynecological exam when she feels ready, usually at about age 18. She should begin exams earlier if she becomes sexually active, or has problems with her periods. Information about what an exam is like is usually available through peer health groups, health services at school, or from private doctors' offices.
-- S. Yates, 11/27/95; Category: Women's Health

For some time I have been experiencing pain during intercourse (it has always been painful). I have been sexually active for only three months. After intercourse, I get this weird discharge, and I feel pain for almost a week after having done it. Is this normal? Should I visit a specialist?

It is not uncommon to experience some pain after intercourse when a woman first becomes sexually active. The vagina is now having to stretch far more to allow intercouse, and sometimes the opening becomes irritated.

You can minimize this discomfort by taking time to gradually stretch the vaginal opening with your fingers. You can do this stretching every few days and it will help to open the vagina, and make it easier for you to relax the muscle at the vaginal opening when you do have intercourse. Also you may need to use a lubricant if your vagina is dry. Be certain to check to be sure your lubricant is compatible with condom use. Increasing the length of foreplay will also increase your body's ability to lubricate itself.

It is normal to have a discharge after intercourse. Intercourse releases cervical and vaginal secretions which you need for lubrication. Depending on the contraceptive method you use you will probably also have residual contraceptive which your body naturally cleans out in the form of discharge. If you continue to have problems, I would suggest that you have your symptoms evaluated by your doctor, college health service, or other health clinic, to rule out an infection or other types of problems.
-- S. Yates, 11/27/95; Category: Women's Health

I am 19 years old and I have had a lump in my breast for over a year now. When I first noticed it, I immediately went to a doctor to have it checked out. The doctor made me feel really stupid for being there and told me it was only fat tissue. Now it is over a year later and it is still there. Should I have it checked out again?

I think it is very reasonable, and probably a good idea, for you to have your breast examined again. Although it would be very rare for someone of your age to have cancer of the breast, it is always a good idea to get a new or unusual lump checked.

Generally speaking, if there has been no change in size of a lump, no changes in the overlying skin, no unusual nipple discharge, and if the exam still suggests a soft or rubbery lump, then you can usually be reassured that it is not cancerous. Over time, by checking your breasts every month, you should begin to get more comfortable with what your normal breast feels like, will become familiar with normal variations in the texture of the breast, and also more aware of a growth that is new or somehow different.

If your doctor makes you feel stupid for asking to have a lump checked, you might consider telling him or her how you felt. When breast cancer is the leading cancer among women, a cautious approach to any changes in your breast is warranted. If you feel intimidated by your doctor and cannot talk it through, you might consider finding someone else with whom you feel more comfortable.

-- R. Jandl, 11/9/95

I heard on the news yesterday that pregnant women should not eat vegetables during the first eight weeks. Is it true that vegetables build up toxins in the fetus?

The story you heard may have been describing a theory that suggests that vegetables with a strong smell when cooked -- like broccoli or cauliflower -- may cause some pregrnant women to feel sick. Some pregnant women have especially bad bouts of morning sickness lasting beyond the first trimester. Many theories about why this happens have been posed. This theory suggests that perhaps this was an evolutionary survival measure that prevented pregnant women from eating foods that might be poisonous to their fetus. This theory goes on to say that perhaps there are compounds in the Brassica family (cauliflower, brussel sprouts, and broccoli) that are bad for pregnant women.

This theory does not appear to be substantiated. Certainly, many women consuming vegetables have had healthy babies. And we do know for sure that eating a healthy diet --with lots of fruits and vegetables-- is important for a healthy baby.

-- L. Hill Einbinder, 11/9/95

Sounds like a new scheme to get out of eating vegetables to me! Pregnant women should eat a well balanced diet in order to get adequate nutrition, vitamins and minerals. Sometimes in the 1st trimester (12 weeks) the nausea makes a balanced diet difficult. In those cases women should eat what they can without nausea, and worry more about balanced nutrition when they feel better.

-- S. Yates, 11/9/95

Why should you not get a flu shot if you are pregnant?
-- HH

Influenza vaccination is actually indicated for pregnant women who have underlying high-risk health conditions, but is not routinely recommended for those who are otherwise healthy. Although experience is limited, no evidence exists that the available vaccines will harm the fetus. Influenza vaccine can be given to any person who wishes to reduce the risk for influenza infection except for those rare persons who have anaphylactic hypersensitivity to eggs. (Source: Guide for Adult Immunization--Approved by the American College of Physicians).
-- R. Durning, M.D., 10/30/95

Breast cancer runs in my family and I would like to know if it is a good idea to go on the pill?

A family history of breast cancer is not an absolute contraindication to using the pill for contraception. Most studies suggest that birth control pill use is not related to later risk of breast cancer. There are some studies that show there may be some link, but not in all women. Interestingly, birth control pills actually protect against later ovarian and uterine cancer in women. Therefore I would advise that your decision be made together with your gynecologic care provider, taking into account your medical history, your family history, and your ability to successfully use other contraceptive methods. Another birth control option for you to consider would be progesterone-only methods such as Depo-provera shots or Norplant implants.
-- Susan Yates, M.D., 10/30/95

I have been on ON777 for five years now, and plan to be on it for at least another five years. I understand the riskes in taking the pill, but I was wondering if the odds of these risks increase the longer I am on the pill?

The risks of oral contraceptives are not increased because of years of use. Taking the pill for five or more years does not change the overall risks. Actually the benefits may be increased over time, by lowering the lifetime risk of ovarian and uterine cancer, and lowering the risk of ovarian cysts and bleeding problems with your periods. If, however, a woman smokes cigarettes and is older (greater than age 30-35), she does have an increased risk of heart disease on the pill. Those risks are due to the cigarettes though, and women may safely take the pill until menopause if they are nonsmokers. Incidentally, being on the pill does not make it more difficult to get pregnant once you stop using the pill.
-- Susan Yates, 10/27/95

How common is the incidence of women who have had their fallopian tubes "cut and tied" becomming pregnant anyway? How is the procedure done?

There are a number of procedures that will interupt a woman's Fallopian Tubes (the tubes leading from the uterus to the ovaries) to induce sterilization. The idea, of course, is to prevent the sperm and egg from meeting, as nature is want to do. Generally, the tubes can be clipped with a metal or plastic clip, cut and tied, or cut and cauterized. There are technical pros and cons to each of these. However, the further away the severed ends of the tubes are left, the greater the likelihood of success.

Surprisingly, the chances of becoming pregnant after a "tubal" is done, although less than one percent, is not nil. That's because the ends of the tubes can eventually reunite of their own accord. Compared to other forms of birth control, however, this failure rate is quite good.

Tubal ligation should be considered irreversible. However, if enough of the tube ends remain after the procedure has been done, it is technically feasible to reconnect the tube, making pregnancy possible once again, for some proportion of these women.

-- R. Jandl, 10/13/95

I am pregnant with my second child. The first (quite healthy, full term one) zipped out in 3 hours of labor. What are the odds that my second labor will be longer or shorter, assuming full term & good health?
-- PJ

Usually after the first pregnancy and labor, subsequent labors have a shorter active phase. This means that while the irregular contractions that lead up to labor may take as long or longer than in your first pregnancy, the intense contractions that accompany the rapid opening of the cervix last for a shorter amount of time. Every pregnancy is unique, however, and your labor this time can be different depending on many factors, including the size of your baby, the quality of your contractions, the baby's position, etc. I would suspect given your first labor, that you should at least be prepared for another short labor, and should have transportation and child care readily available for whenever you need it.
-- S. Yates, M.D., Tripod Consultant, 10/20/95

Does it mean anything if a woman gets her period two or sometimes three weeks late?

I have not had my period for two months now. I am definitely not pregnant because I have never had sex before. Could the stress of starting college be upsetting my menstrual cycle?

It is very common for women to have episodes of menstral irregularity, with cycles often varying between three and eight weeks apart. Generally, unless you wait longer than three months for a period, or develop heavy and prolonged bleeding, it is okay to simply wait for your body to return to a more normal schedule. Of course, it is important to check for pregnancy if you are late and have been having intercourse.

Irregular periods often happen in response to stress, such as going away to school, changes in diet or weight, or changes in intensity of exercise. However, you should contact your doctor if you develop bleeding between periods, or if your body has other changes (such as increased hair growth, worse acne, or spontaneous discharge from the nipples of your breasts) along with irregular periods.
-- S. Yates, M.D., Tripod Consultant, 10/20/95

I have had an area in my right breast that feels like a bruise for the past few months. Sometimes worse than others. There is not a bruise or lump there. It just hurts to touch. I am 41 years old and have two children ages 20 and 18. I am not on birth control and haven't been for 22 years. No other health problems just don't know how serious this can be. I hate to go to the doctors for mammogram. I have had them before. Last one about a year ago.
-- SR

A painful area in the breast can mean many things. If you have had such pains before, that come and go over a long period of time, chances are there is nothing serious going on. You could have something as minor as a bruise, or an engorged cyst. However, breast pain is an important sign of breast cancer, as well as infection ("mastitis"). You have provided some important information about your age, sexual activity, and reproductive history. But there are other questions affecting your risk of breast cancer, such as whether or not you have a family history of breast cancer, the age at which you started to menstruate, whether or not there is a discharge from the nipple, and others, that will help determine how concerned you should be, and whether or not a mammogram is indicated.

Many women do not like going to the doctor's for an examination, or they are afraid that they will be told something worrisome that they are afraid to hear. As understandable as this is, it really is not in your best interest to avoid a careful breast examination; or to avoid screening tests that could be very reassuring, or that could pinpoint a problem at an early stage, and thereby make treatment easier, and the outcome more positive.

-- R. Jandl, 10/13/95

It is my understanding that RU486, the abortion pill, is available in countries other than the United States. Is there another type of abortion pill that is available in the U.S. that my doctor could prescribe that is similiar to RU486?
-- CR, Southern Illinois University

You are right that RU486 (Mifepristone) is not available for use in the United States. So much political and ethical controversy surrounds it that there are questions as to when, if ever, it will become available. To our knowledge, there is no other currently available pill for inducing abortion on the market. There have been studies looking at other agents, including a recent study using methotrexate and misoprostol, two medications that are currently used for other purposes. However, these are not sufficiently evaluated for safety and effectiveness to allow clinical use. A conventional abortion procedure is the only other option at this point.

-- R. Jandl, 10/16/95

What are the pros and cons of hormone replacement therapy ?

Hormone replacement therapy, or HRT, is often given to postmenopausal women, and to younger women who have lost ovarian function (e.g. after a total hysterectomy). The hormones typically include estrogen and progesterone, normal female hormones whose production decline after menopause. A complete discussion of hormone replacement therapy is well beyond the scope of "Ask the Doctor," but we can comment on a couple of highlights.

There are three major reasons to consider taking these hormones, and for most women the benefits are substantial:
1) they ease menopausal symptoms such as hot flashes and vaginal dryness;
2) they reduce the risk of heart disease
3) they reduce the risk of osteoporosis, a common condition in elderly women which causes loss of bone strength and fractures.

On the down side, there is concern that the incidence of breast cancer may be increased. The studies are conflicting and not conclusive, but most physicians will not prescribe HRT to any woman with a personal history of breast cancer, or even a family history of breast cancer. The risk of endometrial cancer, which is elevated in women who take estrogens alone, is not increased when progesterone is also taken.

There are many other factors to be considered. When patients are selected properly, the potential benefits of HRT will greatly outweigh the risks. However, for many women the choice remains a difficult one.

Recommended Reading: University of California at Berkeley Wellness Letter, Volume 12, Issue 1, October 1995.

-- R. Jandl, 9/21/95

I've been noticing a vaginal discharge for about a week now. I've been sexually active for the first time, and it's got me worried ... should I be concerned?

Any new or unusual vaginal discharge may warrant evaluation by your health care provider. Not only is a vaginal discharge often uncomfortable, but it may represent an STD and more serious complications may arise if it is left untreated. A physical exam is important to assess the cause of the discharge (including microscopic evaluation) and to rule out pelvic inflammatory disease or other complications. Treatment is usually with antibiotics or medicated vaginal preparations. Condom use provides excellent protection against most STD's and should always be used. The following is a partial list of some of the common conditions which can cause vaginal discharge:

-- C. Ebelke

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