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Menopause begins 12 months after your last menstrual period, in the U.S., the average age is 51. However, hormonal changes typically begin 4-7 years earlier. This period of change, called perimenopause,  is associated with sweeping and fluctuating changes in hormone levels. Symptoms vary from person to person and include:

Irregular periods: This is usually the first sign. The frequency of your periods may become less predictable, and the flow may be heavy or light.

Hot flashes and night sweats: These are sudden feelings of heat, usually most intense over the face, neck and chest. They can cause you to sweat profusely. Some women have a rapid heart rate or chills as well. The actual mechanism behind hot flashes is not yet completely understood but is related to low estrogen levels causing sensitization of the hypothalamus. In response to warm temperatures, the overly sensitive hypothalamus may respond by inducing a hot flash to cause sweating in an attempt to ultimately cool the body.

Sleep problems: You might have insomnia or find yourself waking up more often during the night.

Mood changes: Hormonal changes can often lead to increased anxiety, irritability, or feelings of sadness.

Vaginal Symptoms. During perimenopause, less estrogen may cause the tissues of the vulva and the lining of the vagina to become thinner, drier, and less elastic or flexible—a condition known as “vulvovaginal atrophy” . Vaginal secretions are reduced, resulting in decreased lubrication.  Reduced levels of estrogen also result in an increase in vaginal pH, which makes the vagina less acidic, just as it was before puberty.

Breast changes. Breasts become less dense during midlife, as glandular tissue declines and fatty tissue increases with aging. This decrease in density makes mammograms easier to interpret.

Decreased libido: Some women experience a drop in sexual desire during menopause.

Dry skin, mouth, and eyes: The decrease in estrogen can affect moisture levels in various parts of your body.

Hair changes. The shift in the balance between androgen and estrogen levels can also lead to excessive hair growth in areas of the body where hair follicles are especially sensitive to androgen, such as the chin, upper lip, and cheeks. Many midlife women report the sudden growth of single, thick (often dark) hairs on their chin, while others may notice downy peach fuzz–like hair on their face. 

Treatment

Medications are often used to treat perimenopausal symptoms. Medications are not medically necessary but are used to manage bothersome symptoms. 

  • Hormone therapy. Systemic estrogen therapy — which is commonly prescribed in pill or skin patchform — remains the most effective treatment option for relieving perimenopausal and menopausal hot flashes and night sweats. Depending on your personal and family medical history, your doctor may recommend estrogen in the lowest dose needed to provide symptom relief for you. If you still have your uterus, you’ll need progestin in addition to estrogen. Systemic estrogen can help prevent bone loss.
  • Vaginal estrogen. Estrogen can be administered directly to the vagina using a vaginal tablet, ring or cream. This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissue. It can help relieve vaginal dryness, discomfort with intercourse and some urinary symptoms.
  • Antidepressants. Certain antidepressants related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs) may reduce menopausal hot flashes. An antidepressant for management of hot flashes may be useful for women who can’t take or wish to avoid estrogen for health reasons or for women who need an antidepressant for a mood disorder.
  • Gabapentin (Neurontin). Gabapentin is approved to treat seizures, but it has also been shown to help reduce hot flashes. This drug is useful for women who can’t use estrogen therapy for health reasons and for those who also have migraines.
  • Fezolinetant (Veozah). This medicine is a hormone-free option for treating menopause hot flashes. It works by blocking a pathway in the brain that helps regulate body temperature.

Other recommendations include:

  • Switching to heavier/thicker moisturizers to combat skin dryness. Products containing hyaluronic acid are recommended because they help to increase the moisture content in your skin
  • Incorporting weight training using weights or body weight which helps to prevent the age associated loss of muscle mass, and increases testosterone which can have benefical effects on mood and libido
  • Using a lubricant during partnered sex and/or masterbation 


Ozempic, Wegovy, and Mounjaro are FDA-approved drugs initially designed to treat type II diabetes. Of the three, Wegovy is specifically approved by the FDA for chronic weight-loss management. These drugs, as well as their less pricey, non-brand-name equivalent– compounded semaglutide, which may be manufactured through state-licensed compounding pharmacies across the US – belong to a class of pharmaceuticals called glucagon-like peptide-1 (GLP-1) receptor agonists. These drugs, as you’ve surely heard if you’ve opened any social media app in the last year, have been shown to lead to weight-loss as a side effect, by acting to suppress appetite, slow the rate at which the stomach empties, and to control blood sugar.

Unfortunately, studies have shown that most individuals gain a significant portion of this weight back a year after discontinuing use of these drugs [1].  Therefore, prior to initiating use with weight-loss as the goal, it is essential that you work with a dietitian or other qualified healthcare professional to plan out your “exit strategy.” In other words, how will you maintain your weight once you reach your goal and eventually discontinue use of these drugs?

Some of the lifestyle changes we will discuss and begin to integrate into your daily life as you consider use of a GLP-1 receptor agonist for weight loss include:

  1. The importance of building muscle mass through strength training and meeting individual protein needs.
  2. Moderating carbohydrate intake. As your dietitian, we will work together to make tweaks and changes to your diet including healthful swaps to decrease refined carbohydrate intake and increase protein, healthy fats, and whole grains in the diet.
  3. Pinpointing palatable foods within your dietary and cultural preferences that satiate and fill you up….for the long haul. These are the foods that will aid you in eating less overall.
  4. Methods to increase sleep quality and manage stress.

Book an appointment with our dietitian, Holly Murphy, MS, RD, IBCLC today to discuss your personalized path towards better health and well-being through medical nutrition therapy, including supervised medical weight-loss.

Reference:

  1. https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.14725


Hot flashes, sleeplessness, pain during sex: For some of menopause’s worst symptoms, there’s an established treatment. Why aren’t more women offered it?

For the past two or three years, many of my friends, women mostly in their early 50s, have found themselves in an unexpected state of suffering. The cause of their suffering was something they had in common, but that did not make it easier for them to figure out what to do about it, even though they knew it was coming: It was menopause.

The symptoms they experienced were varied and intrusive. Some lost hours of sleep every night, disruptions that chipped away at their mood, their energy, the vast resources of good will that it takes to parent and to partner. One friend endured weeklong stretches of menstrual bleeding so heavy that she had to miss work. Another friend was plagued by as many as 10 hot flashes a day; a third was so troubled by her flights of anger, their intensity new to her, that she sat her 12-year-old son down to explain that she was not feeling right — that there was this thing called menopause and that she was going through it. Another felt a pervasive dryness in her skin, her nails, her throat, even her eyes — as if she were slowly calcifying.

Then last year, I reached the same state of transition. Technically, it is known as perimenopause, the biologically chaotic phase leading up to a woman’s last period, when her reproductive cycle makes its final, faltering runs. The shift, which lasts, on average, four years, typically starts when women reach their late 40s, the point at which the egg-producing sacs of the ovaries start to plummet in number. In response, some hormones — among them estrogen and progesterone — spike and dip erratically, their usual signaling systems failing. During this time, a woman’s period may be much heavier or lighter than usual. As levels of estrogen, a crucial chemical messenger, trend downward, women are at higher risk for severe depressive symptoms. Bone loss accelerates. In women who have a genetic risk for Alzheimer’s disease, the first plaques are thought to form in the brain during this period. Women often gain weight quickly, or see it shift to their middles, as the body fights to hold onto the estrogen that abdominal fat cells produce. The body is in a temporary state of adjustment, even reinvention, like a machine that once ran on gas trying to adjust to solar power, challenged to find workarounds.

I knew I was in perimenopause because my period disappeared for months at a time, only to return with no explanation. In the weeks leading up to each period, I experienced abdominal discomfort so extreme that I went for an ultrasound to make sure I didn’t have some ever-growing cyst. At times, hot flashes woke me at night, forcing me straight into the kinds of anxious thoughts that take on ferocious life in the early hours of morning. Even more distressing was the hard turn my memory took for the worse: I was forever blanking on something I said as soon as I’d said it, chronically groping for words or names — a development apparent enough that people close to me commented on it. I was haunted by a conversation I had with a writer I admired, someone who quit relatively young. At a small party, I asked her why. “Menopause,” she told me without hesitation. “I couldn’t think of the words.”

‘It suggests that we have a high cultural tolerance for women’s suffering. It’s not regarded as important.’

My friends’ reports of their recent doctors’ visits suggested that there was no obvious recourse for these symptoms. When one friend mentioned that she was waking once nightly because of hot flashes, her gynecologist waved it off as hardly worth discussing. A colleague of mine seeking relief from hot flashes was prescribed bee-pollen extract, which she dutifully took with no result. Another friend who expressed concerns about a lower libido and vaginal dryness could tell that her gynecologist was uncomfortable talking about both. (“I thought, hey, aren’t you a vagina doctor?” she told me. “I use that thing for sex!”)

Their doctors’ responses prompted me to contemplate a thought experiment, one that is not exactly original but is nevertheless striking. Imagine that some significant portion of the male population started regularly waking in the middle of the night drenched in sweat, a problem that endured for several years. Imagine that those men stumbled to work, exhausted, their morale low, frequently tearing off their jackets or hoodies during meetings and excusing themselves to gulp for air by a window. Imagine that many of them suddenly found sex to be painful, that they were newly prone to urinary-tract infections, with their penises becoming dry and irritable, even showing signs of what their doctors called “atrophy.” Imagine that many of their doctors had received little to no training on how to manage these symptoms — and when the subject arose, sometimes reassured their patients that this process was natural, as if that should be consolation enough.

Now imagine that there was a treatment for all these symptoms that doctors often overlooked. The scenario seems unlikely, and yet it’s a depressingly accurate picture of menopausal care for women. There is a treatment, hardly obscure, known as menopausal hormone therapy, that eases hot flashes and sleep disruption and possibly depression and aching joints. It decreases the risk of diabetes and protects against osteoporosis. It also helps prevent and treat menopausal genitourinary syndrome, a collection of symptoms, including urinary-tract infections and pain during sex, that affects nearly half of postmenopausal women.

A posed photograph of a middle-aged woman, cropped tightly to show her ear and part of her face, with drops of sweat visible on her face.
Photo Credit…Marta Blue for The New York Times

Menopausal hormone therapy was once the most commonly prescribed treatment in the United States. In the late 1990s, some 15 million women a year were receiving a prescription for it. But in 2002, a single study, its design imperfect, found links between hormone therapy and elevated health risks for women of all ages. Panic set in; in one year, the number of prescriptions plummeted. Hormone therapy carries risks, to be sure, as do many medications that people take to relieve serious discomfort, but dozens of studies since 2002 have provided reassurance that for healthy women under 60 whose hot flashes are troubling them, the benefits of taking hormones outweigh the risks. The treatment’s reputation, however, has never fully recovered, and the consequences have been wide-reaching. It is painful to contemplate the sheer number of indignities unnecessarily endured over the past 20 years: the embarrassing flights to the bathroom, the loss of precious sleep, the promotions that seemed no longer in reach, the changing of all those drenched sheets in the early morning, the depression that fell like a dark curtain over so many women’s days.

About 85 percent of women experience menopausal symptoms. Rebecca Thurston, a professor of psychiatry at the University of Pittsburgh who studies menopause, believes that, in general, menopausal women have been underserved — an oversight that she considers one of the great blind spots of medicine. “It suggests that we have a high cultural tolerance for women’s suffering,” Thurston says. “It’s not regarded as important.”

Even hormone therapy, the single best option that is available to women, has a history that reflects the medical culture’s challenges in keeping up with science; it also represents a lost opportunity to improve women’s lives.

“Every woman has the right — indeed the duty — to counteract the chemical castration that befalls her during her middle years,” the gynecologist Robert Wilson wrote in 1966. The U.S. Food and Drug Administration approved the first hormone-therapy drug in 1942, but Wilson’s blockbuster book, “Feminine Forever,” can be considered a kind of historical landmark — the start of a vexed relationship for women and hormone therapy. The book was bold for its time, in that it recognized sexual pleasure as a priority for women. But it also displayed a frank contempt for aging women’s bodies and pitched hormones in the service of men’s desires: Women on hormones would be “more generous” sexually and “easier to live with.” They would even be less likely to cheat. Within a decade of the book’s publication, Premarin — a mix of estrogens derived from the urine of pregnant horses — was the fifth-most-prescribed drug in the United States. (Decades later, it was revealed that Wilson received funding from the pharmaceutical company that sold Premarin.)

Feminist perspectives on hormone therapy varied. Some perceived it as a way for women to control their own bodies; others saw it as an unnecessary medicalization of a natural process, a superfluous product designed to keep women sexually available and conventionally attractive. For many, the issue lay with its safety: Hormone therapy had already been aggressively marketed to women in the 1960s without sufficient research, and many women’s health advocates believed that history was repeating itself. The research supporting its health benefits came from observational studies, which meant that the subjects were not randomly assigned to the drug or a placebo. That made it difficult to know if healthier women were choosing hormones or if hormones were making women healthier. Women’s health advocates, with the support of the feminist congresswoman Patricia Schroeder, called on the National Institutes of Health to run long-term, randomized, controlled trials to determine, once and for all, whether hormones improved women’s cardiovascular health.

In 1991, Bernadine Healy, the first woman to serve as director of the N.I.H., started the Women’s Health Initiative, which remains the largest randomized clinical trial in history to involve only women, studying health outcomes for 160,000 postmenopausal women, some of them over the course of 15 years. Costs for just one aspect of its research, the hormone trial, would eventually run to $260 million. The hormone trial was expected to last about eight years, but in June 2002, word started spreading that one arm of the trial — in which women were given a combination of estrogen and progestin, a synthetic form of progesterone — had been stopped prematurely. Nanette Santoro, a reproductive endocrinologist who had high hopes for hormones’ benefit on heart health, told me she was so anxious to know why the study was halted that she could barely sleep. “I kept waking my husband up in the middle of the night to say, ‘What do you think?’” she recalled. Alas, her husband, an optometrist, could scarcely illuminate the situation.

‘When I started out, I had a slide that said estrogen should be in the water. We thought it was like fluoride.’

Santoro did not have to wait long. On July 9, the Women’s Health Initiative’s steering committee organized a major news conference in the ballroom of the National Press Club in Washington to announce both the halting of the study and its findings, a week before the results would be publicly available for doctors to read and interpret. Jaques Rossouw, an epidemiologist who was the acting director of the W.H.I., told the gathered press that the study had found both adverse effects and benefits of hormone therapy, but that “the adverse effects outweigh and outnumber the benefits.” The trial, Rossouw said, did not find that taking hormones protected women from heart disease, as many had hoped; on the contrary, it found that hormone therapy carried a small but statistically significant increased risk of cardiac events, strokes and clots — as well as an increased risk of breast cancer. He described the increased risk of breast cancer as “very small,” or more precisely: “less than a tenth of 1 percent per year” for an individual woman.

What happened next was an exercise in poor communication that would have profound repercussions for decades to come. Over the next several weeks, researchers and news anchors presented the data in a way that caused panic. On the “Today” show, Ann Curry interviewed Sylvia Wassertheil-Smoller, an epidemiologist who was one of the chief investigators for the W.H.I. “What made it ethically impossible to continue the study?” Curry asked her. Wassertheil-Smoller responded, “Well, in the interest of safety, we found there was an excess risk of breast cancer.” Curry rattled off some startling numbers: “And to be very specific here, you actually found that heart disease, the risk increased by 29 percent. The risks of strokes increased by 41 percent. It doubled the risk of blood clots. Invasive breast cancer risk increased by 26 percent.”

All of those statistics were accurate, but for a lay audience, they were difficult to interpret and inevitably sounded more alarming than was appropriate. The increase in the risk of breast cancer, for example, could also be presented this way: A woman’s risk of having breast cancer between the ages of 50 and 60 is around 2.33 percent. Increasing that risk by 26 percent would mean elevating it to 2.94 percent. (Smoking, by contrast, increases cancer risk by 2,600 percent.) Another way to think about it is that for every 10,000 women who take hormones, an additional eight will develop breast cancer. Avrum Bluming, a co-author of the 2018 book “Estrogen Matters,” emphasized the importance of putting that risk and others in context. “There is a reported risk of pulmonary embolism among postmenopausal women taking estrogen,” Bluming says. “But what is ‘risk’? The risk of embolism is similar to the risk of being on oral contraceptives or being pregnant.”

The study itself was designed with what would come to be seen as a major flaw. W.H.I. researchers wanted to be able to measure health outcomes — how many women ended up having strokes, heart attacks or cancer — but those ailments may not show up until women are in their 70s or 80s. The study was scheduled to run for only 8½ years. So they weighted the participants toward women who were already 60 or older. That choice meant that women in their 50s, who tended to be healthier and have more menopausal symptoms, were underrepresented in the study. At the news conference, Rossouw started out by saying that the findings had “broad applicability,” emphasizing that the trial found no difference in risk by age. It would be years before researchers appreciated just how wrong that was.

A posed photograph of a middle-aged woman, cropped tightly to show part of her head and face, with her eyes closed and her hands cradling her forehead.
Photo Credit…Marta Blue for The New York Time

The “Today” segment was just one of several media moments that triggered an onslaught of panicked phone calls from women to their doctors. Mary Jane Minkin, a practicing OB-GYN and a clinical professor at Yale School of Medicine, told me she was apoplectic with frustration; she couldn’t reassure her patients, if reassurance was even in order (she came to think it was), because the findings were not yet publicly available. “I remember where I was when John Kennedy was shot,” Minkin says. “I remember where I was on 9/11. And I remember where I was when the W.H.I. findings came out. I got more calls that day than I’ve ever gotten before or since in my life.” She believes she spoke to at least 50 patients on the day of the “Today” interview, but she also knows that countless other patients did not bother to call, simply quitting their hormone therapy overnight.

Within six months, insurance claims for hormone therapy had dropped by 30 percent, and by 2009, they were down by more than 70 percent. JoAnn Manson, chief of the division of preventive medicine at Brigham and Women’s Hospital and one of the chief investigators in the study, described the fallout as “the most dramatic sea change in clinical medicine that I have ever seen.” Newsweek characterized the response as “near panic.” The message that took hold then, and has persisted ever since, was a warped understanding of the research that became a cudgel of a warning: Hormone therapy is dangerous for women.

The full picture of hormone therapy is now known to be far more nuanced and reassuring. When patients tell Stephanie Faubion, the director of the Mayo Clinic Center for Women’s Health, that they’ve heard that hormones are dangerous, she has a fairly consistent response. “I sigh,” Faubion told me. She knows she has some serious clarifying to do.

Faubion, who is also the medical director of the North American Menopause Society (NAMS), an association of menopause specialists, says the first question patients usually ask her is about breast-cancer risk. She explains that in the W.H.I. trial, women who were given a combination of estrogen and progestin saw an increased risk emerge only after five years on hormones — and even after 20 years, the mortality rate of women who took those hormones was no higher than that of the control group. (Some researchers have hope that new formulations of hormone therapy will lessen the risk of breast cancer. One major observational study published last year suggested so, but that research is not conclusive.)

The biggest takeaway from the last two decades of research is that age matters: For women who go through early menopause, before age 45, hormone therapy is recommended because they’re at greater risk for osteoporosis if they don’t receive hormones up until the typical age of menopause. For healthy women in their 50s, life-threatening events like clots or stroke are rare, and so the increased risks from hormone therapy are also quite low. When Manson, along with Rossouw, did a reanalysis of the W.H.I. findings, she found that women under 60 in the trial had no elevated risk of heart disease.

‘I remember where I was when John Kennedy was shot. I remember where I was on 9/11. And I remember where I was when the W.H.I. findings came out.’

The findings, however, did reveal greater risks for women who start hormone therapy after age 60. Manson’s analyses found that women had a small elevated risk of coronary heart disease if they started taking hormones after age 60 and a significant elevated risk if they started after age 70. It was possible, researchers have hypothesized, that hormones may be most effective within a certain window, perpetuating the well-being of systems that are still healthy but accelerating damage in those already in decline. (No research has yet followed women who start in their 50s and stay on continuously into their 60s.)

Researchers also now have a better appreciation of the benefits of hormone therapy. Even at the time that the W.H.I. findings were released, the data showed at least one clear improvement resulting from hormone therapy: Women had 24 percent fewer fractures. Since then, other positive results have emerged. The incidence of diabetes, for instance, was found to be 20 percent lower in women who took hormones, compared with those who took a placebo. In the W.H.I. trial, women who had hysterectomies — 30 percent of American women by age 60 — were given estrogen alone because they did not need progesterone to protect them from endometrial cancer, and that group had lower rates of breast cancer than the placebo group. “Nonetheless,” Bluming and his co-author, Carol Tavris, write in “Estrogen Matters,” “we have yet to see an N.I.H. press conference convened to reassure women of the benefits of estrogen.” Anything short of that, they argue, allows misrepresentations and fears to persist.

Positive reports about hormone therapy for women in their 50s started emerging as early as 2003, and they have never really slowed. But the revelations have come in a trickle, with no one story gaining the kind of exposure or momentum of the W.H.I. news conference. In 2016, Manson tried to rectify the problem in an article for The New England Journal of Medicine, issuing a clear course correction of the W.H.I. findings as they pertained to women in their 40s and 50s. Since she published that paper, she feels, attitudes have changed, but too slowly. Manson frequently speaks to the press, and as the years passed — and more data accumulated that suggested the risks were not as alarming as they were first presented — you can almost track her increasing frustration in her public comments. “Women who would be appropriate candidates are being denied hormone therapy for the treatment of their symptoms,” she told me in a recent interview. She was dismayed that some doctors were not offering relief to women in their 50s on the basis of a study whose average subject age was 63 — and in which the risk assessments were largely driven by women in their 70s. “We’re talking about literally tens of thousands of clinicians who are reluctant to prescribe hormones.”

Even with new information, doctors still find themselves in a difficult position. If they rely on the W.H.I., they have the benefit of a gold-standard trial, but one that focused on mostly older women and relied on higher doses and different formulations of hormones from those most often prescribed today. New formulations more closely mimic the natural hormones in a woman’s body. There are also new methods of delivery: Taking hormones via transdermal patch, rather than a pill, allows the medication to bypass the liver, which seems to eliminate the risk of clots. But the studies supporting the safety of newer options are observational; they have not been studied in long-term, randomized, controlled trials.

The NAMS guidelines emphasize that doctors should make hormone-therapy recommendations based on the personal health history and risk factors of each patient. Many women under 60, or within 10 years of menopause, already have increased baseline risks for chronic disease, because they are already trying to manage their obesity, hypertension, diabetes or high cholesterol. Even so, Faubion says that “there are few women who have absolute contraindications,” meaning that for them, hormones would be off the table. At highest risk from hormone use are women who have already had a heart attack, breast cancer or a stroke or a blood clot, or women with a cluster of significant health problems. “For everyone else,” Faubion says, “the decision has to do with the severity of symptoms as well as personal preferences and level of risk tolerance.”

For high-risk women, other sources of relief exist: The selective serotonin reuptake inhibitor paroxetine is approved for the relief of hot flashes, although it is not as effective as hormone therapy. Cognitive-behavioral therapy has also been shown to help women with how much hot flashes bother them. Doctors who treat menopause are waiting for the F.D.A.’s review of a drug up for approval this month: a nonhormonal drug that would target the complex of neurons thought to be involved in triggering hot flashes.

Conversations about the risks and benefits of these various treatments often require more time than the usual 15-minute slot that health insurance will typically reimburse for a routine medical visit. “If I weren’t my own chair, I would be called to task for not doing stuff that would make more money, like delivering babies and I.V.F.,” says Santoro, now the department chair of obstetrics and gynecology at the University of Colorado School of Medicine, who frequently takes on complex cases of menopausal women. “Family medicine generally doesn’t want to deal with this, because who wants to have a 45-minute-long conversation with somebody about the risks and benefits of hormone therapy? Because it’s nuanced and complicated.” Some of those conversations entail explaining that hormones are not a cure-all. “When women come in and tell me they’re taking hormones for anti-aging or general prevention, or because they have some vague sense it’ll return them to their premenopausal self — and they’re not even having hot flashes — I say, ‘Hormone therapy is not a fountain of youth and shouldn’t be used for that purpose,’” Faubion says.

Too many doctors are not equipped to parse these intricate pros and cons, even if they wanted to. Medical schools, in response to the W.H.I., were quick to abandon menopausal education. “There was no treatment considered safe and effective, so they decided there was nothing to teach,” says Minkin, the Yale OB-GYN. About half of all practicing gynecologists are under 50, which means that they started their residencies after the publication of the W.H.I. trial and might never have received meaningful education about menopause. “When my younger partners see patients with menopausal symptoms, they refer them to me,” says Audrey Buxbaum, a 60-year-old gynecologist with a practice in New York. Buxbaum, like many doctors over 50, prescribed menopausal hormone therapy before the W.H.I. and never stopped.

A posed photograph of a middle-aged woman, cropped tightly to show her neck and part of her face, with her hands kneading the back of her neck.
Photo Credit…Marta Blue for The New York Times
Education on a stage of life that affects half the world’s population is still wildly overlooked at medical schools. A 2017 survey sent to residents across the country found that 20 percent of them had not heard a single lecture on the subject of menopause, and a third of the respondents said they would not prescribe hormone therapy to a symptomatic woman, even if she had no clear medical conditions that would elevate the risk of doing so. “I was quizzing my daughter a few years ago when she was studying for the board exams, and whoever writes the board questions, the answer is never, ‘Give them hormones,’” Santoro says. In recent years, there has been some progress: The University of Pennsylvania has established a menopause clinic, and Johns Hopkins now offers a two-year curriculum on the subject to its medical students. But the field of gynecology will, most likely for decades to come, be populated by many doctors who left medical school unprepared to offer guidance to menopausal women who need their help.

I didn’t know all of this when I went to see my gynecologist. I knew only what my friends had told me, and that hormone therapy was an option. The meeting was only my second with this gynecologist, a woman who struck me as chic, professional and in a bit of a hurry, which was to be expected, as she is part of a large health care group — the kind that makes you think you’d rather die from whatever’s ailing you than try to navigate its phone tree one more time. Something about the quick pace of the meeting — the not-so-frequent eye contact — made me hesitate before bringing up my concerns: They felt whiny, even inappropriate. But I forged on. I was having hot flashes, I told her — not constantly, but enough that it was bothering me. I had other concerns, but since memory issues were troubling me the most, I brought that up next. “But that could also just be normal aging,” she said. She paused and fixed a doubtful gaze in my direction. “We only prescribe hormones for significant symptoms,” she told me. I felt rebuffed, startled by how quickly the conversation seemed to have ended, and I was second-guessing myself. Were my symptoms, after all, “significant”? By whose definition?

The NAMS guidelines suggest that the benefits of hormone therapy outweigh the risks for women under 60 who have “bothersome” hot flashes and no contraindications. When I left my doctor’s office (without a prescription), I spent a lot of time thinking about whether my symptoms were troubling me enough to take on any additional risk, no matter how small. On the one hand, I was at a healthy weight and active, at relatively low risk for cardiovascular disease; on the other hand, because of family history and other factors, I was at higher risk for breast cancer than many of my same-age peers. I felt caught between the promises and, yes, risks of hormone therapy, the remaining gaps in our knowledge and my own aversion, common if illogical, to embarking on a new and indefinitely lasting medical regimen.

‘Menopause has the worst P.R. campaign in the history of the universe, because it’s not just hot flashes and night sweats.’

Menopause could represent a time when women feel maximum control of our bodies, free at last from the risk of being forced to carry an unwanted pregnancy. And yet for many women, menopause becomes a new struggle to control our bodies, not because of legislation or religion but because of a lack of knowledge on our part, and also on the part of our doctors. Menopause presents not just a new stage of life but also a state of confusion. At a time when we have the right to feel seasoned, women are thrust into the role of newbie, or worse, medical detective, in charge of solving our own problems.

Even the most resourceful women I know, the kind of people you call when you desperately need something done fast and well, described themselves as “baffled” by this stage of their lives. A recent national poll found that 35 percent of menopausal women reported that they had experienced four or more symptoms, but only 44 percent said they had discussed their symptoms with a doctor. Women often feel awkward initiating those conversations, and they may not even identify their symptoms as menopausal. “Menopause has the worst P.R. campaign in the history of the universe, because it’s not just hot flashes and night sweats,” says Rachel Rubin, a sexual-health expert and assistant clinical professor in urology at Georgetown University. “How many times do I get a 56-year-old woman who comes to me, who says, Oh, yeah, I don’t have hot flashes and night sweats, but I have depression and osteoporosis and low libido and pain with sex? These can all be menopausal symptoms.” In an ideal world, Rubin says, more gynecologists, internists and urologists would run through a list of hormonal symptoms with their middle-aged patients rather than waiting to see if those women have the knowledge and wherewithal to bring them up on their own.

The W.H.I. trial measured the most severe, life-threatening outcomes: breast cancer, heart disease, stroke and clots, among others. But for a woman who is steadily losing hair, who has joint pain, who suddenly realizes her very smell has changed (and not for the better) or who is depressed or exhausted — for many of those women, the net benefits of taking hormones, of experiencing an improved quality of life day to day, may be worth facing down whatever incremental risks hormone therapy entails, even after age 60. Even for women like me, whose symptoms are not as drastic but whose risks are low, hormones can make sense. “I’m not saying every woman needs hormones,” Rubin says, “but I’m a big believer in your body, your choice.”

Conversations about menopause lack, among so many other things, the language to help us make these choices. Some women sail blissfully into motherhood, but there is a term for the extreme anxiety and depression that other women endure following delivery: postpartum depression. Some women menstruate every month without major upheaval; others experience mood changes that disrupt their daily functioning, suffering what we call premenstrual syndrome (PMS), or in more serious cases, premenstrual dysphoric disorder. A significant portion of women suffer no symptoms whatsoever as they sail into menopause. Others suffer near-systemic breakdowns, with brain fog, recurring hot flashes and exhaustion. Others feel different enough to know they don’t like what they feel, but they are hardly incapacitated. Menopause — that baggy term — is too big, too overdetermined, generating a confusion that makes it especially hard to talk about.

No symptom is more closely associated with menopause than the hot flash, a phenomenon that’s often reduced to a comedic trope — the middle-aged woman furiously waving a fan at her face and throwing ice cubes down her shirt. Seventy to 80 percent of women have hot flashes, yet they are nearly as mysterious to researchers as they are to the women experiencing them — a reflection of just how much we still have to learn about the biology of menopause. Scientists are now trying to figure out whether hot flashes are merely a symptom or whether they trigger other changes in the body.

Strangely, the searing heat a woman feels roaring within is not reflected in any significant rise in her core body temperature. Hot flashes originate in the hypothalamus, an area of the brain rich in estrogen receptors that is both crucial in the reproductive cycle and also functions as a thermostat. Deprived of estrogen, its thermostat now wonky, the hypothalamus is more likely to misread small increases in core body temperature as too hot, triggering a rush of sweat and widespread dilation of the blood vessels in an attempt to cool the body. This also drives up the temperature on the skin. Some women experience these misfirings once a day, others 10 or more, with each one lasting anywhere from seconds to five minutes. On average, women experience them for seven to 10 years.

What hot flashes might mean for a woman’s health is one of the main questions that Rebecca Thurston, the director of the Women’s Biobehavioral Health Laboratory at the University of Pittsburgh, has been trying to answer. Thurston helped lead a study that followed a diverse cohort of 3,000 women over 22 years and found that about 25 percent of them were what she called superflashers: Their hot flashes started long before their periods became irregular, and the women continued to experience them for as many as 14 years, upending the idea that, for most women, hot flashes are an irritating but short-lived inconvenience. Of the five racial and ethnic groups Thurston studied, Black women were found to experience the most hot flashes, to experience them as the most bothersome and to endure them the longest. In addition to race, low socioeconomic status was associated with the duration of women’s hot flashes, suggesting that the conditions of life, even years later, can affect a body’s management of menopause. Women who experienced childhood abuse were 70 percent more likely to report night sweats and hot flashes.

Might those symptoms also signal harm beyond the impact on a woman’s quality of life? In 2016, Thurston published a study in the journal Stroke showing that women who had more hot flashes — at least four a day — tended to have more signs of cardiovascular disease. The link was even stronger than the association between cardiovascular risk and obesity, or cardiovascular risk and high blood pressure. “We don’t know if it’s causal,” Thurston cautions, “or in which direction. We need more research.” There might even be some women for whom the hot flashes do accelerate physical harm and others not, Thurston told me. At a minimum, she says, reports of severe and frequent hot flashes should cue doctors to look more closely at a woman’s cardiac health.

As Thurston was trying to determine the effects of hot flashes on vascular health, Pauline Maki, a professor of psychiatry at the University of Illinois at Chicago, was establishing associations between hot flashes and mild cognitive changes during menopause. Maki had already found a clear correlation between the number of a woman’s hot flashes and her memory performance. Maki and Thurston wondered if they would be able to detect some physical representation of that association in the brain. They embarked on research, published last October, that found a strong correlation between the number of hot flashes a woman has during sleep and signs of damage to the tiny vessels of the brain. At a lab in Pittsburgh, which has one the most powerful M.R.I. machines in the world, Thurston showed me an image of a brain with tiny lesions represented as white dots, ghostlike absences on the scan. Both their number and placement, she said, were different in women with high numbers of hot flashes. But whether the hot flashes were causing the damage or the changes in the cerebral vessels were causing the hot flashes, she could not say.

About 20 percent of women experience cognitive decline during perimenopause and in the first years after menopause, mostly in the realm of verbal learning, the acquisition and synthesis of new information. But the mechanisms of that decline are varied. As estrogen levels drop, the region of the brain associated with verbal learning is thought to recruit others to support its functioning. It’s possible that this period of transition, when the brain is forming new pathways, accounts for the cognitive dip that some women experience. For most of them, it’s short-lived, a temporary neurological confusion. A woman’s gray matter — the cells that process information — also seems to shrink in volume before stabilizing in most women, according to Lisa Mosconi, an associate professor of neurology at Weill Cornell Medicine and director of its Women’s Brain Initiative. She compares the process the brain undergoes during those years of transition to a kind of “remodeling.” But the tiny brain lesions that Thurston and Maki detected don’t resolve — they remain, contributing incrementally, over many years, to an increased risk of cognitive decline and dementia.

In the past 15 years, four randomized, controlled trials found that taking estrogen had no effect on cognitive performance. But those four studies, Maki points out, did not look specifically at women with moderate to severe hot flashes. She believes that might be the key factor: Treat the hot flashes with estrogen, Maki theorizes, and researchers might see an improvement in cognitive health. In one small trial Maki conducted of about 36 women, all of whom had moderate to severe hot flashes, half of the group received a kind of anesthesia procedure that reduced their hot flashes, and the other half received a placebo treatment. She measured the cognitive function of both groups before the treatment and then three months after and found that as hot flashes improved, memory improved. The trial was small but “hypothesis generating,” she says.

Even adjusting for greater longevity in women, Alzheimer’s disease is more frequent in women than men, one of many brain-health discrepancies that have led researchers to wonder about the role that estrogen — and possibly hormone therapy — might play in the pathways of cognitive decline. But the research on hormone therapy and Alzheimer’s disease has proved inconclusive so far.

Whatever research exists on hormones and the brain focuses on postmenopausal women, which means it’s impossible to know, for now, whether perimenopausal women could conceivably benefit from taking estrogen and progesterone during the temporary dip in their cognitive function. “There hasn’t been a single randomized trial of hormone therapy for women in perimenopause,” Maki says. “Egregious, right?”

What’s also unclear, Thurston says, is how the various phenomena of cognitive change during menopause — the temporary setbacks that resolve, the progress toward Alzheimer’s in women with high genetic risk and the onset of those markers of small-vessel brain disease — interact or reflect on one another. “We haven’t followed women long enough to know,” says Thurston, who believes that menopause care begins and ends with one crucial dictum: “We need more research.”

A posed photograph of a middle-aged woman, cropped tightly to show her neck and part of her torso, with her hands in sharp focus in front of her chest and her fingers winding together.
Photo Credit…Marta Blue for The New York Times

In the information void, a vast menopausal-wellness industry has developed, flush with products that Faubion dismisses as mostly “lotions and potions.” But a new crop of companies has also come to market to provide F.D.A.-approved treatments, including hormone therapy. Midi Health offers virtual face-to-face access to menopause-trained doctors and nurse practitioners who can prescribe hormones that some insurances will cover; other sites, like Evernow and Alloy, sell prescriptions directly to the patient. (Maki serves on the medical advisory boards of both Midi and Alloy.)

Alloy holds online support groups where women, clearly of varying socioeconomic backgrounds, often vent — about how hard it was for them to find relief, how much they are still suffering or how traumatized they still are by the lack of compassion and concern they encountered when seeking help for distressing symptoms. On one call in July, a middle-aged woman described severe vaginal dryness. “When I was walking or trying just to exercise, I would be in such agony,” she said. “It’s painful just to move.” She was trying to buy vaginal estradiol cream, an extremely low-risk treatment for genitourinary syndrome; she said there was a shortage of it in her small town. Until she stumbled on Alloy, she’d been relying on antibacterial creams to soothe the pain she felt.

The space was clearly a no-judgment zone, a place where women could talk about how they personally felt about the risks and benefits of taking hormones. At one meeting, a woman said that she’d been on hormone therapy, which she said “changed my life” during perimenopause, but that she and her sisters both had worrying mammograms at the same time. Her sister was diagnosed with breast cancer and had her lymph nodes removed; the woman on the call was diagnosed with atypical hyperplasia, which is not cancer but is considered a precursor that puts a woman at high risk. The NAMS guidelines do not indicate that hormone therapy is contraindicated for a woman at high risk of breast cancer, leaving it up to the woman and her practitioner to decide. “My new OB-GYN and my cancer doc won’t put me on hormones,” the woman said. She bought them from Alloy instead. “So I’m kind of under the radar.”

No one at the meeting questioned the woman’s decision to go against the advice of two doctors. I mentioned the case to Faubion. “It sounds to me like she felt she wasn’t being heard by her doctors and had to go somewhere else,” she said. Faubion told me that in certain circumstances, higher-risk women who are fully informed of the risks but suffer terrible symptoms might reasonably make the decision to opt for hormones. But, she said, those decisions require nuanced, thoughtful conversations with health care professionals, and she wondered whether Alloy and other online providers were set up to allow for them. Anne Fulenwider, one of Alloy’s founders, said the patient in the support group had not disclosed her full medical history when seeking a prescription. After that came to light, an Alloy doctor reached out to her to have a more informed follow-up conversation about the risks and benefits of hormone therapy.

As I weighed my own options, I sometimes asked the doctors I interviewed outright for their advice. For women in perimenopause, who are still at risk of pregnancy, I learned, a low-dose birth control can “even things out,” suppressing key parts of the reproductive system and supplying a steadier dose of hormones. Another alternative is an intrauterine device (IUD) to provide birth control, along with a low-dose estrogen patch, which is less potent than even a low-dose birth-control pill and is therefore thought to be safer. “Too much equipment,” I told Rachel Rubin, the sexual-health expert, when she suggested it. “This is why I don’t ski.” I found myself thinking often about an insight that Santoro says she offers her patients (especially those under 60 and in good health): If you’re having any symptoms, how can you weigh the risks and benefits if you haven’t experienced the extent of the benefits?

In November, I started on a low-dose birth-control pill. I am convinced — and those close to me are convinced — that my brain is more glitch-free. I have no hot flashes. Most surprising to me (and perhaps the main reason for that improvement in cognition): My sleep improved. I had not even mentioned my poor quality of sleep to my gynecologist, given the length of our discussion, but I had also assumed that it was a result of stress, age and a sweet but snoring husband. Only once I took the hormones did I appreciate that my regular 2 a.m. wakings, too, were most likely a symptom of perimenopause. The pill was an easy-enough experiment, but it carried a potentially higher risk of clots than the IUD and patch; now convinced that the effort of an IUD is worth it, I resolved to make that switch as soon as I could get an appointment.

How many women are doing some version of what I did, unsure of or explaining away menopausal symptoms, apologizing for complaining about discomforts they’re not sure are “significant,” quietly allowing the conversation to move on when they meet with their gynecologists or internists or family-care doctors? And yet … my more smoothly functioning brain goes round and round, wondering, worrying, waiting for more high-quality research. Maybe in the next decade, when my personal risks start escalating, we’ll know more; all I can hope is that it confirms the current trend toward research that reassures. The science is continuing. We wait for progress, and hope it is as inevitable as aging itself.

Read the article on NewYorkTimes.com



Ask your provider at your next visit to learn more about this and get testing, which is covered by most insurance plans; or Schedule a Virtual Consultation with our Gynecologist, Dr. Faust-Rakos HERE!

WEDNESDAY, June 1, 2022 (HealthDay News) — Not every woman is ready to become a mom in her late teens, 20s or even by her mid-30s, but a natural decline in fertility can make it more difficult to have a baby at age 40 and beyond.



HPV stands for human papillomavirus. HPV is a group of more than 200 related viruses. About 40 kinds can infect your genital area — your vulva, vagina, cervix, rectum or anus — as well as your mouth and throat. These kinds of HPV are spread during sexual contact. (Other types of HPV cause common warts like hand warts and plantar warts on the feet — but these aren’t sexually transmitted.)

Genital HPV infections are very, very common. In fact, most people who have sex get the HPV at some point in their lives. Most people with HPV have no symptoms and feel totally fine, so they usually don’t even know they’re infected.

Sexually transmitted HPV types fall into two groups, low risk and high risk. Low-risk HPVs mostly cause no disease. However, a few low-risk HPV types can cause warts on or around the genitals, anus, mouth, or throat. High-risk HPVs can cause several types of cancer. There are about 14 high-risk HPV types. Two of these, HPV16 and HPV18, are responsible for most HPV-related cancers.

You can get HPV by having vaginal, anal, or oral sex with someone who has the virus. It is most commonly spread during vaginal or anal sex. It also spreads through close skin-to-skin touching during sex. A person with HPV can pass the infection to someone even when they have no signs or symptoms.
If you are sexually active, you can get HPV, even if you have had sex with only one person. You also can develop symptoms years after having sex with someone who has the infection. This makes it hard to know when you first got it.

Testing for HPV occurs as part of cervical cancer screening. If you test positive, you may need further tests and/or treatment to monitor you more closely and treat abnormal cells. This could include:
Colposcopy — a procedure to look more closely at the cervix to see if there are precancerous cells
LEEP or Loop Electrosurgical Excision Procedure — a treatment to remove precancerous cells from the cervix with an electrical current.

If you haven’t been vaccinated, you should consider the HPV vaccine which goes by the name Gardasil 9. It can protect against strains of the virus that you have not come in contact with. Recent studies also suggest that vaccination helps prevent against reinfection.

The HPV vaccine is given in a series of shots. For people ages 15-45, the HPV vaccine is 3 separate shots. The second shot is given 2 months after the first, and the third shot is given 4 months after the second shot. So, in all, it takes about 6 months to get all 3 shots. Please reach out with questions.



Schedule* an Initial Fertility Consult (covered by your insurance) with our Gynecologist Dr. Faust-Rakos HERE!

*Dr. Faust-Rakos will further talk to you about this and order any necessary tests, and then you will be scheduled in our office with Dr. Wheeler.


 

Understanding Ovulation and Fertility

Welcome to “Ovulation and Fertility 101,” where we will review ovulation and fertility, from the different phases in your monthly cycle to your fertile window, to predicting ovulation, to your lifestyle’s impact on your chances of becoming pregnant and more.  

First thing’s first: the math behind your cycle. 

Your monthly cycle begins on the first day of your period and ends when the next period begins, generally lasting between 24 and 28 days, but shorter or longer than that can also be normal. For some women, the length from cycle to cycle varies and may change as they get older, which is usually nothing to worry about. Most girls start having their period when they’re between 12-13 (the onset of the period is called the menarche). Women typically stop having their periods at an average age of 51, which is menopause. The menopausal transition typically takes a few years and is different for everyone.

Understanding Your Monthly Cycle & Ovulation

As you already know, your monthly cycle is about more than just menstruation. It’s many different processes that work together, involving your brain, ovaries and uterus communicating through hormones to essentially prepare your body for pregnancy. Read on for a step-by-step breakdown of what happens during your cycle: 

    1. Menstruation (Uterine Cycle): Everything starts with your period, which is essentially your body shedding off blood and tissue from inside your uterus (‘the lining’) through your vagina. An average period lasts between 4-6 days. This shedding happens because pregnancy did not occur, and the blood and tissue are not necessary to support a growing embryo, fetus and baby – until the next cycle when this happens all over again.
    2. Follicular phase (First Half of the Cycle): While your uterus is busy getting rid of last month’s tissue, your ovaries are beginning to prepare for this month’s ovulation. The pituitary gland, a hormone-producing area inside your brain, kicks this process off by releasing follicle-stimulating hormone (FSH). This hormone tells your ovaries that it’s time to prepare an egg for ovulation (release one egg from either one of your two ovaries). Both ovaries are filled with sacs (‘follicles’) containing one egg each, which are now all beginning to mature in a race to see which one will become the dominant follicle. A few days after your period ends, the largest follicle (the “dominant” follicle) will prepare to rupture so it can release the egg at ovulation. This follicle is now producing an increasing amount of estrogen, with peak levels right before ovulation. On average, this phase lasts 10-22 days.
    3. Proliferative Phase (Uterine Cycle): Another name for the follicular phase, this time describing what is happening in the uterus. In the days between the end of your period until ovulation, your uterus is rebuilding the thick inner lining that it shed while you were menstruating. This process occurs because of the rising levels of estrogen produced by the dominant follicle, and is meant to prepare your uterus for “housing” an embryo.
    4. Ovulation: About midway through your cycle – again, variations are normal – an egg is released from one ovary into the fallopian tube. This happens thanks to high estrogen levels that instruct the brain to release luteinizing hormone (LH), which is what triggers ovulation and the hormone measured in Ovulation Predictor Kits (OPKs). This hormone spikes 12-48 hours before ovulation. At this point, you’re about 13-15 days away from your next period.
    5. Luteal Phase (Second Half of the Cycle): 
      • After the egg has burst through the follicle and been released to travel into the fallopian tube, the dominant follicle that previously contained the egg transforms into a cyst (corpus luteum), which produces progesterone and estrogen. 
      • If the egg is fertilized, the progesterone also supports your pregnancy. If not, the cyst will break down, causing progesterone and estrogen levels to drop, inducing menstruation.
      • Most women have a 12-14 day luteal phase.
    6. Secretory Phase (Uterine Cycle): Another name for the luteal phase, this time describing what is happening in the uterus. The lining of your uterus produces certain chemicals that will either support a pregnancy or help break down the tissue in preparation for your period (the phase gets its name from secreting chemicals).

Why Do I Have A 21-Day Menstrual Cycle? What Impacts the Length of My Cycle?

The length of the menstrual varies from woman to woman, with the average woman getting her period every 28 days. However, 21-40 day cycles can still be considered normal and healthy and can lead to successful pregnancies. 

Some factors that may impact the length of your cycle are your age, genes, overall health, body mass index (BMI), your lifestyle, the use of birth control methods and stress. Given that most of your cycle is determined by your hormones, anything that can throw them off balance has the potential to impact the length of your cycle. This includes your diet, exercise, stress, jet lag, excessive alcohol consumption, the morning-after pill and other factors. Health conditions, such as Polycystic Ovary Syndrome (PCOS), can also impact your cycle. Speak to your OB/GYN if you’re worried about your cycle or have noticed significant changes recently.

When Am I Most Fertile During My Cycle?

You’re most fertile in the three days leading up to and including ovulation. For many women, this ‘fertile window’ is typically 13-15 days away from the start of their next period. However, these numbers are unique to each woman, so it’s important to learn the length of your cycle and the time you normally ovulate before relying on averages that may not be helpful in your conception journey. 

It’s unlikely to get pregnant right after your period, but sperm can sometimes survive in the body for up to seven days, so it is not impossible (sperm usually survive about five days)!  

How Long After Ovulating Am I Fertile? What is the “Fertile Window”? 

As mentioned earlier, a woman’s ovulation occurs about midway through her cycle, and an ovulated egg lives for 12-24 hours. Sperm have strong survival skills, allowing them to survive in the female body for about five days. This means you can get pregnant anywhere from five days before ovulation to a day after ovulation. This period is considered your fertile window. After this time, you can no longer get pregnant, as the egg is no longer alive and ready for fertilization. 

How Do I Measure and Track My Ovulation? 

There are a few ways you can track and predict ovulation – and increase your chances of becoming pregnant. If you came here to read about Ovulation Predictor Kits, skip to the next question!

One option is Ovulation Calculators/Calendars/Charts/Apps, which generally work best for women with very regular periods as they are based on the typical length of your menstrual cycle. You start by entering the date of the first day of your last period and the length of your regular cycle. It will then use an average number of days for the different phases of your monthly cycle that we outlined above (unless you provide more specific estimates). Based on this information, it will then predict ovulation and your fertile window. 

Another way to track approaching ovulation is by monitoring the consistency of your cervical mucus. This requires you to look at and touch your vaginal discharge daily, just in case you don’t do this already. When your body is about to ovulate, and while it is ovulating, the mucus will transform into an egg-white-like consistency (called “Egg White Cervical Mucus” or EWCM) which is designed to help sperm travel from the vagina to the uterus. 

Last but not least, you can monitor your Basal Body Temperature (BBT) to predict ovulation. Your BBT is your body’s temperature when you first wake up in the morning, or when you’re fully “at rest.” As you’re nearing ovulation, your BBT will increase, which you can track with special thermometers. You’re most fertile in the three days leading up to and including ovulation, so tracking your temperature will allow you to determine the best moment to have sex. Your body temperature varies throughout the day and is based on your activity level – if you want reliable measurements, you have to be consistent and take your temperature first thing every morning, which means this method isn’t for everyone. BBT can also vary based on your health level (if you’re sick, it will be off), the amount of sleep you get, the time you wake up and even the number of times in the night you get up to pee!

Other indicators for nearing ovulation are more difficult to track, including increased sexual desire, breast tenderness, and a change in the way your cervix is positioned (no, you don’t need an OB/GYN to monitor this). Still, women usually stick to OPKs, charting, EWCM and BBT.

Do Ovulation Predictor Kits Work? What Are Some Popular Ovulation Predictor Kits?

Yes, they work, and yes, you should get some! Ovulation Predictor Kits (OPKs) are a popular and easy way to monitor impending ovulation. They work by detecting luteinizing hormone (LH) in your urine, which is the hormone that tells your ovary to release an egg into the fallopian tube (i.e., to ovulate). OPKs detect the surge of LH in your body as you’re about to ovulate, which means you should be having sex for the next two-three days once you get a positive test result. 

There are many kits on the market, and some also detect estrogen and progesterone in addition to LH, which may give you an earlier warning that ovulation is coming. The Clearblue Digital Ovulation Predict Kit is a popular option as it’s easy to read (a smiley face will tell you to have sex), and it is OB/GYN-recommended. Wondfo LH Ovulation Strips and Pre-mom Ovulation strips are also solid choices and very affordable compared to Clearblue. Ultimately, your choice comes down to convenience (easy-to-read), the hormones you want to track (LH, or LH + estrogen + progesterone) and cost.

*If you have Polycystic Ovary Syndrome (PCOS), you can have a high LH level throughout the cycle, which means these tests won’t work as well to predict when you’re about to ovulate, if it all, since PCOS can prevent ovulation entirely.

Does Weight Affect My Ovulation Cycle and Fertility? What About My Age?

Yes, research strongly suggests that excess weight, particularly abdominal fat, can cause hormonal imbalances, increasing the risk of irregular menstrual cycles and reducing fertility. A healthy diet and exercise that leads to weight loss and hormonal regulation can significantly improve the regularity of your menstrual cycle.

Age is one of the most significant factors affecting a woman’s chances of becoming pregnant. A woman is born with all the eggs she will ever have in her life and these eggs age with her, impacting quantity and quality as she gets older. A woman’s fertility will start a significant, yet slow, reduction in her early 30s, with a drop at 35 and an even bigger one at 37, decreasing annually. Once a woman is in her early 40s, her chances of conceiving either naturally or with In Vitro Fertilization (IVF) is low, although multiple family building options still exist for women in their 40s. 

Is Ovulation the Only Predictor of Fertility?

You cannot get pregnant naturally unless you ovulate. Still, even if you do ovulate, you may not get pregnant – this is why ovulation is only one of several fertility indicators. Others include the thickness of your uterine lining, the openness of your fallopian tubes, the health of your partner’s sperm and the quality of your eggs, to name a few.

Can I Ovulate Twice a Month?

Some very limited research suggests that women can ovulate more than once a month. However, this still needs to be confirmed by additional independent studies. You can certainly ovulate more than one egg at the same time (hello, fraternal twins), but this is still counted as one episode of ovulation.

Now that you have a better understanding of ovulation and fertility, you can start tracking your cycle and trying to conceive. 

Just remember that every woman is different, cycles vary based on what’s happening in your life at the moment, and that pregnancy can take several months even when everything is working perfectly – when sex happens during ovulation in a healthy young couple, the chance of pregnancy each month is just 25 percent. If you’re under 35, you can try to conceive for up to a year before seeking help, whereas you should see a fertility doctor after six months of trying if you’re 35 or older.

Happy baby-making!

Schedule* an Initial Fertility Consult (covered by your insurance) with our Gynecologist Dr. Faust-Rakos HERE!

*Dr. Faust-Rakos will further talk to you about this and order any necessary tests, and then you will be scheduled in our office with Dr. Wheeler.



Can you tell the difference between flu vs. strep vs. COVID-19? Cold and flu season is in full swing, and COVID-19 cases are rising once again. Knowing what symptoms to look for when you first start feeling sick can help. Read on to learn the key factors to consider when determining which illness you have and what to do.

Strep vs. COVID-19 and Other Illnesses

Strep

Strep throat is a bacterial infection that can cause severe throat pain, swollen lymph nodes, fever and white patches on the tonsils. Strep will not typically include other cold and flu like symptoms, like a runny nose or cough. Strep throat can be specifically tested for and is easily treated with antibiotics. Antibiotics will help prevent a serious but rare problem called rheumatic fever and reduce the time you are contagious. About 10% of sore throats in adults are caused by strep.

COVID-19

COVID-19 is a viral illness caused by the novel coronavirus that produces many symptoms including Sore throat, runny nose, nasal congestion, persistent cough, and headache. If you are experiencing these symptoms – you can start with a home test. If this is negative, repeat the test 24 to 48 hours later. If your test is positive and you have risk factors for severe COVID, please contact us right away to schedule an appointment to discuss Paxlovid. Paxlovid must be started within 5 days of symptom onset.

Flu

The flu is another viral illness that is similar to the common cold but much more severe symptoms. Sometimes it can be hard to tell the difference because the flu affects your nose, throat, and lungs and has many of the same symptoms as a cold. The flu is commonly diagnosed with a rapid antigen or diagnostic test. Antivirals are available but they must be given within 2 days of symptom onset and only shorten symptoms by about 12-24 hours.

Sinus Infection

Many of the symptoms of a sinus infection are the same you’d experience with a bad cold. They include: postnasal drip (that thick mucus in the back of your throat), discolored nasal discharge (green, yellow or brownish mucous coming out of your nose), stuffy nose or nasal congestion and tenderness or pain in the face – usually under the eyes or around the nose. You can also have headaches, tooth pain, coughing from the post nasal drip, fever, fatigue, a bad smell in your nose or a bad taste in your mouth and bad breath. Most sinus infections are viral, however if your symptoms are lasting more than a week, please make an appointment as antibiotics may be necessary.

Pneumonia

Pneumonia is a secondary infection in the lungs that can cause high fever, chest pain, difficulty breathing, shortness of breath and cough. It’s usually caused by bacteria, fungi, or viruses like COVID-19. Pneumonia is usually diagnosed with a chest X-ray to look for inflammation in the lungs and is commonly treated with antibiotics.

How Can I Avoid Getting Sick?

You can help prevent illnesses by:

  • Wearing a mask in public.
  • Stay up to date with vaccinations
  • Practicing good hygiene, using hand sanitizer with 60 percent alcohol, and disinfecting surfaces.
  • Ensuring you’re taking good care of yourself and addressing any underlying conditions.
  • Not touching your face, eyes, or mouth.
  • Steering clear of anyone who is sick, whether it’s strep vs. COVID-19.


Whether you are just beginning to consider expanding your family, want to plan for the future through egg freezing, or have struggled with fertility issues for some time, it can be empowering to understand the impact that diet and healthy-weight can have on fertility outcomes.

Dietary patterns focused on plant-based and anti-inflammatory foods are associated with improved fertility [1]. For example, try filling at least half of your plate with fruits and vegetables, choose healthy monounsaturated fats instead of saturated and trans fats, and make at least half your grains whole. 

Along with healthy eating, it is important to achieve and maintain a healthy weight. For women who are considered overweight or obese based on a BMI greater than or equal to 25, weight-loss may improve fertility. In addition to a balanced diet, moderate-intensity physical activity for at least 150 minutes per week can aid in meeting this goal.

For more information on foods for fertility and creating a personalized eating plan, schedule a visit with our Registered Dietitian and lactation consultant, Holly Murphy, MS, RD, LDN, IBCLC.

[1] Panth, N. et al. The Influence of Diet on Fertility and the Implications for Public Health Nutrition in the United States. Front Public Health. 2018. doi: 10.3389/fpubh.2018.00211


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1632 Pine Street
Philadelphia, PA 19103
Phone: 215-735-7992
Fax: 215-735-7991
Email: info@rwwc.com

Hours

Mon & Wed:  8am – 8pm

Tues, Thurs, Fri: 8am – 4pm

Sat: 9am – 2pm

Sun: Closed

Don’t forget to contact us first when seeking medical care!

 

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