Breast pain

Breast pain is a common and concerning symptom in women.  Breast pain can either be cyclical and associated with hormonal changes or noncyclical and constant.  Cylical breast pain associated with hormonal changes tends to be bilaterally (both breasts) and tends to feel heavy, achy, and full.  Noncyclical breast pain tends to be one sided and can be more sharp or stinging.  Causes of noncyclical, one sided breast pain can be a cyst, infection, trauma, pain in the underlying ribs, or nerve disease.  In women being evaluated for breast pain, cancer is the cause in only 1-6% of the patients. 
If a women has breast pain that is cyclical or noncylical, clinical evaluation by her physician is recommended.  The physician will determine if the pain is associated with hormonal changes.  The physician will determine if the pain is one sided or not, is associated with a specific mass, and if there is any associated causes of the pain.  After determing the answers to these question, the physician will perform a careful exam to evaluate for any nodule or cyst in the breast that could be the cause of breast pain. 
If a woman has a normal breast exam and pain that is cyclical in nature, a physician can reassure the patient that the pain is most likely hormonal in nature.  However, if the pain persists for longer than 3-6 months or if the patient notices any masses, it is important to follow up with one's physician for an additional examination.
If a woman has noncyclical breast pain, an examination by one's physician and an imaging study is recommended.  If a woman is under the age of 35, an ultrasound may be the best choice because the density of women's breasts under the age of  35 which make mammograms less useful.  If she is over 35, a mammogram would be recommend.  If there are any abnormalities found on the imaging studies, biopsy is recommend either by a breast surgeon or radiologist. 
If the imaging studies or breast biopsies turn out normal, treatment for breast pain include wearing a well supported and fitted bra, and pain reliever medication such as ibuprofen or acetominophen.  Some studies suggest that caffeine avoidance and use of vitamin E or evening primrose oil is helpful.  Other studies suggest these things do not help.
It is important to discuss any breast pain or concerns with your physician.
Please look at the following link for more info:
http://www.uptodate.com/contents/patient-information-common-breast-problems?source=see_link

Placenta previa

Abnormal placenta locations during pregnancy can be a serious complication during pregnancy.  Placenta previa is associated with bleeding during pregnancy and can cause significant and life threatening bleeding.  There are three types of placenta previa-total, partial, or marginal.  In total placenta previa, the placenta completely covers the cervical os (opening),  whereas in partial placenta previa, only a portion of the cervix is covered.  In a marginal placenta, the placenta does not cover the cervix but is nearby the opening and may cause bleeding during contractions.
Placenta previa occurs in about 1 in 200 pregnancies and occurrs more often in women greater than 35 years, African American women, women who have been previously pregnant, women who smoke, women who live at higher altitude, or in women with a previous cesarean section. 
Approximately 5-15% of women will be diagnosed with a placenta previa at their 20 week anatomy scan.  90% of these women will have a normal placental location at term.  This is due to the lower aspect of the uterus growing during pregnancy which will then cause the edge of the placenta to move farther away from the cervix.
The clinical symptoms of placenta previa are painless bleeding.  This bleeding can range from spotting to hemorrhage requiring emergent surgery and delivery, although this is rare.  One third of women with a previa experience bleeding before 30 weeks gestation, 1/3 experience bleeding between 30-35 weeks gestation, and 1/3 experience bleeding after 35 weeks gestation.  If a women does experience bleeding, it is imperative for them to contact their physician for examination.  If a women is remote from term (37 weeks), their bleeding is stabilized and they may receive a blood transfusion.  If a women is at term, delivery is recommended.
Conditions associated with placenta previa that adversely affect the pregnancy include poor fetal growth, preterm contraction or rupture of membranes, abnormal presentation of the fetus (ie breech), and placenta accreta.  Placenta accreta is a serious complication of pregnancy in which the placenta invades the uterus.  Approximately 2/3 of women with a placenta accreta will need a hysterectomy at the time of delivery secondary to the significant bleeding associated with an accreta. 
Depending on a woman's amount of bleeding due to the previa, she may be placed on activity restrictions including no heavy lifting, no intercourse, or even modified bed rest. 
Placenta previa is a serious complication in pregnancy but most women can be safely managed by their obstetrician to result in a term or near term delivery.

Breech presentation in pregnancy

Breech presentation at term (fetus is bottom first or feet first) occurs in less than 5% of pregnancies.  There are numerous causes of breech presention such as an abnormally shaped uterus (ie heart shaped), low amniotic fluid, high amniotic fluid, abnormal placenta placement, uterine fibroids, uterine scarring, fetal malformations, and decreased fetal mobility.  Random chance plays a signficant factor as well.
Most fetuses settle into their final position in the uterus around 34 weeks although certainly fetuses may switch positions even at 40 weeks or beyond.  If one is diagnosed with a breech fetus after 34 weeks,  management options include trying to turn the fetus to cephalic or head down position, scheduling a planned cesarean section, or attempting a vaginal breech delivery. 
External cephalic version is a procedure that an obstetrician will perform in the labor suite to attempt a change in the fetus's position.  A fetus is monitored via fetal heart rate monitoring usually for one half hour.  An ultrasound is performed to verify that adequate amniotic fluid is present.  An obstetrician will then push on the fetus through the maternal abdominal wall to attempt the fetus to "somersault" into position.  The success rate is variable and depends again on the factors that caused the breech position in the first place.  Risks associated with the procedure are infrequent (less than 5% of the time) but including fetal heart rate deceleration, placental abruption, rupture of amniotic membranes and stillbirth.  A fetus is monitored via fetal heart rate monitoring after the procedure as well.
Recent clinical trials have shown that fetuses born via cesarean delivery due to breech presentation instead of vaginal delivery tend to have decreased morbidity (illness or injury) or mortality (death).  This is because when a fetus is born via vaginal delivery in the breech presentation, the umbilical cord is more likely to get compressed, thereby decreasing the blood flow to the fetus.  The fetal head is also more likely to become stuck in the birth canal.  Most fetuses in breech presentation that do not convert to cephalic presentation after an attempted external cephalic version are born via cesarean section.
Some women choose to have a vaginal breech delivery which may be acceptable as long as they understand the above risks and are at a hospital where obstetricians are skilled in breech deliveries. For more information, please look at the following links:
http://www.ncbi.nlm.nih.gov/pubmed?term=11052579
http://www.acog.org/~/media/F65E95C3644349F1AEFABBB8B560CBE5.ashx

Twin pregnancies

Twin pregnancies are becoming increasingly more common in Amercia secondary to women choosing to have children at a later age and the increased use of assisted reproductive technology to aid in achieving pregnancy.  Twins are either monozygotic (one egg fertilized by one sperm splitting into two eggs) or dizygotic (two eggs fertililzed by two different sperm).  Monozygotic twins are identical genetically where dizygotic are different genetically.  The frequency of dizygotic twins increase as a woman ages and has more children.
Twin pregnancies have more risks associated with them and require increased monitoring.  Twins have an increased risk for intrauterine growth restricion(small baby), premature delivery, congenital birth defects, abnormal placental development and stillbirth.  Because of these risks, a woman who has a twin pregnancy will need frequent doctor visits, ultrasounds and prenatal testing.
When a woman is diagnosed with a twin pregnancy, it is important to determine by ultrasound whether the twins have two placentas and two sacs, one placenta and two sacs, or one placenta and one sac.  The risks of the above mentioned complications are more common in pregnancies with one placenta and one sac.
It is also important to consider genetic testing for chromosomal abnormalities in twin pregnancies.  A woman has a double risk of chromosomal abnormalities with twins secondary to having two fetuses instead of one.  Screening tests include a first trimester ultrasound and blood test. Invasive diagnositic testing is also available in the first trimester by chorionic villus sampling.  (Please see my previous post on genetic screening in pregnancy for more detail regarding these tests and procedures). 
It is important for a woman with twins to obtain a detailed anatomy ultrasound of the fetuses between 18-22 weeks.  As twins have an increased risk of congential birth defects, it is important to try to detect these during this ultrasound.
As a woman progresses further in pregnancy it is important to monitor the fetal growth by ultrasound.  Twins tend to grow at the same rate of single pregnancies until 32 weeks and then have slower growth.  Twins can also have vascular connections in their placenta which enable one twin to grow larger than another.  It is important to monitor this because if one twin is larger than another by greater than 10 % weight, the smaller twin has an increased risk of stillbirth. 
It is also important to monitor the fetal well being during pregnancy by antepartum testing.  This involves monitoring the fetuses heart rate for approximately 30 minutes twice per week and checking the amniotic fluid once per week.  This testing reveals whether the uterus is still a good environment for the fetuses allowing them to grow and obtain adequate blood flow.  This testing will usually begin at 32 weeks and continue until delivery.
A woman has increased risk of medical complications associated with twin gestation as well.  She is more likely to develop gestational diabetes or pre-eclampsia (elevated blood pressure in pregnancy).  It is important to have regular doctor visits to monitor for these symptoms.
The average age for twin delivery is 35 weeks.  This delivery age would change depending on what type of twin gestation a woman has.  The route of delivery (vaginal versus cesarean) depends on a number of factors.  For a twin pregnancy consisting of one sac and one placenta, the optimal route of delivery will always be cesarean delivery usually around 32 weeks.  For twins with two sacs and one placenta, optimal delivery is usually between 36-37 weeks gestation.  The route of delivery depends on the presentation of the fetuses.  If both fetusus are vertex (head down), vaginal delivery is recommended.  If the first fetus is breech (bottom or feet down) cesarean delivery is recommended.  If the first fetus is vertex and the second fetus is breech, vaginal delivery is possible as long as the second fetus is not greater than 20 % of the first fetus's weight.  For twins with two sacs and two placentas, delivery is usually recommended at 38 weeks.  The route of delivery depends on the same factors listed above.
It is important to be under an obstetrician's care during pregnancy to facilitate the best pregnancy outcome possible.  Please read further for more info:
http://www.acog.org/~/media/For%20Patients/faq092.ashx

Body changes in the first trimester of pregnancy

A woman's body goes under significant changes during pregnancy due to hormonal changes and the growth of the fetus.  These changes can cause concern if it is your first pregnancy.  This post will discuss normal changes in the first trimester of pregnancy.
A woman's threshold signal for thirst is altered causing a woman to drink more often which in turn causes a woman to need to urinate more often.  The change in thirst occurs to increase a woman's total volume of water in her body.  This increase allows a woman to increase her blood volume as well as contribute to the fluid content in the placenta and the amniotic fluid. 
A woman's appetite will increase during the first trimester in general, depending on how nauseated they feel.  A recommended amount of increased calories per day is 300 calories per day throughout the pregnancy.
Nausea and vomiting affect approximately 70 % of pregnancies.  It usually begins during the 4-8th week of pregnancy and usually stops by the 14-16th week.  Eating small meals frequently, ginger supplements, vitamin B6 or accupuncture wrist bands may be helpful.  There are also anti-nausea medication for women with more severe symptoms.
Constipation or diarrhea are also common in the first trimester which likely due to changes in the motility of the small intestines and large intestines. 
Breast changes associated with early pregnancy include tenderness and tingling sensations.  This occurs beginning the 4th week throught the 8th week.  The breasts continue to enlarge throughout pregnancy to prepare for lactation.  The nipples and the areola also enlarge.
Skin changes also occur during pregnancy.  Women may notice increaed acne which is due to the changes in hormones.  A woman may also noticed increased pigmentation (or darkening of the skin) during pregnancy.  This will usually resolve after delivery but may persist for some women.
A woman will also notice fatigue during pregnancy, especially the first trimester.  This usually improves during the second trimester but may redevelop during the third trimester.
Changes or symptoms that may occur during the first trimester that should prompt contact with your physician include vaginal bleeding, cramping, or severe nausea with an inability to maintain food intake.
I try to encourage my patients to hang in there through the first trimester.  Most patients will feel much better during the second trimester!

Infertily Evaluation

Infertily can be a frustrating and nerve wracking experience for couples.  Most couple will conceive within one year of attempting pregnancy.  Approximately 70% of couples conceive within the first 6 months and 85-90% by 12 months.  However, 10-15% of couples have not conceived after one year of unprotected intercourse.  A couple may choose to pursue evaluation at any point in their attempts at conception.  Most physicians recommend evaluation after one year of trying; however, a couple may want to present for earlier evaluation depending on their age. 
The three main causes of infertility include ovulation dysfunction or anovulation(no ovulation occurring), fallopian tube scarring or disease, and sperm abnormalities.  An evaluation by a physician for infertility will focus on a careful history and physical examination.  A physician will want to know if a patient is having regular menstrual cycles which indicate regular ovulation.  For a patient with irregular menstrual cycles, it is possibile that a low frequency of ovulation is occurring which would contribute to infertility.  A physician will also want to know if a patient has a history of sexually transmitted diseases such as chlamydia.  A history of chlamydia can cause fallopian tube scarring which makes it difficult or impossible for the egg to enter the uterine cavity.  A physician will also want to know if a couple has had a previous pregnancy together or if the partner has fathered any other pregnancies.  It is also important to know if a patient has had any previous surgeries on her cervix or in her uterus that could be affecting the sperm's ability to enter the uterus or a fertilized egg's ability to implant in the uterus. 
Initial diagnostic testing for infertility include male partner semen analysis.  Sperm abnormalities account for 35 % of infertility cases.  A semen anlaysis is simple to perform.  A man provides an ejaculate sample to the lab within 30 minutes of ejaculation.  A man should refrain from intercourse or ejaculation for 48 hours prior to the test.  The semen analysis will evaluate for total sperm count, sperm motility (number of sperm moving), sperm morphology (number of sperm shaped normally), and progressive motility (sperm moving in the forward direction). Abnormalities in these areas can contribute to infertility.  If abnormalities are found, a second semen analysis is usually performed to verify the test.  If the abnormalities persist, a man is usually referred to a urologist for evaluation of the cause of sperm abnormalities.
Other diagnostic testing for infertility include testing for ovulatory function.  This can be done by evaluating a patient's menstrual calendar, testing a woman's basal body temperature and tracking it throughout her cycle, testing progesterone levels in the blood, or testing a woman't urine for luteinizing hormone(the hormone which signals the ovary to release an egg).  For women who are menstruating at regular intervals, having cycles in similar length and experiencing premenstrual and menstrual symptoms usually confirms ovulation.  A woman whose basal body temperature rises consistently is also likely ovulating.  A blood progesterone level can be checked usually one week after ovulation, and if elevated, indicates ovulation has occurred.  The "ovulation indicator kit" will generally become positive one day before ovulation occurs.  This kit is testing a woman's urine for luteinizing hormone. A woman should use this kit daily approximately 2-3 days prior to the expected day of ovulation.  Ovulation dysfunction affects approximately 15 % of couples experiencing infertility.
Fallopian tube abnormalities are a common cause of infertility and occur in 30-35% of infertile couples.  Abnormalities may be due to previous infection, ectopic pregnancies, or surgeries on the fallopian tube.  Endometriosis can also cause fallopian tube scarring.  To evaluate for fallopian tube abnormalities a physician may choose a radiologic test called a hysterosalpingram.  This test involves injecting fluorescent dye into the uterine cavity and evaluating the dye as it moves through the fallopian tubes.  The test is usually performed 2-5 days after the last day of menses.  Another testing option would be laparoscopy (minimally invasive surgery) to directly evaluate the fallopian tubes as dye is injected into the uterus.  This allows a thorough evaluation of the pelvic organs.
Further resources regarding infertility evaluation include:
http://www.uptodate.com/contents/patient-information-evaluation-of-the-infertile-couple?source=see_link
http://www.acog.org/~/media/For%20Patients/faq136.ashx
http://www.reproductivefacts.org/

Urinary incontinence

Urinary incontinence is a very common symptom in women, particularly as one ages or after having children.  However, just because it is common does not mean it is normal and one has to live with it.  High blood pressure and diabetes are common in the American population and health care professionals do not recommend just dealing with it.  There are two most common types of urinary incontinence are stress incontinence and urge incontinence.  The classic symptoms of stress incontinence include leaking urine when laughing, coughing, sneezing, exercising, bending over, ect.  Essentially, any activity that increases the abdominal pressure in the abdomen can cause leaking of urine. The classic symptoms of urge incontinece include leaking of urine after feeling a sudden and strong urge to urinate and not being able to make it to the bathroom in time.  Women often have certain triggers that cause these urges such as putting the key in the door, running water, brushing their teeth, ect.  A woman can also have symptoms of both types of incontinence which is call mixed incontinence.  There are treatment options for both types of incontinence.

For a woman with stress incontinence, it is important to identify how often it is happening, how much she leaks when it happens, what activities cause it to happen, and how much it is bothering her when it happens.  For some women, they leak only a small amount when they have a cold and have coughing.  This small amount of leaking may not be bothersome for her.  Other women may leak every time they run, laugh, sneeze, cough or do heavy lifting.  This frequency of leaking could be very bothersome to her.  For a woman presenting for evaluation of her symptoms, I would recommend a careful history and physical examination, focusing on the above questions.  During the exam, it is important to determine whether the urethra has support or if ligaments that normally support the urethra have been damaged.  It is also important to recreate a scenario in which the woman leaks.  This is done by filling her bladder with sterile saline and then having her cough or laugh.  This examination helps to determine which treatment would be beneficial.

Treatment options for stress incontinence include expectant management (meaning monitoring symptoms over time until the symptoms become bothersome enough that one would like to proceed with therapy).  Other options include pelvic physical therapy.  There are physical therapists who specialize in strengthening the pelvic muscles which help women to have better support for their urethra and bladder and decrease the amount of leaking that occurs.  This therapy does involve a physical therapist performing a pelvic exam.  This treatment option is ideal for women with mild symptoms who are motivated to perform physical therapy.  Another treatment option includes a pessary.  A pessary is a device that is placed into the vagina.  The pessary creates support for the bladder and urethra.  It is placed in the vagina and normally removed once per week by the woman for cleaning.  The physician will fit the patient for a pessary that is comfortable and does not fall out.  The pessary works well for women with mild to moderate stress incontinence who do not or are not able to perform physical therapy or surgery.  The disadvantage of the pessary include needing to remove it for cleaning and intercourse and also the slight possibility of the pessary causing an erosion into the vagina.  Another treatment option for stress incontinence is surgical management.  Surgery involves placing a small mesh sling underneath the urethra which then recreates the supportive ligaments that have been damaged.  The surgery is an outpatient procedure and a woman is able to resume her normal activities quickly but is recommended to refrain from intercourse and heavy lifting for 4 weeks.  Surgery is very effective with approximately 90% of women having no leaking of urine or markedly less urine loss.  The risks include damage to nearby organs, risk of bleeding, risk of infection, and the risk of continued symptoms.  Surgery is a good option for women with moderate to severe symptoms who have failed other treatment options or who desire surgical management.

Urge incontinence is usually treated with behavior modifications and medication.  Urge incontinence occurs because the bladder contracts to urinate even though a woman may not be ready for urination.  The bladder may contract because it is too full with urine, or because of certain foods or liquids that cause irritation.  The bladder may also contract due to certain medications such as diurectics which a woman may be on due to medical problems such as high blood pressure and heart failure.  When a woman presents for evaluation of urge incontinence, it is again important to perform a thorough history and physical exam.  It is important to determine how often a woman has urge symptoms, what triggers her urge symptoms, to evaluate her medications, fluid intake, and food intake.  It also important to determine how often a woman is going to the bathroom and whether they feel they have emptied their bladder. 

Treatment options include behavioral therapy, restriction of fluids, avoidance of certain bladder irritants or medications, and treatment with medications.  Behavioral therapy includes retraining one's bladder to not send a message to one's brain every 30 minutes that it is time to urinate or to not send that message during certain situations such as hearing running water or brushing one's teeth.  Many women may leak because they are consuming too many liquids.  If one is drinking more than 64 ounces of fluid per day, their bladder may sense that it is full often and contract in response.  A treatment option includes restriction of fluid.  Avoidance of caffeinated beverages and bladder irritants such as acidic foods can also help decrease urinary urge symptoms.  Medication therapy includes medicine that decreases the frequency of bladder contractions.  If the bladder is contracting less, then one has less urge symptoms and less leaking.  The side effects of medication include dry mouth and constipation.

I recommend for any women experiencing bothersome urinary incontinence symptoms to be evaluated by either her gynecologist or urologist that is trained in treating urinary incontinence in women.  There are many noninvasive and minimally invasive treatment options that can signficantly improve their quality of life.

Additional resources include:

The American Urogynecology Society

http://augs.org

http://www.uptodate.com/contents/patient-information-urinary-incontinence-treatments-for-women?source=see_link