Dr. Victoria J. Mondloch, M.D.

Your question is not an easy answer. But first, let me tell you that recurrent fibroids mean an Estradiol dominance; that means that you make a higher percentage of Estradiol (E) than the 2nd female hormone or Progesterone (P4). Having an E dominance helps stimulate fibroids to grow and stimulates the growth of new fibroids. Fibroids are also recurrent, usually within 2-3years if the E dominance doesn’t rebalance. The better chemical balance is to have a P4 dominance but most healthcare providers don’t follow your hormone levels so you wouldn’t know what your body chemistry was telling you.

Age 49 also has a significantly higher incidence of E dominance due to irregular periods and not ovulating each month which means you don’t make P4 if you don’t ovulate. Age 49 usually means 1 year away from average age of menopause (age 50); this year before menopause, or perimenopause is known for it’s significant hormone swings up and down of Esradiol levels, usually with lower or absent P4 levels. This means that you may actually grow any fibroids bigger and faster in a shorter period of time.



Now to answer your question; the best way to choose the right type of uterus removal or hysterectomy is

1. know the size of the uterus, usually described as #weeks pregnant; for example, 8wks, 10wks, 12wks and so on. This matters because 12wks size or less has a higher percentage of being removed as a vaginal hysterectomy. If the uterus is between 12wks and 20wks (top of the uterus can be felt at your belly button level (umbilicus level), then adding a laparascope or belly button camera that can help to surgically visualize and then control the blood supply to the uterus, tubes and ovaries under direct visualization. This means that the hysterectomy can be started laparascopically and then finished vaginally; this means smaller mini-incisions versus a large abdominal incision that takes longer to recover from. But that large uterus then still needs to come out through the vagina, kind of like delivering a baby vaginally.
2. Are the fibroids to the uterus multiple, changing the outside shape of the uterus to such an irregular size that trying to take it out vaginally won’t fit; then the hysterectomy needs to be abdominal.
3. Do you also have a bladder that is falling down, causing urine leakage (incontinence) that could be helped by ‘tucking it up’ or doing a bladder repair at the same time as the hysterectomy? If you are having a vaginal hysterectomy, doing a bladder repair is easily added to your procedure without any further external incisions.
4. Do you also have a rectal hernia that could be helped by ‘tucking it down’ or doing a rectal repair at the same time as a vaginal hysterectomy can easily be added to your procedure.
5. Is there a question of pre-cancer of the uterus, significant anemia or recurrent bad Pap smears? All of these questions also need to be asked and answered to know if a vaginal or abdominal hysterectomy is the best choice.
6. Is there a history of recurrent ovarian cysts or polycystic ovarian disease or a BRCA positive genetic picture to the patient making them a higher risk of ovarian cancer? These would make the case for having your ovaries removed along with the uterus. In the past, taking out ovaries along with the hysterectomy was the standard of care because they were close to becoming ‘non-functional’; this approach is no longer an automatic recommendation as many practitioners feel that it is not necessary or helpful to take out normal ovaries, even if close to menopause.

I realize that this is not a short answer; but it is a more complete answer and will give you a head start on how to talk to your doctor about which approach is best for you. But regardless, have your female and male hormone levels checked as E dominance can also put you at higher risk of bad mammograms and breast cancer, even if you have a hysterectomy!

Dr. Victoria Mondloch

victoriajmondlochmdsc.com

Vulvar itching or pruritis at age 32, esp with thick yellow or yellow-green discharge is usually bacterial vs yeast which is usually white runny or chunky. Most times the bacterial infection is an overgrowth of a bacteria that is typical and usual to the vaginal vault called Gardnerella. However, when there is an increase in sexual intercourse and higher incidence of semen which is basic pH (8.5-9.0) vs the acid pH of the vaginal vault (usually 5.5), then there is a stimulation and overgrowth of Gardnerella which smells like rotten fish when it reaches a large enough concentration. Abnormal bleeding, spotting or spotting with intercourse can also trigger Gardnerella caused by the breakdown of red blood cells which triggers the same overgrowth of Gardnerella. Many times it will take care of itself with having a menstrual bleed and it will ‘self-clean’. However, when it causes itching or the odor is notable to others, then treatment with either oral Flagyl as an antibiotic or Metrogel as a vaginal antibiotic gel for 1 or 3 nights is appropriate but does require a prescription from a healthcare provider. Occasionally this bacterial will also irritate the urethral opening and mimic a bladder infection but it rarely travels into the bladder. Wearing barrier protection protects you from this ‘dump’ of basic fluid into your vaginal vault so consider this as another option for treatment. If your issue is abnormal bleeding, then seek advice from your healthcare provider as checking hormone blood levels is appropriate, especially day 21 of your cycle or when your healthcare provider decides of your cycle is irregular.

Premature aging of body tissues is definitely tied to the drop in Estradiol in the female body. Estradiol is one of 2 major female hormones and is called ‘the fountain of youth’ by many. The role of Estradiol in the body is to increase blood supply per square inch to tissues with Estradiol or E receptors. It begs the question, ‘how many tissues in our body have E receptors?’ The answer: every single tissue in our body has E receptors and every tissue in your body notices when your E levels drop or go away with menopause. So in my patients, I strongly endorse bio-identical hormone replacement. However, Estradiol replacement without properly balancing it with Progesterone is the key; it’s all about balance. Average age of menopause in the US is 50.5yo so 44yo is early and your body deserves to have premenopausal Estradiol (E) values until age 50 to help protect your bones from early bone loss called osteopenia, then osteoporosis as it continues to progress. Ask your doctor to check your blood levels of Estradiol and Progesterone (P4) as both female hormones are important and must be balanced to keep all of your female body organs protected; this includes your brain, your skin, your GI tract, your heart, your muscles, etc. You get the idea; bio-identical hormone replacement is not only good for you, it gives you back what your body is no longer making for you, but it needs to be followed and balanced. If only Estradiol is replaced without Progesterone, it can put you at risk for hyperstimulation of female organs like breast (bad mammograms), uterus (fibroids, abnormal bleeding) and ovaries (cysts that can rupture). If you take both Estradiol + Progesterone and have those levels followed and balanced by bloodwork, you are much less likely to have any hyperstimulation issues and your body will act forever age 40-45yo. If your doctor won’t check your levels, then ask them why as the North American Menopause Society actually endorses women taking bio-identical hormone replacement even after age 65yo when the benefits outweigh the risks. If your doctor is unfamiliar with how to manage you and you have no good option in your area, please check my website; victoriajmondlochmdsc.com or call my office 262-524-9116 to find out how we can help. Also, watch for the book due out end of July on Amazon called Full Bloom; Perimenopause, Menopause and Beyond. This book is the newest authority on how to understand the science surrounding women’s hormone cycles, hormone loss and how to properly hormone replace including the literature on its safety profile and cardiovascular protection. Lastly, check out the link to CUTV News radio (internet radio) and listen to the Women in Excellence 10wk radio series that will be aired on-line; I will be doing the women’s health segment that airs every Tuesday at 2o’clock central time starting 7/02/19; check your time zone as the show is live-stream broadcast.

Swollen glands are a reaction of the immune system in a regional area; reactions can occur against inflammation that a local tissue reaction cannot handle easily such as a large area bruise. However, most ‘swollen glands’ are a reaction of the immune system against an infection; if the immune system can handle it locally, then glands do not get recruited. If the infection is larger or the immune system needs to recruit ‘more helpers’, then it will call in ‘more troops’ and the lymph nodes will reflect that increased activity. However, when something goes awry in the lymph node, or a problem cell that actually turns cancerous in a lymph node, then that node can get overridden with those cancer cells; this is called lymphoma. Despite pregnancy being a 9month time in a woman’s life when she is doing something that her body may have not done before and her immune system may not have seen before, the body does not typically ‘attack’ the fetus or pregnancy so the immune system is not sensitized to the pregnancy tissues or the fetus so there is not a typical ‘swollen gland’ reaction by the body.

Yes, low back pain and missed periods could mean + pregnancy as the enlarging 2 month pregnant uterus would be the size of a moderately opening fist, putting pressure on the bladder, the rectum and the coccyx or tailbone as the enlarging uterus is still small enough to remain in the pelvis. Once the uterus reaches 3months size, it is too large to remain in the pelvis and it starts to raise out of the confines of the boney pelvis. Of course, missed periods and back pain could also mean an ovarian cyst which can also reach the size of the 2month pregnant uterus, putting the same pressures on the bladder, the rectum and the coccyx; and it can twist on its own stalk and cut off its own blood supply, this is a surgical emergency as it is extremely painful and you can strangulate and cause your ovary to die. Doing a home pregnancy urine test, available at any dollar store or pharmacy can tell you if you are pregnant or not. If you are pregnant, then make an appointment with your doctor to start your prenatal care. If you are not pregnant, then please seek a doctors appointment with pelvic exam and possible ultrasound to determine why you have an enlarged uterus. You may also find out that you are not pregnant, meaning you may have an enlarging uterine fibroid that is putting pressure on your tailbone. Whichever direction your pregnancy test takes you, you still need to determine why you have pain and missed periods; checking your blood hormone levels for Estradiol and Progesterone as your female hormones can help determine if there is a problem with your cycles; checking your blood hormone levels to also include Total and Free Testosterone can help determine if you may have Polycystic Ovary Disease. You should also check your thyroid blood tests as underactive or overactive thyroid can cause a change and possible slowdown in your GI tract to cause you to become bloated or constipated, another reason for gas or stool to remain in your lower colon, pushing against your uterus and tailbone also causing low back pain.

There are many options to help with periods and the many types of menstrual flow that women encounter. Options that are available:

1. Pads – these come in many sizes and shapes promising to help with light days, modium days and for those heavy or overnight flows that can even wrap around your undergarments to prevent soiling your clothing. However, patients will feel the moisture against their skin and it can be uncomfortable and not necessarily the best choice if you lead an active lifestyle, especially for women who use swimming or pools as a part of their exercise regimen. Pads can overflow and cause soiling of clothing, leading to embarrassing situations. And remember, the best way to clean blood from clothing is to use 0.9% salt water which lifts the red blood cells from your clothing vs water which breaks the red blood cells and leaves a ‘ghost’ of the cell or a stain that will not go away. Bleach doesn’t work as well either because the red blood cell breaks open, again leaving a ‘ghost’.
2. Tampons are an internal absorbent option that is also graded for light, regular, super and super-plus flow options. Patients can even walk 2 tampons up together at a time if you experience a super heavy flow if you are involved in a situation or a timing that has you unable to change your tampon supply in a 2hr period. Tampons are usually comfortable to wear as long as there is enough flow to absorb through 50% of the tampon; otherwise, insertion or removal can be ‘catchy’ or a little uncomfortable as it pulls against dry vaginal tissues. Tampons are only meant to be in place for approx. 4hr during the day and many experts will advise against overnight use until you know you are not sensitive to the absorbent materials used in tampons. There is a small subset of patients who have had an allergic reaction to the absorbent materials used in tampons so always use for only a 2-4hr window when you are first trialing tampons to be certain you don’t have a tissue reaction with swelling, redness or warmth to your outer vulvar tissues; if you do, remove the tampon immediately, take some oral Benadryl and see a professional for an exam. There are also patients who may already have a bacterial vaginal infection occurring; that is not the time to put in a tampon which will hold blood product and infection in a tampon in your vaginal vault for at least 4hour vs allowing it to drain, also causing vaginal irritation; you may require an antibiotic if the infection is on-going. However, the vast majority of patients will safely be able to wear internal tampon protection without risking injury or infection.
3. A third option is a vaginal cup which is reusable and is also sized for the amount of flow it can hold; using this type of protection allow for a reusable option and you are not adding to a landfill as you are not using a disposable product.
4. A fourth option is an absorbent wicking undergarment called Thinx; it can absorb the equivalent of a super tampon into the undergarment without the patient feeling moisture against their skin and without staining to the clothing that you are wearing, even if you are wearing white. This is an option for the very active outdoors woman or anyone not wishing to risk the tampon string that may travel outside of their undergarment or secondary overflow pad. This garment is approx. $35 per pair but they can be washed and are reusable so they are environmentally friendly and will not add to the landfill.

Painful intercourse is a distressing symptom that can seem to come out of nowhere, even in a stable and healthy sexual relationship. There are a few considerations:

1. Are you under stress? Any type of stress; work stress, financial stress, emotional stress or physical stress can all contribute to an imbalance in your hormones and cause decreased natural lubrication causing vaginal dryness, this then ‘catches’ dry penile skin on dry vaginal vault tissues doesn’t glide, it rubs and can irritate.
2. Are you in the swings of hormone ups and downs that occur with perimenopause? Hormone levels in your 1yr or more before menopause can cause good lubrication one month and poor lubrication the next month, all based on female hormone swings; these levels can be easily checked by your health care provider so ask for these levels, they are a simple blood test.
3. Are you in menopause or post-menopausal? The female body stops making female hormones with menopause and this means poor or no lubrication. The vaginal vault is meant to be elastic which means it will stretch without tearing and it is meant to have lubrication to allow for appropriate glide and pleasure with intercourse. Taking female hormone away at menopause can be very distressing to many of our body systems, but it is particularly distressing when it negatively impacts our sexual part of our lives and our marriage. And you don’t want to feel responsible but realize that it ISN”T YOUR FAULT!!! Ask your doctor to have your female hormone levels checked; there are some simple solutions that work: vaginal Estradiol cream can be used locally without changing a blood level of Estradiol in your bloodstream. You can also have a combination Estradiol + Testosterone or an Estriol + Testosterone compounded vaginal cream custom made for you if your bladder is also misbehaving with urgency (wanting to void every 30min) or with symptoms that mimic a bladder infection with painful urination but no evidence of a bladder infection. Don’t be embarrassed to talk to your healthcare provider about using an Estradiol based hormone cream vaginally to help; it’s not your fault that your body stops making female hormone.
4. Another less common reason for painful intercourse, especially if it is painful with deep thrust only is if your pelvic organs are starting to ‘fall’ or prolapse; the uterus wants to relax and fall down the vaginal toward your vaginal opening so that with intercourse, the uterus is pushed back in further than it is used to and that ‘stretch’ on it’s support ligaments is now painful; and that pain can go all the way to your groin because that’s where the round ligament attaches.
5. Lastly, make certain that you don’t have any type of vaginal infection such as a yeast infection; if you are taking an antibiotic for any reason, it can affect the balance of the normal bacterial that reside in a woman’s vaginal vault and cause yeast overgrowth that you may not even be aware of. Over the counter treatment with yeast creams designed for a woman’s vagina are perfectly safe to try at home; if you don’t get results, then get checked by your healthcare provider.

Miscarriage at 4months pregnant is less common that a miscarriage during the 1st 3months. If there was a documented pregnancy with a fetus and a fetal heart beat that grew in utero to >12wks, then genetic testing on the fetal products should have been performed. In addition, there is an increased risk of a blood clotting disorder that can be the reason for miscarriage and could lead to future miscarriage if not properly diagnosed. Many times, blood clotting disorder is not recommended until recurrent miscarriage x 3 occurs but this is usually referring to 1st trimester miscarriage.

Blood clotting disorder work-up includes Factor V Leiden, Antiphospholipid antibody, Anticardiolipin antibody, Protime, Prothrombin time, Methyltetrohydrate Folate Reductase deficiency (MTHFR deficiency), Factor VIII and CBC for platelet count. This testing can be very expensive so be certain that your healthcare provider checks with your insurance regarding correct ICD-10 coding as ‘recurrent miscarriage’ which means 3 miscarriage in a row during 1st 12 weeks or a 2nd trimester miscarriage. If any of this testing above is positive, it may mean that the mom needs to be given treatment to prevent blood clotting throughout the pregnancy; this may mean shots of blood thinner injected subcutaneously or into the abdominal skin daily. In addition, a lesser known cause of recurrent miscarriage which can occur in the 1st or 2nd trimester is a low Progesterone level which leads to a poor uterine lining that is not healthy enough to support continued growth of the fetus. Progesterone can be easily tested by blood test, is relatively inexpensive and is pharmaceutically available as a vaginal gel or as an oral pill. Progesterone is also prescribed in preterm labor to help stop preterm labor.

For those couples who need to seek this level of counselling and healthcare help, seek a high risk obstetrician who will do the work-up with you ahead of time so that when pregnancy does occur, you have many of your health concerns already addressed; finding out at the beginning of a pregnancy that there is a potential concern is not the time to find out this type of information.

Plan B is a short version of the pill with a more concentrated dosing. Any dose of artificial hormone will suppress natural ovarian functioning but even a high dose of birth control pill will not usually cause a permanent infertility, ovaries usually will return back to normal functioning in 6-12months. So if you are thinking about conception in less than 12months, it’s a good idea to come off of any artificial hormone and let your periods come back to normal functioning on their own and use a barrier contraception like condoms to help control exposure without interfering with hormone production.

The better question to ask is ‘Is PCOS a lifetime diagnosis?’ If PCOS is the reason for the elevated fasting glucose but normal insulin level (called hyperglycemia) or elevated fasting glucose plus elevated insulin (called insulin resistance) or Type 2 diabetes which is a persistent elevated fasting glucose plus elevated insulin, then controlling the hormone imbalance of PCOS may actually help with fasting glucose and insulin levels. PCOS or Polycystic Ovary Syndrome is by definition a male/female hormone imbalance; your ovary produces a higher percentage of Total and Free Testosterone than it should which can suppress normal production of your 2 female hormone levels of Estradiol and Progesterone. This hormone imbalance needs to be brought back into balance which is the first step. If you cannot drop the Testosterone levels back to 15th% of normal range which is considered age appropriate, then your other hormones in your body try to come to the rescue and help out; this includes your insulin level. A fasting insulin level for women is not a well recognized value; it is only listed as a normal lab range for men. The lab range is <24.9 but I recommend the female range of <15; however, optimal levels for Alzheimer’s prevention actually lists <4.5!! (reference: End of Alzheimer’s by Dr. Dale Bredesen). In other words, sugar is the enemy. So addressing lifestyle issues such as cutting white sugar and man-made carbohydrates from your diet is an important step toward addressing your fasting glucose and insulin levels. Some patients with PCOS will have a drop in glucose and insulin occur with dropping their Testosterone levels; however, some patients have a more moderate or severe PCOS that require Metformin to help them even if they are successful in dropping their Testosterone levels, it just takes following the bloodwork to know how your body is responding. So once you start on Metformin, you may also bring back normal periods and may even ovulate on a more regular basis which is important if you want to get pregnant.

So ask your doctor to check your bloodwork: you need day 21 of your cycle bloodwork if you wish to tie your Estradiol, Progesterone, Total Testosterone and Free Testosterone levels to your fasting glucose and insulin levels (4hr fasting). Only by knowing where your levels are can you know if your Metformin is helping not only your blood sugar but also your female cycles.

And remember, if you have an elevated glucose and require Metformin, you are at increased risk for diabetes in pregnancy that may even require insulin and you are at increased risk for type 2 diabetes later in life. So learn as much as you can about how your body responds to Metformin now, how it impacts your female/male hormone levels now so you can help protect your health in the future.

Folic acid is part of the Vitamin B family and taking B Vitamins is always good for stress relief and to support your adrenals. In addition, Folic acid is a building block of your DNA, thus it helps with cellular turnover in every part of your body. Since our body literally turns itself over in tissues as little as every 7days and in our red blood cells and bone marrow every 120days, we literally ‘reinvent’ ourselves on a regular basis. So when you are thinking of conceiving, having a good building block for building good DNA is a smart idea, especially if you have any irregularity to your cycles. The recommended dose is 1mg or 1,000ng of folic acid; however, the best folic acid is methylfolate. The methyl helps the body most efficiently do it’s job in your body and since your body will benefit whether you are trying to conceive or not, it’s always a good idea. Folic acid is a water soluble supplement, meaning that it reaches many parts of your body quite easily and you excrete out the extra that your body doesn’t need in your ‘water’ or through your kidneys. Patients who have a family history of spina bifida or ‘open spine’ are even encouraged to take up to 4mg or 4,000ng of folic acid daily and to start up to 3-6months ahead of trying to conceive. So to answer your questions, yes it is always a good idea to start folic acid, especially methyl folic acid up to 3months before trying for conception to give your baby the best ‘pre-nutrition’ that you can.

One last tidbit; folic acid is also recommended when patients have an abnormal Pap smear as it is involved in cellular turnover and the cervix is certainly turning over cells on a regular basis. So if you have an ASCUS (Atypical Squamous Cells of Undetermined Significance) or even a mild dysplasia/CIN-1 (Cellular Intraepithelial Neoplasia-1), then taking Folic acid daily can help you reverse your Pap smear back to negative!

If this discharge is not chunky or itchy, it is likely not a yeast infection and will not respond to using an anti-fungal such as Monistat cream or even the Diflucan oral treatment. What is more likely is hormone change. When women are in their 30's they start to have wider fluctuations in their female hormones of Estradiol and Progesterone, with a faster drop in their Progesterone causing an Estradiol dominance. This change in hormone balance causes a pH change that is subtle in the vagina but causes a shift in the balance of microflora that changes the normal discharge. This change in discharge is usually non-irritating but just 'different'. Have your doctor check your hormone levels on d21 of your cycle to confirm but it likely will show Estradiol dominance vs Progesterone to Estradiol balance or Progesterone dominance. Progesterone is the equalizer and stabilizer of the lining of your uterus but it balances and stabilizes the rest of how your female organs work. So changing that balance causes changes in the pelvis, thus you get a change in discharge. If your doctor is reluctant to check your levels, or doesn't feel comfortable working with you on this issue, then find a healthcare provider who is. If you cannot find one in your area, then contact my office e-mail at vmondloch@gmail.com and let us help.

Many patients will be instructed to follow a basal body temperature chart but may not be told how to interpret the graph. Make certain that you mark day 1 as the first day of your cycle, mark each and every day’s temperature, taking at the same time of day each day, including weekends. The most important thing to know is that if you have an ovulatory cycle, you will have approx. 0.8 degree Fahrenheit increase in temp approx. d14 or halfway through the graph or menstrual cycle and keeping that higher average temperature until your next period at approx. d28. This biphasic temperature graph indicates ovulation; less than 0.8 degree increase from d14-28 of cycle may not actually be enough of a temp increase and may actually indicate low Progesterone. A graph that shows no real increase in temp indicates no ovulation is occurring or no Progesterone production; this needs to be investigated by your doctor. I always recommend patients have their day 3 Estradiol level drawn; if <150 on blood test, then you are not making enough Estradiol to support a healthy lining or healthy stimulation of an ovarian follicle and you will likely not ovulate so it won’t be useful to even try to conceive that cycle. I also then recommend patients have d21 Estradiol + Progesterone drawn. If Progesterone (P4) is less than 20, then supplemental P4 is recommended in your next cycle, taking every night from d15-28 of your cycle (or your period) as you may actually be unable to maintain a pregnancy if the P4 is too low. This situation is called a ‘chemical pregnancy’ as you never really know that you conceived because the lining in the uterus is not strong enough to hold a healthy pregnancy; only a blood quantitative HCG or blood pregnancy test would be able to answer this question.

If you are not showing an 0.8 degree increase in your temp or if your temperature never rises at all, then you are not ovulating; this can occur for up to 3 to 6months coming off of birth control pills and can occur for up to 12months coming off of the Depo Provera shot.

Approx 10-15% of patients may actually make a higher Testosterone amount than they should (average is a Free Testosterone value of >15th% of the female range). If you make higher Free Testosterone than 10-15%, you may actually not ovulate due to a condition called Polycystic Ovarian Syndrome or PCO disease. The PCO syndrome can have associated symptoms like facial acne, abnormal weight gain, male pattern hair loss to upper forehead or even top of crown of head and/or excess hair to upper lip/sideburns chin; some patients will even be shaving this excess hair. However, you may have PCO disease vs syndrome and may have elevated Free Testosterone levels but not enough to have the other symptoms mentioned above so you go undiagnosed by your doctor. Medicine will not diagnose a patient with infertility until you have tried for 12months and are still not pregnant. However, more and more patients are waiting longer to start their family and do not have the luxury of waiting an entire year to then find out there is a medical issue that needs to be addressed. In addition, once you are labeled with ‘infertility’, you may not have certain tests covered by your insurance because you may require a prior authorization; this means that your insurance company is already thinking you may cost them a lot of money for a work-up and they want to keep tabs on all aspects of the medical work-up and they may approve some testing but not other testing, making those unapproved tests an out of pocket cost to you. I always recommend knowing as much about your cycles and your hormone levels before you even think about trying, you are then being proactive and can work with more simple bio-identical hormone replacement if your levels return low or imbalanced before you feel rushed for time or face testing that you may suddenly have to pay for and may not have budgeted for.

Once you have appropriate hormone levels and whether or not you need additional Progesterone or not, you may still require fertility medication to help you ovulate; this medication is called Clomid and can usually be prescribed at low to medium dose by your GYN but must be carefully followed to be certain that you do not have ovarian hyperstimulation. Hyperstimulation may cause more than one follicle to ovulate; if 2 ovulate, you may experience twins, or if 3 ovulate, you may experience triplets; this sounds exciting but places you in a high risk pregnancy situation which a high risk of premature labor or even hypertension or toxemia with pregnancy which can put both you and your babies at risk and almost always results in early hospitalization with time off work and additional costs that again you may not have budgeted for. Clomid should always be under the supervision of an experienced GYN as a very small percentage of patients may even have abdominal ascities or extra abdominal fluid that can cause respiratory and GI issues. As well, Clomid may not be enough to stimulate ovulation; these patients then may require more intensive infertility work-up or in-vitro fertilization which is rarely covered by insurance and entails surgery to harvest eggs and surgery to put sperm and eggs or fertilized embryos into your uterus. Lastly, your male partner may also need a semen analysis to make certain he is ‘shooting good swimmers’ as he may have a low sperm count or a high percentage of abnormal looking sperm; this also needs further medical evaluation or work-up with a Urologist.

This is a great question. When a miscarriage occurs before 12wks pregnant or in the 1st trimester, that is the most common, but can still have multiple reasons. Statistics say that 1 in 10 women will miscarry, no matter what the reason; that’s a statistic most women never hear.

Common reasons for 1st trimester miscarriage:

1. Genetics of the fetus are just not destined to make a healthy fetus, either from the woman’s egg or the man’s sperm.
2. Low Progesterone <20 that doesn’t make for a lush uterine lining for the fetus to implant into. Low Progesterone can also lead to pre-term labor later in a pregnancy.
3. Poor control of known medical conditions such as thyroid dz, poorly controlled diabetes, severe ulcerative colitis with diarrhea and GI bleeding as well as others, esp if strong medication with category C, D, or higher is being taken by the mom.
4. Clotting disorders that may not manifest until a pregnancy occurs; these can cause microclotting in the placenta, which cuts off blood supply to the fetus (see the list in #5 of the 2nd trimester miscarriage list below).
5. Certain viruses such as the virus that causes 5ths disease can only give mild symptoms to the mom, but catastrophic to the fetus.
6. Abdominal trauma such as a motor vehicle accident with an intact lap belt as well as a missing lap belt.
7. A significant fall on your bottom which jars or may even fracture the pelvic bone structure or tailbone.
8. A fever of 102.5 or greater from any reason.
9. A maternal diagnosis of anovulation (not ovulating) or irregular ovulating per menstrual cycle such as polycystic ovary, or PCO; this diagnosis may only have a patient ovulating once every couple of months or, in a severe case, ovulation may be so irregular as to require fertility medication or an infertility specialist.

However, there are less common reasons for a 2nd trimester miscarriage, or from 12-24wks:

1. Abnormal genetics that allow the fetus to grow to this stage of pregnancy, but will not support life outside the womb; doing genetics on the "products of conception" are important to perform.
2. Low Progesterone <20 can still be responsible and an easy issue to "fix," but difficult if your healthcare provider doesn’t feel this may be a cause.
3. Poor blood pressure control or a variant of pre-eclampsia (severe high blood pressure in pregnancy) can occur that causes dangerous blood pressures before 20wks pregnancy that can cause damage to the blood vessels of the placenta or even cause a stroke in the fetus. If this condition occurs before 20wks, it is also dangerous to the mother and can also cause stroke or even rupture of internal organs such as rupture of liver or spleen, which can cause internal bleeding or even death.
4. Abnormalities to the uterus such as fibroids or a prior uterine scar from a prior C-section or myomectomy can cause altered blood flow to that internal section of the uterus where the placenta may grow over; this causes poor blood flow interaction that can also cause painless and sometimes painful bleeding and cramping that can lead to miscarriage. This chain of events with abnormal bleeding can also cause premature rupture of the bag of waters; in that case, the fetal lungs are unable to properly develop and the usual outcome is miscarriage.
5. Again, clotting disorders such as Factor V Leiden, Antiphospholipid antibody syndrome or anticardiolipin antibody syndrome or Methyltetrahydrofolate reductase deficiency (MTHFR) need to be tested.

Because these reasons for 2nd trimester miscarriage are more serious, it’s possible that these reasons may still have the underlying cause remaining to cause a repeat miscarriage in the event of a 2nd pregnancy. So, getting pregnant may not be the problem, staying pregnant may be the bigger problem; check with your healthcare provider as the work-up for a 2nd trimester miscarriage is similar to that for recurrent miscarriage or 3 or more 1st trimester miscarriages.

I realize this is a longer answer than you might have been expecting, but it’s a more complex question with a more complex answer than a 1st trimester miscarriage. Be certain that your healthcare provider has you see an OB-GYN who can do the work-up for you. You can even have a lot of the work-up done remote from the miscarriage in case this testing was missed.

Dr. Victoria J. Mondloch

Thanks for your question. I have another question to ask: is there any malodor associated with this itchiness or pruritic? If so, the most common is a fishy or rotten fish odor that is usually indicative of BV, or bacterial vaginosis; this is caused by a pH change in the vagina to a more alkaline vs. acidic environment. The change in pH from 5.5 to 8.0 can be caused by recent intercourse, as semen has a pH of 8.0-9.0 and, when mixed with acid, causes a reaction. This reaction usually doesn’t bother us unless we have it too little (infrequent timing) or too much. BV can be treated with either "washing it out" by our menstrual flow, but that doesn’t always work. It can also be treated with Metrogel vaginal in an applicator x 1-3 consecutive nights (while not menstruating at the same time) or by oral Flagyl (antibiotic). Check with your healthcare provider.

If you are getting recurrent vaginal pruritis without malodor, then this may actually be an indicator of hormone imbalance. Many women may make more male hormone than the normal range (approx. 15% of a normal laboratory range for Free Testosterone is my rule of thumb), and that can cause a decrease in the amount of female hormone (Estradiol + Progesterone) that your ovary would otherwise make. This imbalance does not always cause abnormal periods or spotting between periods, but it can. If intercourse is uncomfortable, it may also be a sign that your vaginal vault has decreased elasticity or stretchability, and that is also a sign of "low E." The best way to know what your hormone levels are is to have your blood tested by labdraw on d21 of your cycle on a conventional 28-day cycle; this is the day that your body makes its peak of Progesterone and Estradiol (2 days on either side of d21 is also okay or d19-23 of your cycle). Ask your healthcare provider to do bloodwork on you. They would use the ICD-10 code for abnormal menstruation of N62.5 or painful intercourse (Dyspareunia) with IC-10 code R68.82. If you have acne, use L70.0 for ICD-10 code.

If your Free Testosterone comes back higher than 15% of the normal laboratory range, then you may need further evaluation to rule out PCO, or polycystic ovary. PCO is also associated with other Excess Testosterone symptoms such as hair loss to your head, acne, mid-abdominal weight gain, and excess hair to your upper lip or chin. Or you may not have any other symptoms, but still have an elevated Free Testosterone, those are the silent sufferers of Excess Testosterone who are usually never diagnosed or diagnosed late; it can even lead to infertility or late fertility with its increased risks.

Lastly, another hormone that can also cause changes in your female/male hormone balance is your AM Cortisol. Cortisol is made in your adrenals and helps you to manage stress, "WHO HAS STRESS?" When your cortisol levels are too high (stress) or too low (distress), that can also interfere with your female/male hormone balance. Ask your healthcare provider to add AM Cortisol to your laboratory requisition form along with your hormone levels above. This needs to be drawn before 9:00AM to best capture the peak production of Cortisol in your body; the ICD-10 code is F43.0.

In summary, your lab requisition should be for Estradiol, Progesterone, Total Testosterone, Free Testosterone, and AM Cortisol with the ICD-10 codes listed above, drawing before 9:00AM. It’s okay to eat and definitely drink fluids before you go in so your blooddraw goes easily for you.

If none of the above answer your concerns, then you may need to see a GYN specialist who deals in bio-identical hormone replacement as they have a very good understanding of how hormone balance works and how to best rebalance you. Or, contact my office through my website, victoriajmondlochmdsc.com, and we will try to help.