The definition of a hysterectomy is removal of the uterus. A
brief review of female reproductive anatomy may be of help in understanding
hysterectomy.
The uterus is a hollow pear-shaped muscular organ located in
the lower abdomen or pelvis. One end of each fallopian tube is
contiguous with and opens into the side of the uterus, at the upper
end, and the other end lies next to an ovary. At its lower end,
the uterus narrows and opens into the vagina. The lower end of
the uterus is called the cervix. The ovaries lie lateral to and
slightly behind the uterus.
During a woman's reproductive years, a
small cyst forms in an ovary, and an egg is released by an ovary
each month and enters the fallopian tube, where fertilization
may occur if sperm are available. If fertilization occurs, the
fertilized egg implants in the uterine lining and a pregnancy
is initiated. If the egg is not fertilized by a male sperm, the
woman experiences her "period" as
the uterus sheds its lining (endometrium): the blood and tissue
that had accumulated in anticipation of fertilization and pregnancy.
In addition to producing eggs, the ovaries also produce the hormones
estrogen and progesterone. As menopause develops, hormone production
by the ovaries decreases markedly. The ovaries also stop producing
eggs, and menstrual periods eventually stop.
If the uterus and cervix are removed the
term is a total hysterectomy. The term hysterectomy does not
automatically imply anything about the ovaries. A partial hysterectomy
refers to the fact that the cervix was not removed and is not
a term that designates that the ovaries were or were not left
intact. A separate term for removal of the ovaries is used and
is called an oophorectomy. If the fallopian tubes are removed
with the ovaries, the term is salpingoophorectomy. There ways
to do a hysterectomy and the approach depends on the patient’s
history, the indications for the procedure and the size of the
organ itself.
WHAT IS AN ABDOMINAL HYSTERECTOMY? Abdominal
hysterectomy is a surgical procedure in which the uterus is removed
through an incision in the lower abdomen. One or both ovaries and
fallopian tubes may also be removed during the procedure.
HOW WILL I FEEL AFTER THE SURGERY? Abdominal
hysterectomy is a common and safe procedure, but it is still a
major operation. The woman typically stays in the hospital for
2 days, and should plan a period of several weeks to recover at
home, during which normal activities can gradually be resumed.
Usually, fluids and food are offered soon after surgery. Intravenous
fluids may be administered during the first day, particularly if
the woman experiences any nausea or vomiting. Medications are administered
to manage pain and women are asked to get up and walk soon after
surgery. Regaining mobility is particularly important as it helps
to prevent complications, such as blood clots, pneumonia, and gas
pains.
Once home, the woman is encouraged to resume most normal daily
activities as quickly as is comfortable. She is instructed to call
their doctor if she experiences an increase in pain, persistent
nausea or vomiting, bleeding heavier than a menstrual period, or
any signs or symptoms of infection.
WHAT IS A VAGINAL HYSTERECTOMY? Vaginal hysterectomy
is a surgical procedure in which the uterus is removed through
the vagina. One or both ovaries and fallopian tubes may be removed
during the procedure, as well. A vaginal approach may be chosen
if the uterus is not greatly enlarged, and if the condition prompting
the surgery is benign and limited to the uterus. Studies have shown
that vaginal hysterectomy is associated with fewer complications,
a shorter length of hospitalization, and faster recovery than removal
of the uterus through an abdominal incision (abdominal hysterectomy).
WHAT IS A LAPAROSCOPICALLY ASSISTED
VAGINAL HYSTERECTOMY? Some
surgeons use a laparoscope in conjunction with the vaginal hysterectomy
procedure. A laparoscope is a surgical instrument inserted through
a small incision in the abdomen. Using the scope, the surgeon can
see structures within the abdomen, and, if needed, perform procedures
such as removing scar tissue to aid the vaginal surgery. It is
generally believed that a woman can return to normal activities
sooner after a vaginal hysterectomy than after an abdominal hysterectomy.
As a result, sometimes patients who are candidates for abdominal
hysterectomy may have laparoscopy done to help mobilize the uterus
and allow a vaginal hysterectomy to be done instead. Ask your surgeon
if a laparoscope will be used during your procedure.
IS THERE A CHANCE THAT I WILL HAVE AN
ABDOMINAL HYSTERECTOMY INSTEAD? Although infrequent,
after your surgery has begun, your surgeon may find conditions,
such as extensive scar tissue, that make abdominal hysterectomy
the better choice. Sometimes these conditions are not apparent
before surgery. When this happens, the surgeon stops the vaginal
procedure and changes to an abdominal approach.
Supracervical or subtotal hysterectomy There
are situations in which the entire uterus is not removed. A supracervical,
subtotal, or partial hysterectomy refers to a procedure in which
the cervix is left intact. Sometimes during hysterectomy difficulties
arise which make the surgeon decide that leaving the cervix in
place is safer. Also, some women also prefer keeping the cervix
intact as they feel it will contribute to sexual satisfaction after
hysterectomy.
In rare cases of emergency hysterectomy done to control bleeding
following childbirth, the supracervical procedure may be done because,
in this setting, it can be difficult to identify the boundary of
the cervix (or the point at which the cervix ends and the vagina
begins).
If the cervix is not removed, the woman remains at risk for cervical
cancer and must continue to have routine screening for the disease
(Pap smear). In some women, the retained cervix is attached to
the lower uterine segment and its endometrium, meaning that they
will continue to experience menstrual periods.
Prior to planned supracervical hysterectomy, tests should be
performed to exclude any cervical abnormalities. In addition, the
woman should discuss with her doctor the risks and benefits of
leaving the cervix intact.
Fibroids (leiomyomata) Non-cancerous
tumors of uterine muscle, which may occur in up to a third of all
women, and typically shrink after menopause.
Pelvic relaxation Stretching
and weakening of the pelvic muscles and ligaments that allow the
uterus to sag (or prolapse) into the vagina, thought to be associated
with vaginal childbirth.
Adnexal mass A
mass involving the ovaries or, rarely, the fallopian tubes
Cervical abnormalities Precancerous
abnormalities or cancer of the cervix unresponsive to lesser procedures
such as cone biopsy or treatments using laser or cryosurgery.
Endometrial hyperplasia Excessive
growth of the endometrium or the tissue that lines the uterus.
Some types of endometrial hyperplasia may be precursors of endometrial
cancer.
Malignancy Cancer
affecting the uterus or other reproductive organs
Tuboovarian abscess A
collection of pus and inflamed tissue involving the ovaries and
fallopian tubes
Chronic pelvic pain Chronic
pelvic pain may be due to the effects of endometriosis or scarring
(adhesions) in the pelvis and between pelvic organs or sometimes
as a last resort when all other treatments have failed.
Hysterectomy is always a planned or elective procedure, except
in rare situations. For example, the uterus may be removed following
childbirth to treat severe postpartum bleeding when all other interventions
have not controlled the hemorrhage.
WHAT OTHER TREATMENTS MIGHT BE AVAILABLE
FOR MY CONDITION? In some cases, medicines or
limited surgery can be used to treat an underlying condition
and hysterectomy can be postponed or avoided. The decision
to proceed with the surgery should be made mutually by the
woman and her doctor after careful consideration of the woman's
particular medical problem, all available treatment options,
and the risks and benefits of each type of treatment.
Oophorectomy Oophorectomy
is surgical removal of the ovaries. It is sometimes done in conjunction
with hysterectomy. Some women may have a condition that requires
that the ovaries be removed. Others, however, may be asked to make
a choice between keeping the ovaries or having them removed.
If the woman has not gone through menopause, keeping the ovaries
allows for continued natural production of estrogen and progesterone,
and allows the woman to avoid the need for hormone replacement
therapy immediately after surgery. Removal of the ovaries, however,
essentially eliminates the risk of needing additional operations
for future ovarian problems, and may be desired in some women.
The woman should discuss her individual risks and preferences with
her doctor before surgery.
In women who have completed menopause, the ovaries are frequently
removed as part of the surgery because they are not producing large
amounts of hormones, it is easily accomplished as part of the surgery,
and avoids the need for future surgeries should problems with the
ovaries arise.
WHAT ARE THE POSSIBLE COMPLICATIONS
OF THE SURGERY? A number of complications can
occur as a result of hysterectomy. Fortunately, most can be
easily managed and do not significantly impair the healing
process. Complications associated with hysterectomy include:
Hemorrhage Excessive
bleeding occurs in a small number of cases and may require transfusion
and/or a return to the operating room to identify and correct the
cause.
Infection Fever
after hysterectomy is not uncommon. In some women, the fever
may be due to an infection that is treated with intravenous antibiotics.
Rarely, serious infections that are not eliminated by antibiotics
require further surgery.
Damage to other abdominal structures
or organs The urinary bladder, ureters (small
tubes leading from the kidneys to the bladder), and the large
and small intestine are located in the lower abdomen and can
be damaged during hysterectomy. If injury occurs, it may be
detected and corrected at the time of surgery, usually without
subsequent problems.
Thromboembolism Thromboembolism,
or formation of a blood clot in a blood vessel, is a rare complication
after abdominal hysterectomy. Preventive treatment and postoperative
ambulation help to minimize this risk. Women taking oral contraceptives
should discontinue them one month prior to planned surgery, and
use alternative methods of birth control to minimize the risk of
this complication.
Other complications include protrusion of the small intestine
or prolapse of the fallopian tube into the vagina. These occur
very rarely and can be corrected surgically. As with any surgical
procedure, complications related to anesthesia can also occur.
As with any abdominal operation, there is a possibility of eventually
developing a hernia in the incision site.
WILL I NEED HORMONES AFTER THE SURGERY? Hormone
replacement therapy (HRT) is recommended for women who have their
ovaries removed, if they have not yet completed menopause. If HRT
is planned, talk with the doctor about the risks and benefits of
this treatment, and about how long you will continue to take hormones.
In younger women who retain their ovaries, HRT may be needed
at a later date if the ovaries fail to function properly.
Women who have completed menopause may or may not have been taking
hormones prior to hysterectomy. They should talk with the doctor
as to whether hormones will be needed following removal of the
ovaries.
HOW DOES HYSTERECTOMY AFFECT SEXUAL
FUNCTIONING? Hysterectomy
appears to have few, if any, negative effects on sexual functioning.
In a recent study of 1,000 women undergoing hysterectomy, favorable
effects were found, including an increase in the frequency of sexual
activity and a decrease in problems associated with sexual functioning.
WHERE TO GET MORE INFORMATION Your
gynecologist is the best resource for finding out important information
related to your particular case. Because every patient is different,
it is important that your situation is evaluated by someone who
knows you as a whole person.
INFERTILITY
These materials are for your general information and are not
a substitute for medical advice. You should contact your physician
or other healthcare provider with any questions about your health,
treatment, or care.
INTRODUCTION Infertility is defined as the inability
of a couple to become pregnant after one year of unprotected intercourse.
Infertility is a common condition: in any given year, about 15
percent of the couples in the United States who are trying to conceive
are infertile.
The ability of a couple to become pregnant depends on several
factors in both the male and female partners. Among all cases of
infertility, about 20 percent can be traced to male factors, 40
percent can be traced to female factors, 30 percent can be traced
to factors in both the male and female partners. In about 15 percent
of couples, the etiology for infertility cannot be traced to specific
factors in either partner.
Because fertility involves a complex interaction of male and
female factors, doctors routinely involve both partners in the
evaluation of infertility. Today, many tests are available for
evaluating infertility, although these tests may require a substantial
commitment of time, money, and effort. It is important to gather
information about these tests and to carefully discuss the many
options with your doctor.
LIMITATIONS OF INFERTILITY TESTS In
many cases, infertility tests can identify the most likely cause
of infertility and help guide the treatment of this condition.
However, studies have shown that these tests also have limitations.
For many of these tests, the definition and the significance of
a "normal" result are still uncertain. In general, test
results are more likely to be abnormal in infertile couples than
in fertile couples; however, many couples with abnormal test results
are able to conceive. Your doctor can provide helpful information
about the interpretation of infertility test results.
FACTORS ASSOCIATED WITH INFERTILITY A
study of infertile couples showed that several factors were associated
with infertility, although it is unknown if these factors were
actually the cause of infertility. The factors included male reproductive
problems (23 percent of couples); ovulation problems (18 percent);
damage of the fallopian tubes (14 percent); endometriosis (9 percent),
problems with intercourse (5 percent), and an abnormal interaction
of cervical mucus and sperm (3 percent). In 28 percent of the couples
in this particular study, the cause of infertility could not be
determined.
EVALUATION OF MALE CAUSES OF INFERTILITY Although
a variety of tests are available for evaluating male infertility,
many of these tests may not be necessary. Doctors usually begin
with a medical history, a thorough physical examination, and semen
analysis.
Medical history Your past health
and medical history may provide clues about the cause of infertility.
Your doctor will ask about your childhood development; sexual development
during puberty; sexual history; illnesses and infections; surgeries;
drugs that you may take; exposure to certain environmental agents
(alcohol, radiation, steroids, chemotherapy, and toxic chemicals);
and any previous fertility evaluations that you may have had.
Physical examination A physical
examination usually includes a general medical examination, with
special attention to any signs of hormone deficiency or signs of
other conditions that might impair fertility. Your doctor will
measure your height and weight, assess your body fat and muscle
distribution, inspect your skin and your hair pattern, and check
for any breast development. Your doctor will also perform a genital
exam, which can identify structural abnormalities of the reproductive
tract and signs of delayed sexual development or low hormone levels.
Standard semen analysis Standard
semen analysis can provide information about the volume and pH
of semen; the concentration, motility (movement), and shape of
sperm; the presence of immature sperm; and the presence of other
substances and cells that affect fertility.
Your doctor will usually request that you abstain from sex for
at least 2 days before providing the semen sample. Ideally, a sample
should be produced in your doctor's office by masturbation, but
if that is not possible, you may be allowed to collect a sample
at home in a chemical-free condom and deliver it to the lab within
an hour of collection. If the result is abnormal, your doctor will
request two additional samples several weeks apart to confirm whether
or not there is a problem.
Men with a sperm count below 20 million/mL are more likely to
be infertile; however, many men with sperm counts in this category
are fertile. There are no standard measures for the motility and
shape of sperm, but studies in infertile men who have later fathered
children have provided some general estimates of the values associated
with fertility. In these men, more than 40 percent of sperm had
a motility of 2.5 or greater (on a scale of 0 to 4), and more than
30 percent of sperm had the normal oval-shaped head.
Blood tests Blood tests can
provide information about the levels of several hormones that play
a role in male fertility; in men, key hormones are produced by
the hypothalamus, the pituitary gland, and the testes. The hormone
levels and the overall pattern can determine if these structures
are functioning normally. These tests are only performed if the
semen analysis is abnormal.
Genetic tests If your doctor
suspects genetic or chromosomal abnormalities are contributing
to infertility, he or she may order a test to check for missing
or defective regions of genes and chromosomes.
Other tests If your doctor
suspects an obstruction of the reproductive tract, he or she may
order a transrectal ultrasound (TRUS) test. This test can identify
blocked regions of the male reproductive tract. Your doctor may
also request a postejaculatory urine test if retrograde ejaculation
(movement of semen in the wrong direction in the reproductive tract)
is a possibility. Your doctor may also recommend a testicular biopsy
(collection of a small tissue sample) to examine the microscopic
architecture of the testes and to directly check for sperm production.
EVALUATION OF FEMALE CAUSES OF INFERTILITY — Although
a variety of tests are available for evaluating female infertility,
many of these tests may not be necessary. Doctors usually begin
with a medical history, a thorough physical examination, and some
preliminary tests.
Medical history Your past health
and medical history may provide some clues about the cause of infertility.
Your doctor will ask about your childhood development; sexual development
during puberty; sexual history; illnesses and infections; surgeries;
drugs that you may take; exposure to certain environmental agents
(alcohol, radiation, steroids, chemotherapy, and toxic chemicals);
and any previous fertility evaluations that you may have had.
Physical examination A physical
examination usually includes a general medical examination, with
special attention to any signs of hormone deficiency or signs of
other conditions that might impair fertility. Your doctor will
also perform a pelvic examination, which can identify structural
abnormalities of the reproductive tract and signs of low hormone
levels.
Blood tests Blood tests can
provide information about the levels of several hormones that play
a role in female fertility; in women, key hormones are produced
by the hypothalamus, the pituitary gland, and the ovaries. These
hormones include follicle-stimulating hormone (FSH), luteinizing
hormone (LH), and prolactin.
Tests to evaluate ovulation Ovulation
(the release of an egg from an ovary) is essential for fertility.
Abnormalities of ovulation can often be determined from a woman's
menstrual history, her basal body temperature tracking, or hormone
levels such as the pre-ovulatory LH surge or luteal phase progesterone.
Menstrual history Amenorrhea
(absent menstrual periods) usually signals an absence of ovulation,
which is a known cause of infertility. Oligomenorrhea (irregular
menstrual cycles) can signal erratic ovulation; although oligomenorrhea
does not make pregnancy impossible, it reduces the likelihood of
pregnancy.
Basal body temperature Monitoring
of basal body temperature (measured early in the morning when body
temperature is at its lowest point) can help determine if ovulation
is occurring. This temperature usually rises by 0.5ºF to 1.0ºF
after ovulation. However, basal body temperature patterns can sometimes
be difficult to interpret.
Hormone levels Levels of luteinizing
hormone (LH) rise abruptly approximately 38 hours before ovulation.
This hormone surge can be detected using an over-the-counter urinary
test kit. However, this kit may fail to detect the hormone surge
about 15 percent of the time. Therefore, your doctor may recommend
a blood test to confirm ovulation.
Blood levels of the hormone progesterone
are a more accurate indicator of ovulation. Normally, levels
of progesterone rise after ovulation. Progesterone tests are
usually performed 18 to 24 days after the first day of a menstrual
period.
Hysterosalpingography This
procedure can help identify structural abnormalities of the uterus
and fallopian tubes that can contribute to infertility. During
hysterosalpingography, a liquid dye is placed in the uterus and
fallopian tubes to outline these structures on x-rays; hysterosalpingography
is usually performed after the completion of a menstrual period,
but before ovulation.
Hysteroscopy During hysteroscopy,
a thin, lighted tube is advanced into the uterus and fallopian
tubes to directly examine these structures. A hysteroscopy is usually
performed in women who are thought to have an abnormal uterine
cavity on hysterosalpingography or ultrasound; several structural
abnormalities can be surgically treated during hysteroscopy.
Uterine abnormalities Uterine
abnormalities that can contribute to infertility include congenital
structural abnormalities, such as a uterine septum (a band of tissue
that makes the uterine cavity small); abnormalities linked to exposure
to diethylstilbestrol (DES) (a hormone used in the past to prevent
miscarriage), which can cause a T-shaped uterus; fibroids; polyps;
and structural abnormalities that can result from gynecologic procedures.
Fallopian tube abnormalities Scarring
and obstruction of the fallopian tubes is most often due to pelvic
inflammatory disease. Other conditions that can affect the function
of the fallopian tubes include endometriosis and pelvic adhesions
(scar tissue) from abdominal infection or surgery.
Pelvic ultrasound Pelvic ultrasound
can also detect structural abnormalities of the uterus, ovaries,
and other pelvic tissues and organs.
Laparoscopy During laparoscopy,
a thin, lighted tube is advanced through a small abdominal incision
to directly examine the pelvic structures. This test can detect
damage and obstruction of the fallopian tubes, endometriosis, and
other abnormalities of the pelvic structures.
Laparoscopy is the best test for making the diagnosis of endometriosis
or pelvic adhesions (scarring). Furthermore, endometriosis tissue
can be removed during laparoscopy, and this removal has been shown
to improve pregnancy rates in infertile women.
Your doctor will likely recommend laparoscopy if you have had
endometriosis, appendicitis, pelvic surgery, pelvic inflammatory
disease, or other conditions known to affect the fallopian tubes
or uterus. Laparoscopy is also helpful when other tests fail to
reveal a cause of infertility.
Genetic tests If your doctor
suspects genetic or chromosomal abnormalities are contributing
to infertility, he or she may order a test to check for missing
or defective regions of genes and chromosomes.
WHERE TO GET MORE INFORMATION A
doctor is the best resource for finding out important information
related to your particular case. Not all patients with infertility
are alike, and it is important that your situation is evaluated
by someone who knows you as a whole person.
INTRODUCTION — Women
of childbearing age and their partners should be offered preconceptional
evaluation and counseling. This information will help prepare
patients for pregnancy, can benefit the fetus, and may also lead
to a more healthy lifestyle for the patient. The United States
Public Health Service Expert Panel on the Content of Prenatal
Care recommended that efforts to help women and their partners
prepare for pregnancy should be an important part of prenatal
care and that such care should be included in all primary care
services.
Up to 30 percent of pregnant women begin
traditional prenatal care in the second trimester (>13 weeks
of gestation), after the period of maximal organ development
(between 3 and 10 weeks gestation). However, optimizing the health
of the mother before conception is important for improving pregnancy
outcome. This is particularly true for certain populations of
women, such as those with medical disorders (eg, diabetes, phenylketonuria),
nutritional deficiencies (eg, folic acid), and exposure to toxins
or substances that can cause birth defects and abnormalities,
also known as teratogens (eg, cigarettes, alcohol, warfarin,
accutane), in whom preconception care has been shown to reduce
neonatal morbidity and mortality. As an example, of the 4000
pregnancies affected by neural tube defects each year in the
United States, at least 50 percent have been estimated to be
preventable by the use of daily folic acid before conception
and during early pregnancy.
Thus, preconceptional evaluation and counseling provide an opportunity
to identify some of the risks of pregnancy for the mother and fetus,
educate the patient about these risks, and institute appropriate
interventions, when possible, before conception. Potential opportunities
for preconceptional counseling occur during many non-emergency
health care encounters, including:
Premarital examination and testing
Contraception counseling
Evaluation for sexually transmitted
disease or vaginal infection
After a negative pregnancy test
Anytime a woman of childbearing
age presents for a periodic health examination.
Risk factors for adverse outcome that cannot be modified (eg,
maternal age).
Financial issues (eg, lack of health insurance,
nonreimbursible services)
Inadequate training of health care
providers and long wait for appointments
Unplanned pregnancy One-third
to one-half of liveborn infants are the result of unintended pregnancy.
In one study, for example, 40 percent of the mothers surveyed three
to six months after delivery reported that their pregnancy was
unplanned. One-half of women who planned their pregnancy and two-thirds
of the mothers with unintended pregnancies had one or more indications
for preconceptional counseling (smoking within three months of
pregnancy, drinking three or more drinks within three months of
pregnancy, low body mass index, or delayed initiation of prenatal
care [after the first trimester]). These findings suggest that
preconceptional counseling should be provided to all women of childbearing
age, regardless of their immediate pregnancy plans.
Financial issues Preconceptional
counseling may not be fully reimbursed by third-party payers. Many
insurers currently do not provide coverage for screening tests
as part of preconceptional counseling, although these same tests
are covered when performed in early pregnancy. Furthermore, a number
of low income women have multiple risk factors for adverse pregnancy
outcome and are less knowledgeable about pregnancy and health.
These women often do not have any health insurance and, therefore,
may be reluctant to seek preconceptional care. Difficulties with
child care and transportation are also barriers to access services.
Provider factors All women's
health care providers should be trained to perform adequate assessment
of pregnancy risks, offer appropriate recommendations for intervention,
and provide basic patient education. Certain situations should
prompt consideration of referral to genetic counseling or specialty
care.
Lack of coordination among providers of women's health services
can be a barrier to optimum care. Healthcare systems that develop
strategies to provide more culturally competent care, more timely
appointments, and assistance with insurance applications may be
able to increase the number of women seeking early prenatal services.
Patient education
regarding pregnancy risks, management options, and reproductive
alternatives
Initiation of interventions, when possible, to
provide optimum pregnancy outcome.
Risk assessment The key task
in identifying risks to the woman and her pregnancy is to obtain
a thorough history. Several paper and computerized questionnaires
and record forms are commercially available for this purpose. Patient
education and medical interventions can subsequently be initiated
using this database.
Medical history A complete medical
history is useful for discussing how pregnancy can affect maternal
medical conditions and the effect of a medical disorder on the
fetus and pregnancy. The patient's medications (including over-the-counter
and prescription drugs) should be discussed to determine whether
potentially teratogenic substances are being used. It is especially
important to elicit exposure to dietary supplements (eg, herbal
supplements), as patients may not perceive them as medications
that can be harmful to the fetus. A dietary evaluation also should
include an assessment of body mass index and eating habits (eg,
food restrictions).
Age Advanced maternal age is
associated with increased pregnancy risks that include infertility,
fetal chromosomal abnormalities, gestational diabetes, preeclampsia
(formerly called toxemia), and stillbirth. Women should be aware
of these risks and the consequences of delaying conception until
they are over 35 years of age.
Reproductive history The gynecologic
and obstetric histories are important for identifying factors that
may contribute to infertility or complications in a future pregnancy.
Uterine anomalies or maternal in-utero diethylstilbestrol exposure,
for example, can be associated with pregnancy wastage or preterm
birth. The recurrence risk of an adverse outcome (eg, preterm birth,
intrauterine growth restriction, preeclampsia) should be discussed
with women who have a history of pregnancy complications.
Family history Evaluation of
the patient's family history helps to identify genetic risks to
the fetus and maternal medical risks that may not have been appreciated.
As an example, a woman may not be aware that a family history of
blood clots can put her at risk for thromboembolic and pregnancy
complications. For those with a positive family history, referral
to a specialist in genetic counseling is usually required to discuss
carrier testing, the risk of genetic disease in the fetus, options
regarding prenatal diagnosis, and the natural course of the disease.
Substance abuseExposure to
tobacco, alcohol, and illicit drugs can be harmful to both the
mother and fetus.
Use of tobacco in pregnancy has been associated with several
adverse outcomes, including miscarriage, prematurity, and low birth
weight [
A spectrum of birth defects related to alcohol intake during
pregnancy may occur, ranging from subtle growth retardation
and neurobehavioral effects with moderate alcohol intake,
to the fetal alcohol syndrome with heavy use.
Illicit drugs
have variable effects on pregnancy outcome that may be related
to social disturbances in the mother, in addition to effects
of the drugs themselves.
Psychosocial status Psychosocial
stress and financial issues should be identified and appropriate
interventions taken with the help of a community resource specialist.
It is particularly important to screen for the presence of domestic
violence, lack of social support, and barriers to prenatal care
Environmental exposures Questions
about the woman's work, hobbies, pets, and home environment can
identify potentially toxic exposures. Examples of such hazards
include organic solvents used in manufacturing processes, toxoplasmosis
risk from cat litter boxes or eating under-cooked meat, and lead
paint or solder used for decorating or in crafts. There is no convincing
evidence that exposure to common types of electromagnetic field
radiation, such as computer monitors, electric blankets, heated
water beds, and microwave ovens, is harmful.
The Occupational Safety and Health Administration (OSHA) sets
and enforces standards requiring employers to provide a workplace
free from recognized hazards likely to cause serious physical harm.
This information should be available at the patient's workplace.
Caffeine Caffeine consumption
over 250 mg per day appears to be associated with a modest, but
statistically significant decrease in fertility and intake greater
than 500 mg daily appears to increase the risk of spontaneous abortion.
Excess coffee consumption may also increase the risk of stillbirth
(four to seven cups OR 1.4 (95 percent CI 0.8 to 2.5), eight or
more cups and decrease birth weight slightly. For these reasons,
women planning pregnancy should consider limiting daily caffeine
intake to less than 250 mg.
Weight Maternal obesity has
been associated with reduced fertility and several pregnancy complications,
such as increased risks of gestational diabetes, having a child
with a congenital anomaly, and pre-eclampsia. Although weight loss
to reduce pregnancy risks has not been studied (except in women
with polycystic ovary syndrome), the clear overall health benefits
of achieving a normal body mass index have been well described.
Physical examination — The
physical examination in the preconceptional evaluation is the same
as for the routine periodic health evaluation
Laboratory assessment The choice of laboratory
tests depends upon the general guidelines recommended for all pregnant
women and the individual's personal medical history.
Interventions After the pregnancy
risk assessment is performed, preconceptional interventions are
directed at preparing and educating the patient, providing optimum
therapy of medical disorders, and referral for specialized care,
when appropriate.
Maternal medical problems Optimal
management of maternal medical conditions, including changes in
medications to incorporate medications known to be safer in pregnancy,
is an important step.
Substance use Smoking cessation
and reduction during pregnancy improves pregnancy outcome. Women
who are smokers can be counseled on the benefits of smoking cessation
and offered resources to help them quit smoking.
Women who drink alcohol should be counseled to abstain during
pregnancy since there are no data that establish a safe threshold
for alcohol consumption. Patients who have problems with substance
abuse should be strongly advised of the risks of this behavior
and referred to cessation programs in their area.
Depression and psychotropic drugs Patients
with a history of depression or active symptoms of depression should
be treated, if necessary, with drug therapy. Most of the commonly
used psychotropic agents appear to be relatively safe during pregnancy.
Nutrition A
nutritionist may be consulted to evaluate restricted diets or
to offer advice on eating a well-balanced, healthy diet. Megavitamins,
non-essential dietary supplements, and herbal preparations should
be discontinued given the unknown risk to the fetus from such
substances. All women should be counseled to take a multivitamin
with at least folic acid (0.4 mg) to reduce the risk of neural
tube defects. The optimal dose of folic acid to prevent as many
neural tube defects as possible is not precisely known. The United
States Preventive Services Task Force recommends a folic acid
supplement of 400 micrograms/day (the RDA) for all women in the
childbearing years. However, doses well above this amount may
be necessary to maximally reduce the risk of neural tube defects;
therefore, many authorities recommend a supplement containing
800 micrograms for women trying to conceive. Multivitamin preparations
containing more than 5000 IU of vitamin A should be avoided (increased
risk of birth defects at >10,000
IU/day).
The quantity and type of fish consumed should also be regulated
and certain types of fish should be avoided during pregnancy and
the preconceptional period due concerns about possible teratogenic
effects from environmental toxins. Only cooked fish should be eaten.
Exercise Mild to moderate exercise
is not harmful to the healthy pregnant woman or her fetus. Women
who exercise regularly prior to pregnancy may continue with their
usual level of physical exertion during pregnancy. Initiation of
strenuous exercise during pregnancy, on the other hand, should
be avoided.
Immunization Ideally, a woman
should be immune to or immunized against infections that place
her or her fetus at risk. These diseases vary by country and personal
risk factors
Vaccination should be offered to a woman with a negative rubella
titer and she should be advised to wait three months before attempting
conception since this is a live attenuated virus vaccine.
Varicella (chicken pox) infection during pregnancy can be associated with significant
maternal and fetal morbidity and mortality. Not surprisingly, then, many have
suggested screening women prenatally for evidence of prior varicella exposure
in an effort to identify those who are varicella susceptible. A history of
varicella infection is generally reliable. Women who deny a history of clinical
disease should be offered blood testing; most of these women will have a positive
titer due to prior shistory without symptoms. A strategy of vaccinating those
with a negative titer has been found cost effective. Women with high risk of
exposure, such as health care workers, should definitely be vaccinated. Women
who receive varicella vaccine, a life attenuated vaccine, should be advised
to avoid pregnancy for three months.
Patients at risk for hepatitis B infection (eg, women with multiple sexual
partners, household contacts of patients with hepatitis B, healthcare workers)
should be offered hepatitis B vaccine.
HIV infection Women
of childbearing age who are HIV positive should all be offered
preconceptional counseling, with specific emphasis on a thorough
discussion of the risk of transmission of HIV to the neonate and
how the risk can be modified.
Other concerns Additional
common concerns that may be addressed at this time include:
Timing the initial pregnancy and interval between pregnancies.
Concerns about infertility
Fears concerning the pregnancy
Work related issues and maternity leave
Marital issues.
MENOPAUSE
These materials are for your general information and are not
a substitute for medical advice. You should contact a physician
or other healthcare provider with any questions about your health,
treatment, or care.
WHAT IS MENOPAUSE? Prior
to menopause, (which usually occurs between the ages of 45 and
55), many women notice that their periods start to occur more frequently
(as often as every 21 days), but eventually become infrequent.
This time of "transition," called perimenopause, can
last for several years until menopause, when periods stop altogether.
Although the average age of menopause is between 50 and 51 years,
some women experience unusually early menopause (before age 40)
due to surgical removal of the uterus or both ovaries, chemotherapy,
or radiation therapy. However, most cases of early menopause are
unexplained.
With the onset of menopause, a woman's body stops making estrogen
and progesterone. Estrogen and progesterone are the female hormones
produced by the ovaries that prepare the uterus for possible pregnancy.
Hot flashes (or hot flushes), a result of a fall in estrogen levels,
often begin several years before actual menopause and continue
for several years after menopause. They are far more common at
night, and can disrupt sleep. Therefore, many women also experience
symptoms related to sleep-deprivation, such as fatigue, irritability,
difficulty concentrating, and mood swings. Finally, many women
begin to experience vaginal dryness or urinary symptoms, both of
which are related to estrogen deficiency. Estrogen is the most
effective treatment available for hot flashes, symptoms related
to sleep-deprivation and vaginal dryness.
Estrogen has important effects on many other organs, such as
the brain, skin, blood vessels, heart, bone, and breast. Of particular
importance is bone and possibly cardiovascular (heart) health.
Without estrogen, the body is at greater risk of developing osteoporosis,
a disease in which bones lose calcium and become more susceptible
to fracture. In addition, the risk of heart disease in women increases
after menopause, although giving back estrogen (hormone replacement
therapy) has not been shown to prevent heart disease.
WHAT IS ESTROGEN REPLACEMENT THERAPY? —Estrogen
replacement therapy also called ERT, is a way for a postmenopausal
woman to replace the estrogen her body is no longer making. While
it does not make her fertile again, it does eliminate many of the
symptoms of menopause. When women with a uterus take estrogen they
also need to take a progesterone-like hormone (called progestins)
to eliminate the risk of uterine (endometrial) cancer. The term
hormone replacement therapy (HRT) is used when estrogen and progestin
are given together.
HISTORY OF HRT USE — Estrogen
first became popular in the 1960's for the treatment of hot flushes.
At that time, it was also thought that estrogen was a way to preserve
a youthful appearance. Early on, high doses of estrogen were given
(for example, 2.5 mg of conjugated estrogen compared to the standard
0.625 mg dose that is currently used). Since then, the regimens
and the reasons for taking it have been evolving.
It was learned that taking estrogen alone
resulted in an increased risk of endometrial cancer (also known
as uterine cancer).
It was then determined that adding a progestin
to estrogen could prevent the increased endometrial cancer
risk. Therefore, by the mid-1980's, progestins were routinely
added to estrogen replacement therapy (in any woman with an intact
uterus, ie, women who had not undergone a hysterectomy).
Many
studies showed that taking ERT or HRT could prevent the bone
loss that occurs after menopause, which can lead to osteoporosis
and its fractures.
Over 30 studies suggested that estrogen was
an important therapy for both primary (an intervention designed
to prevent a disease from occurring in the first place) and
secondary prevention (an intervention designed to prevent the
recurrence of problems in someone who already has the disease)
of coronary heart disease (CHD). In fact, it appeared that women
taking estrogen reduced their risk of a first heart attack by
50 percent. In addition, estrogen appeared to reduce recurrent
events in women who already had coronary disease.
Because of the
osteoporosis and CHD studies, ERT and HRT began to be prescribed
for the prevention of both diseases, which meant giving it
long-term (more than 5 years).
Breast cancer studies began to
indicate that taking ERT more than 5 years increased the risk
of breast cancer.
Clinical trials, (studies in which women are
randomly assigned to receive active treatment or placebo),
did not agree with the earlier studies. The Women's Health Initiative
(WHI) and the HERS trials (of combined estrogen-progestin therapy),
studies of primary and secondary prevention of heart disease,
respectively, demonstrated that HRT did not prevent heart disease,
and in fact, might increase risk. The WHI trial of combined
estrogen-progestin therapy did observe an increased risk of breast
cancer, but no increase was seen in the trial of unopposed estrogen.
One possible explanation
for the conflicting results between the observational studies
and clinical trials, is that the observational studies had a
problem with "healthy user bias".
This means that the healthiest women (ie. those who were less
apt to have a heart attack), were more likely to be started on
estrogen by their physicians. Therefore, it is possible that
estrogen's beneficial effect on the heart was more related to
the underlying health of the women taking it, rather than the
medication itself.
WOMEN'S HEALTH INITIATIVE — The
Women's Health Initiative (WHI) is a set of clinical trials that
includes two HRT trials. The WHI studied healthy postmenopausal
women aged 50 to 79 years, and the study was scheduled to be completed
in 2005. However, one component of the WHI (continuous, combined
conjugated estrogen (CEE 0.625 mg/day) and medroxyprogesterone
acetate (MPA 2.5 mg/day) versus placebo in over 16,000 women) was
discontinued in 2002 because of an increased risk of coronary heart
disease, breast cancer, stroke, and venous thromboembolism (blood
clots in the leg or lung) over an average follow-up of 5.2 years.
Although there was reduction in risk of osteoporotic fractures
and colon cancer, there was concern that the risks of combined
estrogen-progestin may outweigh the benefits.
The WHI trial of unopposed estrogen (CEE 0.625 mg/day) versus
placebo in women who had undergone hysterectomy (and therefore
did not require a progestin) was also discontinued (early 2004)
because of a small increase in stroke risk (but no increase in
CHD or breast cancer risk).
Only one type of estrogen (CEE 0.625 mg) and one type of progestin
(MPA 2.5 mg) treatment were studied in the WHI brand names Premarin
(unopposed estrogen) and Prempro (estrogen combined with progestin).
Although there are theoretical reasons to believe that other types
of estrogen and progestin, different routes of administration (skin
patch) or lower doses might be safer, to date, there are no studies
to demonstrate that this is true.
The results of the WHI were as follows:
Coronary heart disease — The
rate of coronary events such as heart attacks was 24 percent higher
in the women taking HRT compared to those taking placebo. This
seems like a large increase in risk, but the increase for an individual
woman is low. For example, on average there were 39 CHD events
per year per 10,000 women versus 33 events per 10,000 women taking
placebo (ie, an additional 6 events per 10,000 women per year).
The difference in coronary events developed within the first
year of the study. The risk persisted in years two through five
of the study, but the highest risk was in the first year. Taking
a daily aspirin did not seem to reduce the risk.
In contrast, the WHI trial of unopposed estrogen did not observe
an increase in CHD risk. In the younger women in the trial (ages
50-59), a possible protective effect was seen with estrogen (although
this was not significant).
Secondary prevention was evaluated in the HERS trials of 2763
postmenopausal women with a history of coronary disease .
After nearly 7 years of follow-up, continuous estrogen-progestin
therapy did not reduce the risk of CHD events in women with established
CHD.
Stroke — The
rate of stroke was increased with combined estrogen-progestin.
On average per year, there were 29 strokes in the treatment group
versus 21 events in the placebo group per 10,000 women (8 additional
cases per 10,000 women per year). Most of the increase in risk
was due to nonfatal strokes, and the increase did not appear
until year two of the study (but persisted through year five).
A very similar pattern of risk was seen in the trial of unopposed
estrogen)
Blood clots — The
rate of blood clots (in the leg and lung) increased with combined
estrogen-progestin (34 versus 16 per 10,000 women per year; or
18 additional cases per 10,000 women per year). Risk was also
increased with unopposed estrogen.
Breast cancer — The
risk of breast cancer was increased in the WHI trial of combined
estrogen-progestin. On average, per year there were 38 cases
of breast cancer per 10,000 women versus 30 per 10,000 women
(8 additional cases per year per 10,000 women). Similar findings
have been noted in a number of observational studies, all of
which suggest that the major increase in risk occurs after four
or five years. In addition, the WHI reported that women taking
combined estrogen-progestin were more likely to have an abnormal
mammogram. However, the majority of the abnormal mammograms were
requests to return for additional views.
The results of the trial of unopposed estrogen were quite surprising,
because no increase of breast cancer was seen. In fact, a possible
lower risk was seen, but this was not quite significant. The fact
that an increase in breast cancer risk was seen with combined hormone
therapy, but not with unopposed estrogen suggests that the progestin
component is a very important factor in breast cancer risk.
Osteoporotic fracture — The
risk of osteoporotic fracture was reduced at the hip and spine
in both the trial of combined estrogen-progestin and the trial
of unopposed estrogen. On average, per year there were 5 fewer
hip fractures per 10,000 women in the HRT versus placebo group.
Colorectal cancer — The
risk of colorectal cancer was reduced (6 fewer colorectal cancers
per 10,000 women per year in the trial of combined estrogen-progestin
versus placebo group. This benefit was not seen in the trial of
unopposed estrogen.
Cognitive function and dementia — Although
it had been thought that estrogen may preserve cognitive function
and prevent dementia, data from the WHI do not support this. No
significant improvement in overall cognitive function was seen
with combined estrogen-progestin therapy compared with placebo.
It is still possible, however, that there are benefits for certain
specific types of cognitive function, although this is not proven.
The impact of unopposed estrogen, or taking HRT in the early postmenopausal
years is not known.
In addition, combined estrogen-progestin therapy did not prevent
dementia. To the contrary, an increased risk was seen (approximately
23 additional cases of dementia per 10,000 women per year). It
is not known why dementia risk was higher with hormone therapy,
but one possible explanation is an increased risk of multiple small
strokes (which predisposes women to dementia). Similar results
were reported in the unopposed estrogen trial. The effect of taking
HRT in the early menopausal years on the risk of later dementia
is not known, although many early studies suggest that it is early,
rather than late, exposure to estrogen is important for later cognitive
function.
Endometrial hyperplasia and cancer — Studies
have found that postmenopausal women with a uterus who are treated
with estrogen alone increase their risk of endometrial cancer and
hyperplasia (a precursor to cancer). Within one year, endometrial
hyperplasia can be found in 20 to 50 percent of women receiving
estrogen alone. The risk can be even greater if very high doses
are used or if the unopposed estrogen is continued for many years.
Even when women discontinue the estrogen, the endometrial cancer
risk persists for approximately five years.
In the WHI, only women without a uterus received unopposed estrogen.
In women with a uterus who received combined estrogen-progestin
therapy, there was no increased risk of endometrial hyperplasia
or cancer.
Absolute risk of an adverse event — It
should be emphasized that the absolute risk of an adverse event
occurring in an individual on the estrogen-progestin regimen in
the WHI was extremely low (19 additional events per year per 10,000
women with HRT compared to placebo).
In the trial of unopposed estrogen, it was calculated that overall
risks and benefits would be equal (not taking into account the
effect that estrogen has on hot flashes).
Most now agree that using either unopposed estrogen or combined
estrogen-progestin therapy for symptom relief in young postmenopausal
women in a safe and reasonable option.
OTHER RISKS — There
are many HRT studies in addition to the WHI that provide other
information about breast cancer. In addition, there are other
known risks of HRT such as gallbladder disease that were not
addressed in the WHI report.
Other breast cancer issues — The
degree of increase in breast cancer risk due to estrogen is often
misinterpreted. It is most important for a woman to understand
the absolute risk that she will get breast cancer because she takes
estrogen. It has been calculated that for a 50-year-old woman taking
estrogen, there is a 1 in 100 chance that she will develop breast
cancer over a 10-year period that would not have developed without
estrogen. This estimate would be slightly higher (eg, 1.5 in 100)
for a woman over 65 years of age.
Many studies have reported that if breast cancer does occur during
estrogen therapy, it is biologically less aggressive, and survival
rates are better than when breast cancer occurs in women who were
not taking estrogen. However, in the WHI combined estrogen-progestin
trial, women on hormones had tumors that were slightly larger and
more likely to have spread to the lymph nodes. As mentioned above,
no increase in breast cancer risk was seen in the trial of unopposed
estrogen.
Gallbladder disease — There
is considerable evidence that estrogen therapy, especially in pill
form, is associated with an increased risk of gallbladder disease.
The risk of cholecystectomy, (removal of the gallbladder), increases
the longer a woman uses hormone therapy and the higher the dose
of estrogen used. The risk decreases substantially within one to
three years after a woman discontinues hormone therapy.
OTHER BENEFITS — In
addition to easing the symptoms of menopause, ER/HRT has many
other positive effects.
Menopausal symptoms — Estrogen
is the most effective treatment available for symptoms such as
hot flashes, urinary symptoms, and vaginal atrophy (atrophic vaginitis),
a condition in which the vagina can become dry, resulting in pain
with intercourse.
Quality of life — Women
with severe menopausal symptoms often describe a dramatic improvement
in their quality of life when they are treated with estrogen. This
is due to relief of hot flushes and restoration of normal sleep.
Urinary tract infection — Estrogen
has been found to decrease the frequency of urinary tract infections,
possibly by normalizing the microorganisms present in the vagina.
It does not help the symptoms of urinary incontinence.
Diabetes mellitus — The
WHI reported that HRT appears to reduce the risk of type 2 diabetes
mellitus (adult onset diabetes). However, because of the other
risks of HRT, this effect is insufficient to recommend HRT for
routine diabetes prevention in postmenopausal women.
Depression — Estrogen
may improve mood and decrease depression in some menopausal women.
One study showed that estrogen plus progestin was effective in
perimenopausal women with depression.
WHO SHOULD TAKE HRT? — Data
from the WHI and the HERS trials have led to changes in our recommendations
for hormone therapy. Continuous estrogen-progestin therapy appears
to increase the risk of cardiovascular events and breast cancer;
in addition, other drugs (eg, bisphosphonates, raloxifene) can
protect against osteoporosis. Unopposed estrogen increases the
risk of stroke, but overall, its benefits seem equal to its risks.
As a result, the main reason to take hormone therapy at present
is to control menopausal symptoms.
Menopausal symptoms — Estrogen
or combined estrogen-progestin therapy remains the gold standard
for relief of menopausal symptoms, and therefore is a reasonable
option for most postmenopausal women, with the exception of those
with a history of breast cancer, CHD, a previous blood clot or
stroke, or those at high risk for these complications. In otherwise
healthy women, the absolute risk of an adverse event is extremely
low. Most experts agree that hormone therapy is safe and reasonable
for healthy postmenopausal women who need to take it to relieve
symptoms. When it is used, is should be taken for the shortest
period of time possible.
Administration of estrogen short-term is not associated with
an increased risk of breast cancer, but endometrial hyperplasia
and cancer can occur after as little as six months of unopposed
estrogen therapy; as a result, a progestin must be added in those
women who have not had a hysterectomy.
In women being treated for symptoms, the goal is to eventually
taper and stop the estrogen (unless there is a compelling reason
to continue it long-term). After the planned treatment interval,
the estrogen should be discontinued gradually, for example, by
omitting one pill per week, to minimize recurrence of the menopausal
symptoms.
Low-dose oral contraceptives — A
low-estrogen oral contraceptive (20 µg of ethinyl estradiol)
remains an appropriate treatment for perimenopausal women who seek
relief of menopausal symptoms. Most of these women are between
the ages of 40 and 50 years and are still candidates for oral contraception.
For them, an oral contraceptive pill containing 20 µg of
ethinyl estradiol provides symptomatic relief, contraception, and
sometimes better bleeding control than conventional estrogen-progestin
therapy.
Dose of estrogen — It
is possible that lower doses of estrogen may be safer than estrogen,
while still effectively treating menopausal symptoms. For example,
conjugated estrogens (0.3 mg) or the equivalent dose of other estrogens
(estradiol, estrogen patch) have been shown in some, but not all
studies to relieve symptoms and prevent bone loss. But it is not
yet known whether lower doses of estrogen or different HRT preparations
are safer with regards to breast cancer and cardiovascular risks.
Therefore, it is safest to assume that other preparations carry
the same risk.
Long-term estrogen therapy — Only
a minority of women who are unable to successfully discontinue
estrogen without persistent symptoms should consider long-term
estrogen therapy. If HRT is resumed, the lowest dose possible should
be used, and plans should be made to try another taper at a later
date. It is important that the breast cancer and cardiovascular
risks are discussed in detail with these women.
WHAT FORM DOES ESTROGEN COME IN? — Estrogen
can be taken as a pill (orally), or absorbed through the skin from
a patch (transdermally), or inserted into the vagina.
Estrogen pill — There
are many forms of estrogen pills. The most commonly used preparation,
called Premarin, is made from pregnant mares' urine. Many other
preparations are derived from plant sources, such as soy and yams.
While there is no evidence that plant-derived estrogens work better
or are safer than Premarin, many women prefer them.
Sometimes the dose of estrogen is large enough to protect bones,
but not to completely eliminate menopausal symptoms. When these
symptoms occur, a larger dose may be given for a year or two, but
then the dose is usually reduced.
Besides Premarin, other brands of estrogen include: Cenestin,
Estratab, Menest, Ogen, Estrace, and Gynediol. While these preparations
vary in their potency and dose amounts, they are all effective.
Estrogen patch — There
are many brands of estrogen patches. Those available in the United
States include: Estraderm, Climara, Vivelle, FemPatch, and Alora.
Some patches need to be replaced every few days, others once a
week.
If an equivalent dose is given, transdermal estrogen is just
as effective as oral estrogens in increasing bone density and in
treating menopausal symptoms. But unlike oral estrogen, it has
not been shown to have a beneficial effect on cholesterol levels.
Vaginal estrogen — Vaginal
estrogen is available as a cream, vaginal ring, or vaginal tablet.
Estrogen cream is inserted into the vagina using an applicator
once a day for two to three weeks. After this, the frequency may
be reduced to one or two times weekly. The estrogen vaginal tablet
(Vagifem) is given on a similar schedule.
The vaginal ring, called Estring, is similar to and a bit smaller
than a diaphragm. It is inserted once every three months and does
not need to be removed during intercourse or bathing. The use of
Estring is favored in women who have trouble using vaginal cream
on a regular basis, or in women with reproductive organs that may
be sagging, called prolapse, who would benefit from additional
support.
Vaginal estrogen is an excellent choice for women who want to
control vaginal dryness, stress incontinence, or frequent urinary
tract infections. But unlike the estrogen in pills and patches,
very little is absorbed by the rest of the body and, as a result,
does not have the other positive or negative effects.
There is one vaginal estrogen product for postmenopausal women
that contains a higher dose of estrogen (Femring). This ring is
designed to be absorbed into the bloodstream and relieve hot flashes.
We do not recommend Femring for women who are taking vaginal estrogen
only to relieve vaginal dryness or urinary symptoms.
WHAT TYPES OF PROGESTIN ARE AVAILABLE? — As
noted above, progestins are now routinely added to estrogen for
any woman with a uterus. The most commonly prescribed progestin
is medroxyprogesterone acetate, available in pill form under the
brand names Provera, Cycrin, or Amen. There are other progestin
preparations, like those used in oral contraceptives, but none
have obvious advantages over medroxyprogesterone. A natural progesterone,
called Prometrium, is now approved by the United States Food and
Drug Administration and appears to be a good alternative for women
who cannot tolerate medroxyprogesterone. In addition, natural progesterone
has no negative effect on lipids, and therefore is a good choice
in women with underlying high cholesterol levels.
ARE THERE ALTERNATIVES TO ERT/HRT? — Not
all women are able or willing to take estrogen replacement, and
alternative therapies are available. These are discussed in detail
elsewhere (See "Patient information: Alternatives to postmenopausal
hormone therapy").
SHOULD WOMEN WITH BREAST CANCER EVER TAKE
ESTROGEN? — Although women with breast cancer
often experience early menopause due to adjuvant chemotherapy,
and may have vasomotor symptoms due to tamoxifen therapy, estrogen
therapy should not be prescribed.
In a study called the HABITS trial, 434 women with breast cancer
were randomly assigned to receive two years of HRT (estrogen alone
or with progestin depending upon hysterectomy status) or no hormones.
After 2 years of follow-up, women in the estrogen groups were at
least three times more likely to have a recurrence than women who
did not take hormones. Based upon the excessive risk in the hormone
group, the study was terminated in December 2003.
WHERE TO GET MORE INFORMATION — A
doctor is the best resource for finding out important information
related to your particular case. Not all patients are alike, and
it is important that your situation is evaluated by someone who
knows you as a whole person.
BIRTH
CONTROL
These materials are for your general information and are not
a substitute for medical advice. You should contact a physician
or other healthcare provider with any questions about your health,
treatment, or care.
Contraception or birth control is the use of a medication, device,
or method to prevent pregnancy. Such devices or techniques, known
as contraceptives, can work in a number of ways:
Blocking ovulation, the release of eggs from a woman's ovary
Preventing
sperm from getting into the uterus and fallopian tubes (where
fertilization of the egg by the sperm normally occurs)
Preventing
implantation of the embryo (fertilized egg) into the uterine
lining (endometrium)
Most women of reproductive age in the
United States use some form of contraception. However, unintended
pregnancy is still a common problem in this country. As an example,
according to a survey on fertility conducted in 1995, family
planning, and women's health, almost one-third of births in the
previous five years were unintended. More specifically, 22 percent
were said to be "mistimed," whereas
9 percent were "unwanted."
The apparent failure of contraception may result from several
factors, including improper use, failure to follow treatment recommendations
(noncompliance), or failure of the medication, device, or method
itself. Thus, learning about available contraceptive techniques,
understanding which factors should be considered in your decision-making,
and receiving guidance from your doctor or clinic are essential
in determining the method(s) that may be most appropriate and effective
for your specific family planning and reproductive health needs.
Certain contraceptives, such as intrauterine devices (IUDs) and
injectable contraceptives are consistently associated with a low
pregnancy rate. This is because compliance (using the method correctly
or taking the medication on a regular basis) is not a major factor.
Oral contraceptives, or "birth control pills",
are associated with a low pregnancy rate if they are taken properly
(ie, no missed pills). However, studies indicate that the actual
pregnancy rate is much higher because many women do not take the
pill every day as directed.
Other contraceptive methods such as the
condom, diaphragm/cervical cap, and spermicides can be very effective
if used properly. However, these methods are also associated
with higher "actual" pregnancy
rates because of not using the method consistently or properly.
Overall, contraceptive methods that are
specifically designed for use during intercourse and require
decisions shortly before or at that time (eg, the condom, diaphragm)
are generally less effective than "longer-term" contraceptive
methods (eg, intrauterine device, oral contraceptives).
Hormonal contraceptives including pills, skin patches and
vaginal rings
Injectable contraceptives
Barrier methods
Intrauterine devices (IUDs)
Sterilization
Periodic abstinence
Withdrawal (coitus interruptus)
Oral contraceptives — Oral
contraceptives, also referred to as "the pill," in general
contain a combination of the female hormones estrogen and progestin
(a progesterone-like medication). Other examples of hormonal contraceptives
are those that are injectable (into the muscle) or released gradually
from an intrauterine device.
A combined oral contraceptive contains both estrogen and progestin.
A list of available pills is shown in Table 2. Some pills contain
just a progestin, but these are not prescribed as often, because
they are not quite as effective as the combined pills. The combined
pill reduces the risk of pregnancy by:
Preventing ovulation
Keeping the mucus in the cervix thick
and impenetrable to sperm
Preventing implantation of a fertilized
egg in the uterine lining
Other benefits Other
non-contraceptive benefits of the pill include a reduction in:
Menstrual cramps or pain (dysmenorrhea)
Ovarian cancer
Cancer of the endometrium (uterine lining)
Pelvic inflammatory
disease (PID) (infection of the fallopian tubes)
Iron-deficiency
anemia (a low blood count due to low iron levels)
Nausea, breast tenderness, bloating, and mood changes. These
early side effects typically go away after several months.
Breakthrough
bleeding or "spotting" at the wrong time
of the pill pack. This is particularly common during the first
few months of taking oral contraceptives. In addition, missed
pills can result in breakthrough bleeding.
Complications When "the
pill" was first introduced in the 1960s, the doses of both
estrogen and progestin were quite high. Because of the high doses
used, cardiovascular complications occurred, such as high blood
pressure, heart attacks, strokes, and blood clots in the legs and
lungs. However, reductions in both progestin and estrogen doses
in the currently available oral contraceptives have led to a decrease
in these complications. Therefore, oral contraceptives are now
considered a reliable and safe option for almost all women, with
the exceptions noted below.
The majority of studies suggest that taking (or having taken)
the pill does not increase one's risk of breast cancer. However,
there is some concern that women who carry the BRCA1 gene might
have some further increase in risk if they take oral contraceptives.
It has been estimated that the risk for death associated with
use of oral contraceptive pills by nonsmoking women is 1 in 100,000
pill users, versus 1 in 6000 automobile drivers, and 1 in 10,000
women who carry a pregnancy to term. Women taking hormonal contraceptives
should call their health care provider if they experience abdominal
pain, chest pain, severe headaches, eye problems, or severe leg
pain as these could be symptoms of several serious conditions including
heart attack, blood clot, stroke, liver, and gallbladder disease.
Who should not take the pill? Women
who fall into the following categories should NOT take the pill
(ie, the pill is contraindicated) because of an increased risk
of complications:
Aged 35 or over who smoke cigarettes (very high risk for cardiovascular
complications)
Are pregnant
Have had blood clots or a stroke in the past,
because these women are more likely to have blood clots while
taking the pill
Have a history of an estrogen-dependent tumor
(eg, breast or uterine cancer)
Have abnormal, or unexplained
menstrual bleeding (the cause of the bleeding should be investigated
before starting the pill)
Have active liver disease (the pill could worsen the liver
disease)
Have abnormally high blood levels of triglycerides (a
type of cholesterol which can be further elevated by the pill).
Women with high blood pressure might experience a further
increase in blood pressure. Therefore, they should be seen by
their doctor more frequently while on the pill.
Women who take
medication for seizures (epilepsy) might not get the same contraceptive
benefit from the pill as other women because the seizure medicines
change the way the pill is metabolized.
Women with migraine
headaches associated with visual symptoms or other neurological
symptoms should not use the pill.
Women with diabetes mellitus
who are on the pill might need a slightly higher dose of insulin
or oral diabetes medication. Therefore, they need to be seen
on a regular basis once they start the pill.
How do I start the pill? Ideally,
the pill should be started on the first day of the period to provide
the maximum contraceptive effect in the first cycle. However, most
women start their pill on the first Sunday after the period starts
(because most pill packs are arranged for a Sunday start). Some
form of back-up contraception is needed for the first month if
one chooses the Sunday start, because the full contraceptive effect
might not be provided in the first pill pack.
When can I expect my period? The
pill is taken on a 28-day cycle with 21 days of hormone pills followed
by 7 days of placebo pills ("sugar pills"). It is not
necessary to take the placebo pills, but some women find it easier
to remember to start their next pill pack if they have taken the
placebos. The period should occur during the fourth week of the
pill pack, ie, the "placebo week." However, some women
may experience breakthrough bleeding in the first few months. This
almost always resolves without any intervention.
Continuous pill A
newer preparation is available where hormone pills are taken every
day for 12 weeks, followed by placebo pills for 7 days. This results
in only 4 periods per year (although many women experience breakthrough
bleeding when they start). The convenience of this preparation
has appeal to many women. Similar "continuous" regimens
have been used in the past for problems such as endometriosis.
The long-term safety of the continuous pill is not yet established.
Injectable contraceptives The
only injectable contraceptive currently available in the United
States is medroxyprogesterone
acetate or DMPA (Depo-Provera®). DMPA is injected deep
into muscle, such as that of the buttock or upper arm, once every
three months. A preparation that is given subcutaneously (under
the skin) rather than into the muscle, will be available sometime
in 2005.
DMPA alters the cervical mucus and endometrium, making the cervix
impenetrable to sperm and preventing implantation of a fertilized
egg. It also helps prevent ovulation, but not as reliably as the
pill.
In about 90 percent of women who receive DMPA, the cervical mucus
becomes impenetrable to sperm within 24 hours following initial
injection. In the remaining 10 percent, however, the cervical mucus
remains penetrable to sperm for up to seven days. Therefore, women
who receive their initial DMPA injection following the seventh
day of their menstrual period are advised to use a second form
of contraception for seven days.
Other benefits Additional
benefits of DMPA include a decreased risk of:
Endometrial (uterine) cancer
Pelvic inflammatory disease (PID).
Side effects The
most common side effects of DMPA are:
Irregular, prolonged bleeding and spotting, particularly during
early therapy
Absence of menstrual periods (amenorrhea) in up
to 50 percent of women after one year
Weight gain
Women may also have some additional side effects, such as acne,
depression, and headaches. Those who experience such side effects
should speak with their physicians to discuss possible symptom
management and/or proper contraceptive alternatives.
In women who receive injectable progestin alone, there is no
apparent increase in the risk of cardiovascular complications or
cancer. However, there may be an increased risk of osteoporosis.
Because DMPA is long-acting, this method of contraception may
not be ideal for women who wish to become pregnant shortly after
stopping the medication. Although most women are able to conceive
within 10 months, fertility may not return for as long as 18 months
after the last injection.
There are a number of women who prefer to take DMPA as opposed
to the pill, including those who:
Find it difficult to remember to take a pill every day
Are
done with childbearing
Choose not to take the pill because they
are also on seizure medications (the effectiveness of DMPA
is not altered by these medications).
Transdermal contraceptives (skin patches) — Transdermal
contraceptive patches containing both an estrogen and a progestin
have been shown to be as effective oral contraceptives, and one,
Ortho Evra, has been FDA approved. Some women may prefer a skin
patch over a pill. Risks are similar to those with oral contraceptive
pills.
Vaginal rings — A
vaginal ring (Nuvaring) that releases an estrogen and a progestin
that is absorbed into the body through the vaginal mucosa is
available and is worn for three weeks followed by one week off
(during which time a period occurs).
Contraceptive implants — No
contraceptive implants are currently available in the United States
, although one has been FDA-approved (Jadelle). Two implants (Jadelle
and Implanon) are available in most other countries.
Barrier methods — This
type of contraceptive physically blocks or otherwise prevents sperm
from entering the uterus and reaching the egg for fertilization.
Barrier contraceptives include the condom, diaphragm, and cervical
cap. These contraceptive methods:
Have fewer side effects than hormonal contraceptives
Offer
effective protection against certain sexually transmitted diseases
(STDs)
May be available without a prescription (condom and spermicides)
Spermicides (contraceptive creams or gels), are chemical substances
destructive to sperm. They are also available over the counter
and are typically recommended in combination with barrier contraceptives
(to help maximize the contraceptive effect).
Condom The
condom is a relatively thin, flexible sheath, or cover, placed
over the penis to prevent semen from entering the vagina during
sexual intercourse. To help ensure optimal effectiveness and protection,
partners who choose to use condoms must read and follow all manufacturer's
instructions carefully. In addition, as mentioned above, a spermicide
may help to increase the effectiveness of condom use.
When used properly, in addition to preventing pregnancy, condoms
may offer protection to both partners against STDs and infection
with human immunodeficiency virus (HIV). Studies have found the
following:
There is a decreased risk of gonorrhea and other sexually
transmitted diseases in women who consistently use condoms.
In
a study of HIV-negative women whose only risk for infection
was a stable heterosexual relationship with an HIV-infected partner,
none of the women who consistently used condoms became infected.
Regular
use of latex condoms appears to decrease the risk of HIV infection
by about 69 percent. Evidence suggests that other types of
condoms may be less effective than latex condoms in preventing
HIV transmission.
Those who choose to use condoms should also note that petroleum-based
lubricants may actually degrade the condom, decreasing its effectiveness
in preventing infection. Water-based lubricants are considered
safer.
Synthetic condoms are available, but are currently approved by
the FDA only for people who are allergic to latex.
Diaphragm/cervical
cap The
diaphragm and cervical cap fit over the cervix, preventing sperm
from entering the uterus. These devices are available in multiple
sizes and require fitting by a trained clinician, who can also
explain how to insert them properly. It is essential to realize
that these devices must be:
Used with an appropriate contraceptive cream or jelly containing
spermicides
Left in place for six to eight hours after sexual
intercourse. The diaphragm must be removed after this period.
However, the cervical cap can remain in place for up to 24
hours.
Due to these factors, many women may find such contraceptive
methods less desirable than other available options.
The diaphragm and cervical cap are associated with a decreased
risk of certain sexually transmitted diseases and infections, including
gonorrhea, chlamydia, and pelvic inflammatory disease. Much of
the protective effect is thought to be due to the simultaneous
use of spermicides. However, the effectiveness of these contraceptive
methods is less consistent than condoms in preventing the spread
of HIV infection.
Cervical caps are available in latex (the Prentif cap) or silicone
rubber (FemCap). The latter has a strap to facilitate removal and
comes in three sizes.
Intrauterine devices (IUDs) IUDs
are devices that are inserted by a physician into the uterus through
the vagina and cervix. Most are made of molded plastic and include
an attached plastic string that projects through the cervix into
the vagina, enabling a woman to check that the device remains in
place. (If a woman cannot locate the string, she should use another
method of contraception until she is examined by a physician to
determine whether the IUD is still in place.)
The currently available IUDs are safe and effective methods of
contraception. These devices include:
Copper-containing IUDs. These appear to prevent pregnancy
by inducing an inflammatory reaction within the endometrium,
thereby keeping sperm from reaching the fallopian tubes. Copper-containing
IUDs remain effective for approximately 8 to 10 years.
Levonorgestrel-releasing
IUDs. This IUD decreases menstrual blood loss by 40 to 50 percent
and decreases pain associated with periods. Although highly
effective, some women discontinue it because of complete cessation
of menstrual bleeding.
Reports indicate that these IUDs do not have an adverse effect
on fertility after they have been removed. In addition, for women
using copper-releasing IUDs, there is a lower risk of ectopic pregnancy
(or a pregnancy that develops outside the uterus) as compared with
women who do not use contraceptives. However, use of progesterone-releasing
IUDs increases the risk of ectopic pregnancy relative to women
not using any contraceptive. Therefore, if a woman with an IUD
becomes pregnant, it is essential that the site of the pregnancy
be determined immediately.
The frequency of pelvic inflammatory disease is not increased
in women with IUDs who have a low risk for sexually transmitted
diseases (STDs). However, an IUD is not an ideal choice for women
