Sexual Diseases & Fertility

Sexually transmitted diseases (STDs) are not often discussed in the context of one of their possible consequences: infertility. Great societal stigma has been assigned to these various infectious diseases which are transmitted primarily through sexual or blood contact. Because of this stigma, many women may actually go throughout their lives never knowing they have contracted such a disease until it is too late.

The rapid, epidemic transmission of genital herpes a few decades ago had one positive result -- many people learned that even "nice, clean" people can be infected by an STD. I refer to this as positive because those people then, hopefully, learned about their bodies and took the necessary precautions to avoid further transmission, rather than continuing to look the other way and live in denial of their infection. Unfortunately, however, this more open way of dealing with STDs came to a standstill yet again with the advance of HIV. Now, many are coming to terms with the trademark slogan of HIV activists: "Silence equals death."

For many who have come into contact with an STD, and particularly those who do not yet know that they have been infected, silence may equal infertility and other debilitating health effects. Depending on the specific disease, the amount of time between initial infection and treatment, and the overall health of the infected individual, diseases such as chlamydia, gonorrhea, syphilis, human papilloma virus, herpes simplex, hepatitis B, and others can permanently alter one's life in sometimes dramatic and tragic ways.

What can be done? First, we must continue to fight the senseless stigma which these diseases carry. If you think that you are unaffected by such societal forces, ask yourself "would I feel as comfortable asking my doctor for a chlamydia test as I do asking for a strep throat culture?" Many health practitioners, unfortunately, still maintain that only certain high-risk groups of people, those who have certain lifestyles or behaviors, warrant screening for STDs. What this means is that many of you who are reading this have never been approached by your doctor or midwife about being tested.

Any woman who is trying to conceive should ask her practitioner for a screen of the major STDs, optimally prior to conception. Women (and men) who are experiencing difficulty conceiving should consider STD screening a routine part of their diagnostic period. Practitioners would do well to avoid some of those discomforting questions about you and your partner's sexual pasts by simply running the same tests on every patient, regardless of socioeconomic status, other demographics, and perception.

Last, and perhaps most importantly, teach your children about STDs. Be an advocate for education. Wouldn't it be grand to be able to say that we've sent some STDs the way of the eradicated smallpox? It can only happen through frank and open discussion.


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Smoking and pregnancy

If you think that smoking is not addictive, that cigarettes are a good way to control your weight, and that cigarettes really aren't such a bad habit, we've got news for you.



Women have become addicted to cigarettes over the years, and the tobacco industry has become addicted to women. The industry has spent billions of dollars to get women hooked on one of the most destructive substances in existence.

Cigarette smoking claims the lives of 430,000 Americans each year. Approximately 152,000 are women.

Christy Turlington, a former smoker and one who lost her father to lung cancer, joins the Centers for Disease Control and Prevention (CDC) in a video presentation that takes us inside the tobacco industry and gives us a good look at the myths that cigarette manufacturers use to target women.

Smoking increases a woman's risk of heart disease, stroke, and many forms of cancer. Smoking reduces fertility, increases the risk of pregnancy complications like premature birth and low birth weight, and leads to an earlier menopause.

Know what you really need to know about cigarette smoking and the tobacco industry.



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Ten steps to a healthier pregnancy

WHAT ALL PREGNANT WOMEN SHOULD KNOW ABOUT FITNESS AND NUTRITION

1. Don't stop eating or start skipping meals as your weight increases. Both you and your baby need the calories and nutrition you receive from a healthy diet.

2. Talk with your doctor before starting an exercise program during pregnancy. If you have been exercising, cut back your level of exercise to no more than 80 percent of your prepregnancy level.

3. Stomach upset and morning sickness are common during pregnancy. Some foods you normally love may make you feel sick to your stomach. You may need to substitute other nutritious foods you tolerate better. Likewise, overeating or eating too close to bedtime often causes heartburn. Eating five or six small, nutritious meals a day instead of three large ones may make you feel better.

4. Fish can be a healthful food choice during pregnancy, but don't eat shark, swordfish, king mackerel or tilefish. Click here to find out why.

5. A good way to add calcium to your diet is to cook rice and oatmeal in nonfat milk instead of water. Oatmeal is a great tummy soother too!

6. Drink extra fluids (water is best) throughout pregnancy to help your body keep up with the increases in your blood volume. You'll know you're drinking enough fluid when your urine looks like almost-clear water.

7. Prevent listeriosis, a food-borne illness that could be detrimental to unborn babies, by thoroughly cleaning and cooking all food, and watching out for undercooked or unrefrigerated meats and unpasteurized dairy products which might be contaminated.

8. When cutting down on caffeine during pregnancy, read labels. More than 200 common foods, beverages and over-the-counter medications contain caffeine!

9. Your need for additional calories and certain nutrients such as calcium and vitamin D increase if you are carrying twins. Depending on your pre-pregnancy weight, it is estimated that you need to eat about 150 calories more a day when pregnant with twins then when carrying only one baby. Share stories with other new moms of twins here.

10. During exercise, your oxygen demands increase. Your body is heavier, and your balance may change. You may also tire more easily. Keep these points in mind as you adjust your fitness program.



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Beer and breastfeeding

I just had my first baby, Chloe, and am breastfeeding. My mom says that when she was nursing me, her doctor told her to have a beer every night! I'd love to have a glass of wine, but really don't want to be sharing it with my baby! What do you think?

Your mom is not alone; many women have heard the same thing. They are told that a beer or a glass of wine will help establish their milk supply and keep it flowing. I'm not aware of any scientific studies which have addressed this issue, but alcohol is known to release inhibitions and helps some people relax. It's important to be calm and relaxed while nursing. In fact, most women find that they have trouble nursing when they are tense or in a stressful environment -- it's hard for the milk to get down.

Does this mean that it's a good idea? Well, not necessarily. A small amount of alcohol does get into breast milk, about one percent on average. While many consider this amount harmless, the best way to avoid giving your baby alcohol is to "pump and dump"; after having a glass of wine or other alcoholic beverage, express your milk at the next feeding and discard it. It's fine to resume nursing with the following feeding.



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Ectopic pregnancy

My roommate was just diagnosed with an ectopic pregnancy. I always thought this was a very serious medical emergency that needed surgery, but she was treated with just a shot. Can you help clear this up? Does she really have an ectopic pregnancy?


Ectopic pregnancy is a serious medical problem that is thought to occur in about 2 percent of pregnancies. An ectopic refers to any pregnancy which implants outside of the uterine cavity. While almost all ectopics occur in the fallopian tube (98 percent), they also implant on the ovary, inside the abdominal cavity or within the cervix. Surgery is no longer the only option. Early detection makes it possible for some women to be treated with medication instead of surgery.

A history of pelvic inflammatory disease (PID), especially chlamydia, is the single most important risk factor. Smoking, history of tubal surgery or a previous ectopic, DES (diethylstilbestrol) exposure or IUD use also increase risk. Certain fertility techniques increase the risk of ectopic pregnancy such as in vitro fertilization, GIFT (gamete intra-fallopian transfer), even ovulation induction. However, most ectopic pregnancies occur in women with no apparent risk factors.

The classic warning signs of an ectopic are a late period, vaginal spotting or bleeding, and abdominal pain. In most cases not all three symptoms are present, making the diagnosis more difficult. As an ectopic pregnancy develops, it may grow large enough to tear or rupture the fallopian tube causing internal bleeding and a potentially life-threatening situation. Diagnosing an ectopic pregnancy early is key to avoiding complications. Today, 80 percent of ectopic pregnancies are treated before rupture of the fallopian tube.

The diagnosis is made using a very sensitive pregnancy test (immunoassay for human chorionic gonadotropin, or HCG), ultrasonography, and, if needed, laparoscopy. In a healthy pregnancy, HCG levels rise in a fairly predictable manner. Levels that do not rise appropriately can signal a pregnancy at risk. A progesterone blood test may also be used as an indicator of a healthy pregnancy. Ultrasound is used to locate the pregnancy or look for signs of a potential problem like swelling in a fallopian tube.

Treatment must be tailored to the individual. In some situations, emergency surgery is required to control internal bleeding. When the diagnosis is made early, prior to tubal rupture and the patient is clinically stable, treatment options include surgery or medical management what you referred to as "the shot".

Methotrexate was first used to treat an ectopic pregnancy in 1982 in Japan and has been used in the United States since 1986. But it's not for everyone. Methotrexate is given as one or two shots depending on the size of the patient and the length of pregnancy. HCG levels are followed closely to be sure the pregnancy is resolving. It takes about four weeks for HCG levels to fall to zero. Some women have side effects from the medication such as soreness in the mouth, stomach upset or diarrhea. Methotrexate can also affect liver metabolism, so women who have been treated need to avoid alcohol and folic acid. Methotrexate works about 85 percent of the time, sometimes a second injection is needed. Close follow-up is essential because treatment failures require surgery to remove the ectopic pregnancy.

Methotrexate is less expensive than surgery and since it's less traumatic to the tissues, it can be better for future fertility. While this is a reasonable option in many cases, it's not right for everyone. Some women prefer the "quick-fix" of surgery rather than the month-long process with medication. I hope you find this information helpful. It sounds as if your roommate received excellent, state-of-the-art medical care. I hope that her course proceeds smoothly.


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What is causing me to drool during pregnancy?

I'm three months pregnant and have a terrible problem: I'm drooling all the time. It's embarrassing. I can't go anywhere without a towel to soak up my saliva. What's wrong with me?

You're suffering from a condition known as ptyalism, copious saliva production. Many women find this annoying in pregnancy, but it can also be distressing and may affect your health. Ptyalism was thought to occur in 1 percent of pregnancies, but a recent report from the University of Wisconsin at Madison found one in six women noticed excess saliva during pregnancy (presented by Maureen Van Dinter, N.P. at the 2001 conference of the World Organization of Family Doctors).

Ptyalism usually begins in the first trimester, and most women who experience it find the volume of saliva doubles. It may be milky, thick or bubbly. The saliva is often bitter and can lead to nausea, vomiting or even weight loss. Besides the increased saliva, women with ptyalism often have a coated or thickened tongues or distended cheeks from swollen salivary glands. It can affect the sense of taste or interfere with swallowing. Nearly one-third of women in the study said it disrupted their sleep and 27 percent said it affected their speech.

While it's not clear what triggers ptyalism, diet seems to play a large role. Many women find dairy products make their symptoms worse. For others the culprit is starchy foods. The first step in treatment is making changes in your diet to help reduce symptoms. Most women find that eating fruit can do a lot for alleviating symptoms. Sucking on hard candy or using mouthwash can also help by disguising the bad taste of the saliva. There can also be an emotional component to the problem, and counseling may help.

Be sure to let your doctor know about this problem so you can work together toward a solution.

Wishing you health,



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Is it safe to continue exercising through pregnancy?

I'm three months pregnant, and my husband and I are debating whether or not it's wise for me to keep jogging. I've been running for the past ten years and want to keep it up now that I'm pregnant. He's afraid it's bad for our baby and bad for me. What do you think?

Times have certainly changed. In the past we discouraged women from having any physical activity during pregnancy -- we feared it might rob precious blood flow from the uterus and baby. Today, exercise is considered part of a healthy lifestyle and part of a healthy pregnancy. Women who have normal, uncomplicated pregnancies are encouraged to stay active. In fact, a recent study found that women who exercised regularly beginning early in pregnancy had slightly bigger babies and slightly larger placentas, and experienced no harm at all (Clapp, J.F. Beginning regular exercise in early pregnancy: Effect on fetoplacental growth. Am J Obstet Gynecol 2000;183:1484-1488).

Exercise will improve your mood, help you sleep better and feel better. It can ease some of the aches and pains of pregnancy, like constipation, leg cramps, bloating and swelling. Exercise builds strength and stamina to prepare you for the hard work of labor and delivery -- which can be like running half a marathon! It won't guarantee a painless delivery, but it can help ease the process and speed recovery.

But it can be tough, no matter what shape you're in. A study of well-conditioned runners found performance was cut in half by early third trimester. The normal changes of pregnancy make it harder to exercise and impossible to reach your peak. Most women need 20 percent more oxygen in pregnancy. You have more blood, and your heart works harder to handle the load (increased heart rate). As the uterus grows, your spine alignment shifts forward, throwing off balance. And hormones relax the ligaments, especially in your hips and pelvis, making it easier for childbirth but harder for exercising. And yes, you gain weight -- a fact that makes many activities more difficult.

Most exercise is safe in pregnancy as long as it's done with caution. I think non-impact sports are best, to avoid possible falls or injuries. Swimming, stationary bicycles and yoga are excellent choices. Exercise classes geared toward pregnant women are another option and are a great way to meet other expectant moms. Sports you're accustomed to doing prior to pregnancy can usually be continued, but use common sense and avoid risky activities. And if you weren't active before pregnancy, be sure to go slowly.

Plan ahead. Wear loose, comfortable clothing. Drink plenty of water during and after exercise, and always listen to your body. Work up a good sweat but never push yourself to exhaustion. A good rule of thumb -- you should be able to carry on a conversation. Always warm up and cool down, and keep an eye out for things that could throw you off balance. And avoid outdoor sports when it's hot and humid. Occasional contractions are normal, but stop if you have regular contractions, experience any discomfort or feel lightheaded. Stop immediately and seek medical attention if you have chest pain or bleeding.

Regular exercise is great in pregnancy but talk to your doctor first. Women at risk for pre-term labor or complications of pregnancy should follow exercise routines tailored to their needs. Be sure to ask about specific sports that you like to do. And see if you have any medical problems that would limit your workouts.

Staying fit while pregnant is a wonderful idea -- just keep it fun and safe! --

Wishing you health,



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Can hypnosis help with labor pains?

I just heard about hypnobirthing. Do you think hypnosis can really help with labor pains?

You're not alone. Most women dread labor. Some say it's because we've been bombarded with negative images of childbirth. Whether it's stories from well-meaning family and friends, or comic portrayals in TV or movies, the message comes through loud and clear -- labor hurts.

Proponents of hypnobirthing say reprogramming that message in the subconscious mind is the first step toward having a comfortable labor and birth. Negative images are replaced by positive ones focused on success: "Labor brings you closer to your baby. It's the first project you will do with your baby. It's the most natural thing in the world -- why should it hurt?"

Hypnobirthing, as a form of natural childbirth, adheres to the premise that labor is easier for women who are self-assured, relaxed and cooperative. The theory of natural childbirth is that fear and anxiety lead to tension, which in turn causes pain. That pain can slow the progress of labor, which may even intensify the pain of labor and delivery. Hypnobirthing aims to make labor easier by eliminating fear and tension. It's part self-hypnosis, part relaxation (guided imagery and deep breathing) and plenty of information -- all to help break the fear-tension-pain cycle.

The specifics of labor and delivery are reviewed so you know what to expect and just in case complications arise. Women are taught how the muscles of the uterus and pelvis work so they can visualize what's happening. But again, things are presented in a positive light. Uterine contractions are called "uterine waves" or surges -- preferring to focus on the energy and strength they create.

Expectant mothers are taught to equate uterine surges with normal muscular contractions. They learn to use discomfort as a signal or cue to go into a mild hypnotic state for the duration of the surge if they choose. With self-hypnosis, the mind instructs the body to relax and open -- that it's natural to open the door, the cervix, so the baby can come out.

Women practice with audio tapes containing positive affirmations that are meant to help them reach a deeply relaxed state. For example: "I am at peace with my body. I am at peace with my baby. My body is working to bring me closer to my baby." These affirmations are then repeated by the partner or coach during labor to help trigger deep relaxation.

But it's not for everyone -- not all women are open to the mind-body connection. And to work well, it takes plenty of preparation on the part of the woman and her partner or coach. Hypnobirthing is usually taught as a series of five two-hour sessions with a certified hypnotherapist. It costs about $400 for the series so it's a little more expensive than other childbirth preparation classes.

Hypnobirthing doesn't necessarily mean your labor will be pain-free. Many women still need medication or an epidural for pain. Even so, the information and tools can help ease the process. And there's another plus -- the relaxation techniques will certainly come in handy as you try to manage the stresses of life as a new mom.
Wishing you health,



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Is it safe to have an MRI or x-ray done during pregnancy?

I have a question regarding the safety of MRI/MRA in the first trimester of pregnancy. I underwent an MRI/MRA of the brain when I was five-and-a-half weeks pregnant. I'm very concerned about potential problems as a result of this procedure.

I am wondering whether a therapeutic abortion is appropriate or an over-reaction? Any information you can provide regarding documented and theoretical risks to the embryo would be greatly appreciated.

That's a difficult question. Magnetic resonance imaging, or MRI, is a relatively new procedure -- it hasn't been used on large numbers of patients, so we don't have all the answers. It's always best to avoid unnecessary risks during pregnancy. Medical tests and procedures that aren't essential are generally delayed until after delivery. But complications occur and accidents happen. In these cases diagnostic procedures may be needed to find out what's going on, and how it could affect the health of mother and baby. Sometimes this occurs even before a woman knows she's pregnant. It's only natural to be concerned about the potential hazards in pregnancy.

A number of imaging techniques are used to take a closer look inside the body during pregnancy, including X-rays, ultrasound, magnetic resonance imaging (MRI) and nuclear medicine studies. Most concerns center around X-rays -- radiation is considered harmful and could lead to birth defects. But the risk from radiation depends on the amount of exposure. Fortunately, most diagnostic X-rays carry little, if any, known risks to the fetus because the exposure is very small (less than 5 rad). According to the American College of Radiology, having a diagnostic X-ray does not increase the risk of birth defects or miscarriage, or stunt the growth of the developing baby.

Ultrasound is widely used today and is one of the most common imaging studies performed in pregnancy. Ultrasound doesn't use radiation. Instead sound waves are used to create images. There have been no reports of harm to mother or baby from ultrasound and it can be safely used at any time in pregnancy.

In certain circumstances nuclear medicine studies are used in pregnancy, such as when a blood clot in the lung is suspected. The amount of exposure and risk to the baby depend on the type of isotope used for the study. By selecting the right isotope, exposure can be kept very-low and well below the threshold for risk.

MRI uses magnets and radio waves instead of radiation. Magnetic resonance angiography is a special type of MRI study that focuses on blood vessels. In some cases, contrast material is used to enhance the pictures of the blood vessels. While MRI is thought to be safe in pregnancy, our experience is limited. Until we know more, MRI is best reserved for very specific situations and is generally not recommended in the first trimester. Not because of any known problems, but due to a lack of scientific proof that it's safe. On the other hand most experts prefer to use MRI at any point in pregnancy when the alternative involves radiation.

Talk to your obstetrician about your concerns. While it's impossible to say there is no risk to your baby, the risk may be exceptionally small. Keep in mind that even in the best of situations there are risks, simply because some things are out of our control.

Making healthy choices before and during pregnancy, and getting early prenatal care, can help minimize the risk, but there are still no guarantees of a perfect baby. Learning to live with the unknown, is part of becoming a parent.
Wishing you health,



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Is it possible to become pregnant while on hormone replacement therapy?

Please tell me if it is possible to become pregnant while on hormone replacement therapy if your partner is younger and very virile? I'm hoping your answer is no.

A woman's ability to conceive a child diminishes as she gets older. This is especially true for women who are in the perimenopausal period of their life. Many women conceive in their fifties, and the oldest confirmed spontaneous pregnancy occurred at age 57! A good rule of thumb is to continue using birth control for one year after your last period.

The amount of hormones contained in the standard regimens of hormone replacement therapy (HRT) is about one-quarter the amount contained in low-dose birth control pills. Consequently, HRT will not necessarily prevent ovulation. This is of particular concern for women who are started on a very low dose of HRT as they transition into menopause. They need to continue to use birth control if they are sexually active.

If you started taking HRT after menopause (with ovarian failure confirmed by a lack of menstruation for one year or repeated blood tests documenting follicle-stimulating hormone and luteinizing hormone levels in the menopausal range) then you do not need to use birth control -- no matter how young and virile your partner is!

Another issue here, however, is safe sex. You must keep in mind the possibility of sexually transmitted diseases (STDs). Unprotected intercourse exposes you to gonorrhea, chlamydia, herpes virus, human papilloma virus, and HIV, among others. This is of particular concern as we age because our vaginal tissues may become thinner, making it easier to acquire an STD. Latex condoms used with a spermicide are effective in reducing the risk of transmission of STDs. It is currently recommended that in a new, mutually monogamous relationship, you should both be tested for HIV and have this test repeated in six months. If these tests remain negative, it is safe to discontinue the usage of condoms and spermicide. Be sure to check with your doctor if there are any special circumstances that apply to you.
Stay well.



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What does it mean to have bacteria in your urine when you're pregnant?

What does it mean to have bacteria in your urine when you're pregnant? Is it safe to take Amoxicillin for it? And what if it does not clear up? What does that mean?

A bladder infection or urinary tract infection (UTI) occurs when bacteria travel up the urethra into the bladder and multiply. If the level of bacteria is great enough, your natural immune system can't fight off the infection. Bladder infections are common in pregnancy and often lead to frequent urination, burning with urination, and urinating small amounts at a time. Sometimes, blood may even be seen in the urine. But it's normal in pregancy to have to empty your bladder all the time and only go a small amount when you do (especially in the beginning and end of pregnancy!). So these symptoms don't necessarily mean you have an infection. This opposite is also true -- you can have an infection without any symptoms at all. That is one of the reasons your urine is checked at each visit throughout your pregnancy. Women who've had frequent UTIs prior to pregnancy usually have urine cultures each trimester to look for silent or asymptomatic infections.

Amoxicillin is a penicillin derivative antibiotic and is safe to take during pregnancy. This treatment cures the vast majority of bladder infections. Women who've been treated for many prior infections often develop bacteria that are resistant to first-line antibiotics. These women may need to be treated with broader-spectrum or stronger antibiotics. And women who develop recurrent UTIs in pregnancy are often started on a low dose of antibiotic to be taken daily for the remainder of her pregnancy as a means of preventing infection.

The risk of an uncomplicated UTI during pregnancy is minimal, however some UTIs progress to a kidney infection (pyelonephritis). This condition is associated with fever, chills, nausea, vomiting, and back pain. It warrants strong antibiotics and close observation as it may lead to premature labor.

Stay well and enjoy your pregnancy!



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What is a molar pregnancy?

Could you please explain what a molar pregnancy is?

A molar pregnancy, or hydatidiform mole, is a pregnancy gone awry, resulting in a tumor of the placenta. The chorionic villi of the placenta grow into a grape-like bunch of cysts within the uterus. Molar pregnancies occur in one in 1200 pregnancies in the U.S. and 80 percent are benign. Molar pregnancies are more common in Asian women and women who are over age 40.

Most molar pregnancies are unable to support a fetus and are usually diagnosed in the first trimester. Most women with a molar pregnancy have vaginal bleeding, excessive nausea and vomiting, and some will even pass a grape-like cyst. Molar pregnancies generally grow much faster than a normal pregnancy, yet a fetal heartbeat is not heard. The swollen villi of the placenta produce a markedly elevated level of the pregnancy hormone, beta-human chorionic gonadotropin (B-hCG). An ultrasound examination can confirm the diagnosis. A molar pregnancy may also be diagnosed following a dilation and curettage (D&C) for a miscarriage or missed abortion.

When the diagnosis of molar pregnancy is made, the abnormal pregnancy tissue is removed by a D&C, and serial blood tests are performed to document falling hormone levels. The B-hCG hormone level is monitored every one to two weeks until a normal level is reached. The hormone level is then checked every few months for up to a year, to be certain that the disease is in remission and that no malignant changes have occurred.

Once remission has been confirmed, it's safe to attempt another pregnancy. Early ultrasound should be performed with any subsequent pregnancies, however, because women with a history of molar pregnancy have an increased risk of a second molar pregnancy.

I hope this information is helpful.

Stay well!



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Why does my pregnant wife want to chew ice all the time?

My wife is pregnant, about two months, and she wants to chew on crushed ice all the time. Is she OK? Is this normal? Should we call her doctor?


Pregnant women often have food cravings that have been known to strike at any hour of the day or night. Whether the cravings represent a nutritional need or an emotional need is debatable.

Some women, however, crave foods that have no significant nutritional value, such as crushed ice, lettuce, or even dirt. These women have a condition known as pica. In some cultures pica is very common.

While eating ice or lettuce is not harmful, eating dirt can be a source of a variety of infections and should be avoided. Additionally, there is an association between pica and iron-deficiency anemia. So, yes, your wife should discuss this with her doctor. A simple blood test is used to check for anemia.

Stay healthy!


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Will I be able to breastfeed after having a lumpectomy?

It's been one year since I underwent lumpectomy and radiation for breast cancer. I'm now pregnant (my first) and would like to breastfeed. What do you think?

Congratulations! I would first like to reassure you that you are not alone. In fact, one fourth of women who are diagnosed with breast cancer are premenopausal and up to a third of these women become pregnant after treatment. More and more women are delaying pregnancy until later in life, an age when breast cancer is more common. And with improved surveillance we are detecting breast cancer at an earlier stage, when it can be treated with less radical surgery.

Two main factors will affect your ability to nurse. To begin with, the location of the lumpectomy is important. A lumpectomy performed in the periphery, or outer region, of the breast is less likely to disrupt the ductal system which carries the milk to the nipple. The second factor is the extent of radiation therapy -- this tends to have a greater impact on breastfeeding. Radiation generally involves the entire breast and often produces scarring in the lobules of the breast, where milk production occurs.

It's best to have a wait-and-see approach. Initially your breasts may become very engorged when the milk first comes in. This can be painful, especially in the region of your breast surgery. The volume of milk produced by your involved breast may be significantly less than that produced by the normal breast. Some women find that the normal breast is able to compensate for the demands of the baby, while others need to supplement with formula.

Women who need further radiation or chemotherapy after pregnancy should not breastfeed. There also is no evidence that you can give your baby cancer by breastfeeding, even on the involved side.

There are many rewards of breastfeeding for both mother and baby. The only drawback that I can see in your case is that it is more difficult to detect breast lumps while you are nursing. The breast tissue remains full and somewhat engorged as long as you continue breast feeding, and for up to three months after weaning. For this reason, it's a good idea to have a breast exam with your physician every few months while breastfeeding.

Good luck and stay healthy!



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Is there a proper way to breast feed?

I am writing for a friend who is pregnant and due any day. She is interested in breastfeeding and wants to know if there is an organization she can call to teach her the proper way to breastfeed.

Breastfeeding offers tremendous benefits to mother and baby. Being skin to skin promotes bonding while providing proper nutrition as well as advantages for the immune system. It's convenient, inexpensive and an excellent way to help get back to pre-pregnancy weight!

As for learning the proper way to breastfeed, there is no one perfect way. The best way is usually the way that works best for mom and baby, and this often involves a period of trial and error. While it's the most natural thing in the world for many moms and babies, other pairs need more on-the-job training. It's important to stick with it during the first few weeks, which are always tough. It takes about a month to establish a feeding rhythm and that's when it gets easy.

Have your friend contact La Leche League International, Inc. (9616 Minneapolis Ave., Franklin Park, IL 60131). They offer support and guidance for breastfeeding women. Many childbirth education programs offer classes in breastfeeding. And most new moms receive helpful advice and instruction from the nurses at the maternity ward at the hospital.

Breastfeeding should be encouraged, but it is a matter of personal choice and it's not the right choice for every woman. Some women have medical conditions that prevent nursing, or are taking medications that would be harmful if passed through the breast milk to the baby. Other women try nursing and find that it's just not right for them. Whatever you decide, remember it's your body, and do what's right for you!



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Does alcohol aid with breast feeding?

I just had my first baby, Chloe, and am breastfeeding. My mom says that when she was nursing me, her doctor told her to have a beer every night! I'd love to have a glass of wine, but really don't want to be sharing it with my baby! What do you think?


Your mom is not alone; many women have heard the same thing. They are told that a beer or a glass of wine will help establish their milk supply and keep it flowing. I'm not aware of any scientific studies which have addressed this issue, but alcohol is known to release inhibitions and helps some people relax. It's important to be calm and relaxed while nursing. In fact, most women find that they have trouble nursing when they are tense or in a stressful environment -- it's hard for the milk to get down.

Does this mean that it's a good idea? Well, not necessarily. A small amount of alcohol does get into breast milk, about one percent on average. While many consider this amount harmless, the best way to avoid giving your baby alcohol is to "pump and dump"; after having a glass of wine or other alcoholic beverage, express your milk at the next feeding and discard it. It's fine to resume nursing with the following feeding.

Enjoy your baby and stay well!



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Does spacing affect preterm birth or low birth weight?

I just had a baby in January and I'm already starting to think about the next one! Can you tell me what's the best spacing between kids?

You've asked a very interesting question, but there's no simple answer. For years people have debated the merits of having children two, three, or even four years apart, and valid arguments can be made for each.

Well, now researchers from the Centers for Disease Control and Prevention (CDC) are tying to answer the question on spacing. An interesting study published in the New England Journal of Medicine (NEJM 1999;340:589-594) looked at how spacing affects pregnancy. Bao-Ping Zhu, MD, and colleagues studied the birth certificates of over 173,000 babies born in Utah from 1989-1996, to see if the interval between pregnancies affected birth weight or preterm birth.

They found that babies who were conceived 18-23 months after a previous birth had the lowest risk of preterm birth or low birth weight. And they found that the risks were increased when fewer than six months or more than ten years had elapsed between the birth of one child and conception of the next.

While these findings are helpful, this remains a very personal issue. For many it's a matter of personal preference. However, for others spacing may not be their choice, but may be dictated by financial or job-related concerns, or even infertility.

Whatever the spacing, children are affected by the birth of a sibling. On a bright note, they become more independent. However, many children regress, strive for attention, and may even become hostile or aggressive with the new baby.

Whatever you decide, be sure to give yourselves some time to conceive. It's usually better to be pleasantly surprised than disappointed. And remember, practice makes perfect!

Stay well!



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What's the best way to test for abnormal chromosomes during pregnancy?

Hi! I am 35 and nine weeks pregnant with my third child. My husband and I are weighing the merits of amniocentesis vs. chorionic villus sampling. We would like to know the relative rates of miscarriage of the two procedures. I have also heard that there is a possibility of limb malformation with CVS. Is this true? We also may skip both tests and rely on an AFP test and sonogram. Thanks for any info.

Deciding how to proceed can be difficult. I'm glad to hear that you're weighing your options. A woman's risk of delivering a baby with a significant chromosomal abnormality increases with age. At age 30 the risk is 0.26 percent, it increases to 0.56 percent at 35, and the risk is over 5 percent at age 45. Amniocentesis and chorionic villus sampling (CVS) are the two main ways to test for abnormal chromosomes during pregnancy. If a problem is found, parents can decide whether to terminate the pregnancy, or continue the pregnancy and be prepared for delivering a child with special needs.

Amniocentesis is is the gold standard and is the safer of the two procedures. Amniocentesis has an overall complication rate of 0.5 percent, including needle stick injuries to the fetus, infection, or leaking membranes. Nationwide, the risk of miscarriage from amniocentesis is only slightly higher than the risk of miscarriage in women who have not had an amniocentesis (3.5 percent vs 3.2 percent). In addition to checking the chromosomes, amniocentesis also checks the alpha-fetoprotein level which screens for major malformations such as neural tube defects.

The main drawback of amniocentesis is the timing of the test. This procedure is done in the second trimester at about 16 weeks and it takes a week to ten days to get the results. It can be hard waiting until 18 weeks to find out if all is well. Many centers now offer early amniocentesis which is performed closer to 12 weeks of pregnancy. The complication rate is a little higher than for traditional amniocentesis, but the results are available sooner.

The advantage of CVS is that it's performed earlier in pregnancy -- between ten and 12 weeks -- and the results are available sooner. When CVS was first introduced there were case reports of limb reduction malformations that may have been linked to very early procedures, around eight weeks. Nationwide, the risk of losing a baby after CVS is at least twice the risk of amniocentesis (range 1-4 percent). Additionally, about 10 percent of women have bleeding, spotting or cramping after CVS. Another drawback of CVS is that it does not test directly for AFP levels, so women who undergo CVS need to have a blood test for AFP in the second trimester.

While CVS has greater risks, taking those risks is appropriate for some women, especially those over 40 and also women who are very anxious. Since you have two healthy children and are only 35, amniocentesis may be a better choice. And if you prefer a risk-free approach, a detailed ultrasound and a triple test or AFP would be the next step. Only you and your husband know what's best for the two of you and for your family



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Why do I have discharge oozing from my breast?

Lately, I have been having a little bit of discharge from my right breast. It ranges from clear to milky white liquid. I am worried because I don't know if something is seriously wrong, or if it's normal. I have been told that milk is only produced when you're pregnant. Could this be a symptom of me being pregnant?


It's natural to feel anxious when you notice something new in your breast. Some women notice a spontaneous nipple discharge that stains the inside of a bra or leaves a crusting on the tip of the nipples. For others, the discharge occurs only when the nipple area is squeezed, and yes, a milky discharge can be seen in pregnancy. While it's normal to be able to express a few drops of milk for up to a year after giving birth or weaning a child, a nipple discharge in a woman who is not nursing needs to be evaluated. Most discharges are linked to benign changes in the breast, but it can also be a sign of breast cancer.

Galactorrhea refers to the milky nipple discharge that is not related to pregnancy or breastfeeding. It can involve both breasts or just one, it's usually white or clear, but may be yellow or even green. Galactorrhea can result from increased prolactin hormone secretion by the pituitary gland, or it may be associated with a sluggish thyroid gland (hypothyroidism). Many drugs are known to cause galactorrhea; these include estrogen (birth control pills), phenothiazines, reserpine, butyrophenones, tricyclic antidepressants, metoclopramide, verapamil, and cimetidine. The discharge associated with these medications usually comes from multiple duct openings in both breasts. Trauma to the breast, surgical procedures, anesthesia, and stress have all been linked to galactorrhea. And some women have found that suckling of the breast, such as during sex, can trigger a nipple discharge.

Fibrocystic changes in the breast are a common cause of nipple discharge among premenopausal women. The discharge is usually spontaneous from multiple ducts in one or both breasts, and is most pronounced just before menstruation. The discharge may be green or even brownish and sometimes a biopsy is necessary to fully evaluate the problem.

Discharge that comes from a single duct and is clear or blood-tinged is usually caused by a benign intraductal papilloma or duct ectasia, but is occasionally due to an intraductal cancer, which is more common after age 50. A thorough breast exam and mammogram are indicated, and a ductogram may also be necessary. Treatment of the benign conditions usually involves removal of the duct.

Evaluation of nipple discharge includes a thorough breast exam to screen for lumps and also to check which ducts are involved. Blood tests for thyroid function (TSH) and prolactin are indicated for women with galactorrhea. A mammogram is also appropriate if there is a mass, or based on age alone. And the discharge itself may be checked for signs of infection, blood, fat droplets (seen in milk), or cancer cells.

There are a number of reasons why you may have a discharge from your breasts. While nipple discharge is usually due to a benign process, it's always best to see your doctor for a thorough evaluation



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Since I've stopped breast feeding, I've started losing my hair, why?

I had my second child almost six months ago and stopped breastfeeding when she was five months of age. I have been experiencing extensive hair loss since I stopped breast feeding. This also occurred after I stopped breast feeding my first child, but I didn't lose as much hair, or for as long. Is there any thing I can be doing to stop this? Is it hormones? Should I be concerned and make an appointment to see a doctor? And, if so, which type of doctor? OB/GYN? Thanks for any info!

Women often notice thicker hair during pregnancy. That's because routine hair loss is temporarily suspended. Normally our hair follicles are out of synch -- we lose some hairs (about 100 hairs a day!) and grow others simultaneously. But the high levels of estrogen and progesterone in pregnancy can increase the synchrony of hair growth, which in turn can lead to periods of growth or shedding. When hormone levels return to normal, usually three to six months after delivery, there is often a sudden loss of hair as a large number of growing hairs enter the dying phase.

Fortunately, this diffuse shedding of normal hairs resolves over time without any specific treatment. However, if you're losing clumps of hair, or notice patches or bald spots, ask your doctor for a referral to a general internist or a dermatologist. Hair loss can occur in a variety of situations. With a thorough evaluation, the cause can usually be determined and appropriate treatment started.



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