University of Pennsylvania Health System

Penn Health for Women Newsletter

Monday, May 18, 2015

Menopause, Hormones and Heart Disease: The Battle to Find the Lesser of Three Evils

Hot flashes. Night sweats. Sleep disturbances. Mood swings. Irregular and racing hearts. These are all signs of menopause setting in, the time in a woman's life when her ovaries cease to function. It signals the end her fertility years, her menstrual cycle and a drop in naturally produced hormones.

As if the possibility of menopausal symptoms setting in as early as age 40 isn't unsettling enough, check out these disturbing facts:
  • A woman's risk for heart disease automatically increases at age 40
  • Heart disease is the leading cause of death in women over 40, particularly those in the midst of menopause.
If menopause doesn't cause heart disease, then why is this such a significant time? Estrogen is a hormone that has a positive effect on the cardiovascular system by keeping the blood vessel walls flexible. The decrease in estrogen as menopause sets in causes negative changes to occur to the blood vessels, no longer protecting them in the same way and through the changes in the walls of these vessels, clots are more apt to form. In addition to these changes, in post-menopausal women, blood pressure begins to go up and LDL cholesterol ("bad") levels rise while HDL ("good") stay the same.

So what's a woman to do? It was once thought that hormone replacement therapy (HRT) not only helped stave off these unwanted symptoms of menopause but also helped to keep more serious health threats, such as heart disease, cancer and osteoporosis, at bay. In 2002, however, HRT studies involving these hormones were halted secondary to evidence that women in them showed an increase in risk of heart attack, stroke, breast cancer and even dementia.

The known increase in heart disease in this subset of women has led to increased screening and a more personalized approach when it comes to treating menopause. According to Kelly Anne Spratt, DO, Penn cardiologist, "Treating a woman for menopause depends on many factors, including how severe and life-altering her symptoms are, her current health status, medical and family history and treatment preferences. Many symptoms can be effectively managed through lifestyle changes and other types of therapies."

One thing is clear, however. HRT should not be used to prevent heart disease. Nor should women with heart disease take it. And, women need to enlist the help of a physician. They can start with their primary care doctor or their gynecologist and discuss with him other ways to decrease blood pressure and LDL cholesterol and prevent heart attack and stroke, such as lifestyle modifications (i.e., switching to a heart-healthy diet and quitting smoking) and keeping blood pressure and cholesterol levels under control with the proper medications.

"I would also strongly suggest that menopausal women who have a family history of heart disease or are showing symptoms of heart disease of or have multiple risk factors for cardiovascular disease should seek the professional medical advice of a cardiologist in addition to their primary care physician," adds Dr. Spratt "A woman's risk for cardiovascular disease – including heart attack and stroke – bone loss and cancer is subject to change as she gets older. That's why it's so important for her see a physician regularly to review her health status."

Want to know more about menopause and your risk for heart disease? Sign up for an appointment with a women's health specialist today.

Friday, May 8, 2015

Feeling Well, Healing Well After Pregnancy

The bra that fit perfectly before the baby might not be as flattering now. And your bathroom habits? Well, they may be different, too.

“Urinary incontinence during pregnancy is not uncommon. and makes sense given the changes that take place during pregnancy,” says Uduak Andy, MD. Dr. Andy is a urogynecologist at Penn Medicine, an ob/gyn that specializes in treating women with pelvic floor disorders.

“You have this baby growing in your uterus pushing down on your bladder and urethra. For some women, incontinence will increase as the pregnancy progresses.”

Childbirth can lead to urinary incontinence, too. As your baby makes its way down the birth canal, your pelvic floor muscles may be stretched and, in some cases, even damaged. Even women who have a C-section are not without risk.

Dr. Andy says that because of all the changes a woman may experience throughout her pregnancy and childbirth, it may take anywhere from six weeks to a year to fully recover.

“If a woman is still experiencing pain, painful sex, or urinary incontinence six months after she’s given birth, she may want to see a urogynecologist, who can offer her treatment options and exercises to improve the pelvic floor,” says Dr. Andy. 

Bladder and Pelvic Floor Issues

Women with stress urinary incontinence may leak urine while coughing, sneezing, laughing or exercising.

According to urogynecologist Pam Levin, stress incontinence occurs when the urethra and surrounding muscles of the bladder lose their strength and support.

“Urinary incontinence and pelvic floor disorders don’t have to be a rite of passage for women, or something we just have to deal with as we age," she says.

That's why she created the Feeling Well, Healing Well Program.

Treatments for Urinary Incontinence

Penn's Feeling Well, Healing Well Program focuses on pelvic floor disorders women may experience as a result of pregnancy and childbirth.

“The post-partum time period can be challenging for new moms,” says Dr. Levin. “They might not feel comfortable talking about the issues they are experiencing. We want them to know that we specialize in these disorders and are here to help.”

It’s estimated that nearly 50 percent of women suffer from bladder and pelvic floor disorders at some point in their lifetime; however, there are options so that women don't have to live with their symptoms.

Stress incontinence can be treated with physical therapy, including Kegel exercises, physical therapy, or the use of a pessary, a removable appliance similar to a diaphragm that is inserted into the vagina or rectum to strengthen the pelvic muscles. Collagen injections may also be used to help minimize urine leakage from the bladder.

“In some cases, we recommend surgery to place a hammock or sling under the urethra to provide more permanent support,” says Dr. Levin. During the operation, a sling created from FDA-approved mesh is inserted behind the urethra to support the weakened pelvic muscles.

Women who have vaginal pain after delivery or pain with intercourse may experience muscle spasms or have painful scar tissue that narrows the opening of the vagina.

“Once we learn what is causing the pain, we can determine if a woman needs surgery, physical therapy or both to address the issue,” says Dr. Andy.

Depending on the issue, surgery may be deferred until a woman decides not to have any more children. This decision would be made in collaboration with the patient after a full consultation and discussion about the risks and benefits.

Tuesday, May 5, 2015

Marisa's Story: Defying the Odds in the Intensive Care Nursery

Marisa Mackintosh and her husband were ecstatic to learn they were expecting twins. But when Marisa was three months along, an ultrasound revealed that the babies were having growth problems. Here, she shares the story of her family's difficult journey and the neonatal intensive care team that saved her babies' lives.

When my husband and I learned I was pregnant with twins, we were overwhelmed with surprise, immense joy and anticipation. We dreamt of welcoming them home and introducing them to our beautiful daughter, who was 16 months old at the time. The twins were due August 28, 2013, and we believed we would soon have three healthy and happy children nestled safely under our roof.

Our vision quickly came to a halt at 15 weeks after an emergency ultrasound revealed that one of our babies wasn’t growing well. We were asked to prepare for the unimaginable possibility of losing one or even both babies.

The following weeks were dark and uncertain. Regular ultrasounds were both reassuring and terrifying. 17 weeks became 20 weeks, which became 24 weeks. Of course, we did not want to deliver then, but reaching 24 weeks, we learned, was a milestone. Another ultrasound at 27 weeks showed two babies, growing and defying the odds, though dangerously imbalanced in size and health.

My doctor offered us the opportunity to tour the Intensive Care Nursery (ICN) at Pennsylvania Hospital to get acquainted in the event that we would spend time there. We walked through a door labeled “CHOP Newborn Care at Pennsylvania Hospital” and were greeted warmly by a neonatologist who, with kindness and patience, gave us insight into the world of prematurity. Then a nurse manager gave us a tour, which provided a glimpse of life in the ICN.

One week later, at 28 weeks gestation, the babies decided it was time. On June 7, 2013, we welcomed our miracles William and Daniel (Will and Danny), weighing 2 lbs 12 oz and 1 lb 13 oz, respectively. At this moment, Will and Danny began the fight of their lives. But they – and we – were not alone.

Over the next four months, we witnessed neonatal intensive care at Pennsylvania Hospital's ICN and the Children's Hospital of Philadelphia at its absolute finest. The doctors made decisions that were simultaneously life-saving and delicately mindful of long-term health. The nurses were by our boys’ sides, 24 hours a day, 7 days a week, providing expert care and love when we – with terrible pain – had to leave at night.

It is immensely difficult to think about those days. It conjures up images of our tiny sons connected to devices, separated from us – and each other – by technology. But when reflecting on that time, it is impossible to forget that we were part of something truly incredible. The team at Pennsylvania Hospital became our family, who hugged us, cried with us, answered our endless questions, loved our children – and who celebrated with us when we finally brought our two babies home after 81 and 116 days.

In honor of Neonatal Intensive Care Awareness Month, we want to thank the very special people at Penn Medicine’s ICNs. They give themselves to our babies, and they provide hope to parents. For that we are truly grateful, this month and forever.

Friday, April 24, 2015

When Should You See a Doctor for Irregular Periods?

Maybe you’re in your mid-to-late 20s and and suddenly—after having regular periods for more than a decade—your cycle suddenly stops behaving like clockwork. You’re not pregnant, and you’re nowhere near menopause, so what’s the deal?

Here’s what you should know about how to identify irregular periods, what causes them and when to see a doctor.

What Are Irregular Periods, Anyway?

During a normal menstrual cycle, an egg is released from one of your ovaries during ovulation. If the egg is not fertilized by a sperm, then changing hormone levels signal for your body to shed the blood and tissues that line your uterus, says the Office on Women’s Health (OWH).

This bleeding typically lasts about five days. Then, the monthly cycle repeats itself.

But some women have what is called abnormal uterine bleeding—another term for irregular periods, the OWH explains.

What is abnormal uterine bleeding?
  • Bleeding or spotting between periods
  • Bleeding after sexual intercourse
  • Heavy bleeding during your period
  • Menstrual bleeding that lasts longer than normal
  • Bleeding after you’ve reached menopause
According to the American Academy of Family Physicians (AAFP), between nine and 14 percent of women who have already gotten their first period but haven’t yet reached menopause have irregular periods.

What Causes Irregular Periods?

There are a number of reasons why a woman has irregular periods, says the National Institute of Child Health and Human Development (NICHD). 

When a girl first starts menstruating, it may take some time time before her periods become regular. And periods may stop becoming regular up to eight years before menopause.

Common causes of irregular periods include:

Uncontrolled diabetes—Women with unmanaged diabetes may have irregular periods because the interaction between blood sugar levels and hormones can disrupt a woman’s menstrual cycle, says the American Diabetes Association.

Eating disorders—Women with conditions like anorexia or bulimia may have irregular or missed periods because their bodies are not producing and circulating enough hormones to control the menstrual cycle, according to the Hormone Health Network.

Hyperprolactinemia—Women who have too much of a protein hormone called prolactin in their blood can have irregular periods.

Certain medications, including anti-epileptics and antipsychotics—can cause irregular periods.

Polycystic ovary syndrome—PCOS is caused by imbalanced sex hormones, which can disrupt regular menstruation.

Premature ovarian failure—The ovaries of women with POF stop working before the age of 40, says the National Institutes of Health. Some women with this condition continue to have periods occasionally, however.

When Should You See A Doctor For Irregular Periods?

It may be time to talk to your doctor if:
  • You haven’t had a period for 90 days
  • Your period suddenly becomes irregular
  • You have a period more often than every 21 days
  • You have a period less often than every 35 days
  • Your period lasts for more than a week
  • Your period becomes unusually heavy
  • You bleed between periods
  • Your periods are extremely painful
Source: Office on Women’s Health

A gynecologist will be able to determine the cause of your irregular periods and help you figure out a treatment course. This may include oral contraceptives to regulate your cycle.

Friday, April 10, 2015

Join Penn at the Race for the Cure 5/10

The 25th Annual Komen Philadelphia Race for the Cure® is a Mother’s Day tradition benefiting breast cancer research, education, screening and treatment.

The Penn Medicine Breast Health Initiative (PMBHI) was recently awarded $100,000 from the Susan G. Komen Philadelphia Community Grants Program to provide screening and diagnostic services to an additional 600 women this year.

25 percent of the funds raised by Komen Philadelphia supports the Komen national research program – a peer reviewed cancer research program offering grants in areas such as diagnosis, treatment, public health, survivorship and prevention. The remainder of the funds raised are invested locally in programs like the PMBHI, which help provide access to care and education in our community – both enriching and saving lives.

These are just a few good reasons to come out and join the Penn Medicine team.

25th Annual Komen Philadelphia Race for the Cure®
Mother’s Day: May 10, 2015
Eakins Oval/Philadelphia Museum of Art
5K Run/Walk & 1-Mile Fun Walk
Join us and help make a difference.

Interested in Joining Our Team?

To join the official Penn Medicine Team, patients, friends and family are welcome to visit the official registration page online and follow the instructions.

Race for the Cure Schedule:
7:00 am: Opening Ceremony: 25th Celebration Extravaganza
8:15 am: 5K Run Start
8:25 am: 5K Walk / 1-Mile Fun Walk Start

Other Ways to Show Your Support

Can’t make it on Mothers' Day? You can still support Penn Medicine’s team by making a donation to the team.

If you have questions about joining or would like to tell us why you walk in the Susan G. Komen Race for the Cure, please email Amy Kleger or visit

Thursday, April 2, 2015

Is Egg Freezing Right for You?

In recent news and media coverage, you may have heard about the increasing number of women who choose egg freezing as a way to delay childbearing without the risk of their most fertile years passing them by. That’s because the popularity of this process is on the rise.
Dr. Kaldra

“I’m seeing a lot more patients coming in for egg freezing,” says Suleena Kansal Kalra, MD, MSCE at Penn Fertility Care.

“Women come in and say, ‘You know what? I’m traveling a lot; I’m building my career; I’m 37 years old. I haven’t met Mr. Right, and I’m really not sure I’m going to in the next year or so, and I want to do something to take charge of my fertility.’”

Here’s what you should know about how egg freezing works and if it’s the right option for you.

What Is the Egg-Freezing Process?

During a normal menstrual cycle, “there’s a signal from your brain each month to release one egg,” Dr. Kalra explains. “But we want 10 or more for egg freezing.”

Egg freezing is done in three steps:

1. Hormone injections stimulate your ovaries to produce many eggs.

2. A physician monitors your eggs and hormone levels.

3. The eggs are retrieved, using a transvaginal ultrasound to guide the process, and are immediately frozen.

“Women take about 10 to 12 days of shots on average, and they come in for bloodwork and monitoring,” says Dr. Kalra. “Then we do the egg retrieval, generally within about two weeks of starting the medication. The eggs are flash frozen in a process called vitrification.”

Does Egg Freezing Work?

As with any fertility treatment, “It’s not a guarantee, but it’s certainly an option,” Dr. Kalra explains.

There have been more than 1,000 children born worldwide as a result of egg freezing. And conceiving using frozen eggs does not increase the risk of pregnancy complications or birth defects.

In fact, the rates of live births for fresh versus frozen eggs are about equal, found a December 2014 study in the medical journal Fertility and Sterility.

Is Egg Freezing the Right Option?

You may want to consider egg freezing if you know you want to have children, but you aren’t at the point in your life where you’re ready to become a parent.

Cancer patients may also want to consider egg freezing as a means of fertility preservation before having chemotherapy.

“Ideally, the best time to do it is before 35. The idea is to do it before your egg supply is starting to decline more rapidly,” Dr. Kalra says. “You can come back when you’re 40 and think that you’re at the point where you’re ready to start your family.”

As for how long eggs can stay frozen, “There’s no expiration date,” Dr. Kalra says. “But the ideal time to come back for your eggs is when you’re healthy and in good shape.”

Ultimately, the decision to freeze your eggs is one you must make carefully. If you’re considering egg freezing, a Penn Fertility Care specialist can talk to you about your options.

Wednesday, March 25, 2015

Women: Avoid Sports Injuries

In a perfect world, every run would be completely pain-free. No soreness, no aches and no lingering effects from the previous workout. Unfortunately, many runners constantly deal with a slight disturbance.

Regardless of how careful you are, injuries do occur. And, for women, the rate of injury is slightly higher. Runner’s knee, stress fractures, shin splints and plantar fasciitis are all injuries that are more common with female runners.

“One anatomical difference between men and women leading to greater predisposition to lower extremity injuries is the wider female pelvis, which results in a larger Q-angle,” says Erik Thorell, DO. “This results in increased stress across the knee in particular.”

Simply put, men and women are built differently. Women tend to have smaller, weaker muscles supporting their knees, as well as more lax ligaments. They typically have a larger hip width to femoral length ratio, which leads to greater hip adduction (muscles located towards the lateral portion of the thigh contract and pull the thigh away from the midline of the body). Females are also more at risk of certain injuries because there is added motion in their hips and pelvis.

When it comes to bone injuries, females are, again, more susceptible than their male counterparts. Women have smaller bone dimensions and are predisposed to lower bone density. Also, estrogen, a hormone in women that protects bones, decreases sharply as women age. All of these factors increase the risk of broken bones.

“Though gender differences do predispose women more to certain musculoskeletal injuries, attention to bone health, nutrition, core strengthening and a well-structured exercise routine can mitigate some of these problems,” explains Dr. Thorell.

Tips to Reduce the Risk of Injury

Because women suffer sports injuries more often than men, it is important you take extra care prior to going for a run or completing a race. There are exercises and precautions that can be done by women to reduce the risk of injury.
  • Leg lifts, back bridges and standing hip flexors help to improve motion and flexibility in the hip and glutes area.
  • Weight-bearing exercises help to build and maintain bone density. Attend dance classes, go for hikes, pick up aerobics or simply get into fast walking.
  • Balance exercises, such as Tai-Chi, can help strengthen legs.
  • Wear proper footwear and work out on appropriate (not very hard) surfaces.
  • Don’t suddenly intensify or lengthen your workouts.

Thursday, March 19, 2015

Ignoring Nature’s Call

Lori M. Noble, MD, a primary care physician at Spruce Internal Medicine, located at Penn Medicine Washington Square, discusses the health risks of ignoring nature’s call.

Dr. Noble
The long, grueling days of medical school and residency impart many lessons, far beyond those related to patient care. For instance, the mantra of my residency experience was "eat, sleep and pee when you can."

While I always made eating and sleeping a priority, urinating had a tendency to fall off my to-do list during a busy day.

I imagine this is not something unique to a career in medicine; I'm sure any woman who works in a demanding field can recall a time (or several) when she "held it in" a little longer than would have otherwise been comfortable. It's a pretty common sacrifice we make to get that one last thing done, typically without giving much thought to any potential consequence.

I recently came across an interesting article in a popular women's magazine that addressed the potential impact of holding it in and thought I'd share what I read and add my medical opinion.

Bladders are unique like fingerprints.

There is no real agreed upon amount of time that is considered okay to hold in urine. This is because every woman is different in terms of how hydrated she stays, how large her bladder is and how sensitive her bladder is to the stretch that happens as it fills with urine.

Bottom Line: The average woman will feel comfortable holding her urine for between three and six hours, but there's a lot of variability.

So Why Not Hold It In?

The authors downplay any consequence of holding in urine for a prolonged period of time, noting that the "worst case scenario" is a "bit more of a likelihood" of developing a urinary tract infection (UTI). As a physician and a woman, I take issue with this for a couple reasons:

1. UTIs can be dangerous. In some people, the infection can spread from the bladder up to the kidneys and even into the bloodstream if not treated quickly. Pregnant women and those with certain medical conditions that can affect bladder function (i.e., Multiple Sclerosis, Diabetes, etc.) are already at increased risk for UTIs, so they should be extra vigilant about emptying their bladders regularly to prevent infection.

2. Many women struggle as they get older with urinary incontinence (the loss of bladder control). Stress urinary incontinence is leakage when there is increased pressure applied to the bladder, like with coughing, laughing or jogging. Urge urinary incontinence is leakage because of an intense, involuntary contraction of the bladder, often described as the "I gotta go, I gotta go, I gotta go" feeling. Both can be made worse if the bladder fills up beyond a comfortable capacity.

Bottom Line: There are potential consequences of holding in urine for a prolonged period of time. Listen to your body and take time to go when you feel the urge.

Are There Benefits to Holding It In?

There is some evidence that holding urine can "train" the bladder to be less sensitive to the urge to go, and thus allow a woman to wait a bit longer between bathroom trips. In my opinion, the risks of holding it as outlined above, outweigh this potential benefit.

Bottom Line: When it comes to holding in urine, the risks of infection, leakage and pain outweigh the potential benefit of a modest increase in bladder capacity.

So next time you feel the urge to go, try to fight the instinct to just cross your legs and hold it in for a bit longer – your bladder will thank you for it later!

Concerns about bladder and pelvic floor health? Speak to a Penn urogynocologist.

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