University of Pennsylvania Health System

Penn Health for Women Newsletter

Thursday, August 27, 2015

Sex After Birth: What To Do When It Just Doesn’t Feel the Same

Women tend to assume that after their bodies have bounced back from childbirth, their sex lives should do the same.

But Pamela Levin, MD, Assistant Professor of Clinical Obstetrics and Gynecology at Penn Medicine, knows this is not the case for many women.

A lot of women soon come to realize that sex after birth simply doesn’t feel the same. You may not have the desire, you have trouble getting or you even feel pain during sex.

“If you’re still having persistent discomfort, maybe your body just needs more time,” Dr. Levin says. “But I think once you get past six to eight weeks, we would expect you to start getting back to your usual sexual activity.”

Knowing what causes issues with sex after birth is a good first step in coming up with solutions.

Common Causes of Issues with Sex After Childbirth

1. The birth itself

After birth, “your vagina is different. You had a baby. You may have had a repair. You may have a scar there,” Dr. Levin explains.

Women who had an episiotomy—a cut below their vagina to enlarge the opening for delivery—or who experienced a tear during delivery may find sex painful for the first few months after childbirth, says the American Congress of Obstetricians and Gynecologists (AGOG).

“Depending upon the type of delivery and repair, the sensation may be different,” Dr. Levin says.

2. Stress about sex after childbirth

For many women, stress and anxiety can make sexual challenges worse.

If you get anxious about sex, the anxiety heightens your awareness of every twinge of discomfort. And like a destructive cycle, worrying brings about the very issue you’re concerned about.

3. Changes in hormones

After giving birth, your body’s hormone levels need to readjust to their pre-pregnancy state. This readjustment can reduce your sex drive and sexual response.

For instance, women who breastfeed have lower estrogen levels, which can lead to vaginal dryness.

4. New relationship dynamics

Your relationship with your partner might change after childbirth, too. It will take time for a new sense of balance to emerge in your family. After all, you’ve added a whole new person—and a pretty demanding one, at that.

During this transition period, your interest in sex may not match up with your partner’s. And that’s fine. Talk openly about expectations and what you’re experiencing to make things less confusing.

5. Pelvic organ prolapse

Vaginal childbirth can injure your pelvic floor muscles, potentially leading to a condition called pelvic organ prolapse.

Symptoms range from a sense of dropping or gaping of the vagina to the appearance of a bothersome bulge near the vaginal opening.

Many women simply don’t find sex enjoyable when they’re dealing with pelvic organ prolapse.

When Should You See a Doctor for Issues with Sex After Childbirth?

Sometimes, all you need to get your sex life back on track is time, but most women don’t know they can talk to their doctor about challenges with their sex lives.

Dr. Levin says that because sex may feel different, “getting used to that idea and easing back into intercourse are also factors that come into play."

There’s no standard timeline for when things should start getting back to normal; however, Dr. Levin says that “Anything that extends beyond that standard six to eight weeks of healing should prompt you to talk to your doctor.”

The good news: Sexual issues after childbirth are usually not long-term. Whether you’ve had one child or several, or delivered via c-section or vaginally, none of this should have a long-term impact on your sexual desire, activity or satisfaction in later life.

That means there’s hope. Talk to your doctor if your sex life hasn’t returned to normal after six to eight weeks.

Friday, August 21, 2015

Prolapse Surgery and Why You May or May Not Need It

Many women find the thought of dealing with medical issues “down there” completely cringeworthy. They may choose to suffer in silence from serious health issues—like pelvic organ prolapse.

Not only is this suffering unnecessary, the process of waiting to see what will happen can allow the situation to worsen.

Signs of worsening pelvic organ prolapse include:
  • Pressure or a bulging sensation in the vagina that gets worse as the day goes on
  • Difficulty urinating
  • Lower back pain
  • Urinary leakage during sex
  • Bleeding where the exposed skin rubs on a pad or underwear
When it comes to understanding and treating pelvic organ prolapse, knowledge is power. Here are five things you should know about pelvic organ prolapse surgery.

1. You’re Not Alone

According to the American Urogynecologic Society, there are 3.3 million women in the United States with pelvic organ prolapse, and 300,000 pelvic prolapse surgeries are performed in the country each year. If you're having similar issues and considering surgical treatment, you are definitely not alone.

2. Family Planning Is a Factor to Consider

When deciding if prolapse surgery is right for you, consider your childbearing plans.

In most situations, women who plan to have children should hold off on surgery. This is because prolapse that has been repaired surgically can return during childbirth.

3. You May Have More Than One Surgical Option

Understanding the different types of surgery—how they work and what the recovery is like—can also put your mind at ease.

Two more common surgical options for pelvic organ prolapse are laparoscopic surgery and pelvic reconstructive surgery.
  • Laparoscopic surgery involves making a small incision or incisions in the abdomen to correct the prolapse. This type of procedure is commonly performed on women with prolapsed uteruses. 
  • Pelvic reconstructive surgery, on the other hand, involves repairing the prolapse through the vagina. No abdominal incisions are made in this type of surgery.

4. You Need Enough Time to Fully Recover

Recovery time will vary depending on the type of surgery you have. Generally speaking, you’ll probably need to set aside at least a few weeks for at-home recovery.

Be prepared to take time off from certain activities. You’ll have to stay home from work. You’ll also want to avoid strenuous physical activity—from lifting heavy objects to having sex. This initial rest period typically lasts six to eight weeks.

If that sounds like a long time to recover, remember that the alternative may be years of suffering. A month or two of rest would be a small sacrifice for greater quality of life.

That said, keep this in mind...

5. You May Not Even Need Pelvic Organ Prolapse Surgery

Women with mild symptoms may not need surgery for their pelvic organ prolapse..

There are two main nonsurgical options for treating pelvic organ prolapse: Pessaries and kegel exercises.
  • A pessary is a rubber or plastic donut-shaped device that you insert into your vagina, sort of like vaginal contraceptive diaphragms. It provides internal support for vaginal or uterine prolapse by holding the uterus in place.
  • Kegel exercises—contracting and relaxing your pelvic floor muscles—aren’t necessarily considered a cure, but they can help treat the symptoms of prolapse by strengthening your pelvic floor muscles.
While the option to pursue surgery for pelvic organ prolapse is ultimately a personal one, your urogynecologist can help if you’re undecided about the best treatment. Learn more or make an appointment.

Thursday, August 6, 2015

Diabetes in Pregnancy

Between 14 and 16 million people have diabetes in the Unites States. It's a disease where the body cannot properly break down and use food for energy.

Sometimes women develop diabetes while they're pregnant, called gestational diabetes. The hormone, insulin, helps sugar move from the blood stream into the body’s cells. If a woman gets gestational diabetes, it means there is a problem with her insulin -- that she has high blood sugar during pregnancy.

Approximately four percent of pregnant women develop gestational diabetes while pregnant. It usually begins in the second trimester and often goes away (90 percent of the time) after the baby is born.

It's important for woman who develop gestational diabetes to control their blood sugar levels. If the blood sugar gets too high, it can lead to problems for both the mother and the baby.

Gestational Diabetes Management at Penn

Dr. Celeste Durnwald
Penn’s comprehensive diabetes program is designed for women at risk for gestational diabetes, recently diagnosed with gestational diabetes, and women with diabetes before pregnancy. To obtain the best outcome for mother and baby, the program includes:
  • Consultation with specialists in the care of women with diabetes during pregnancy
  • Nutritional counseling
  • Monitoring glucose levels
  • Recommendations for treatment and lifestyle changes
Celeste Durnwald, MD, director of the Perinatal Diabetes Program at the Hospital of the University of Pennsylvania, has developed guidelines for the management of diabetes during labor and delivery.

“Research has shown that women who develop gestational diabetes have a 30 to 50 percent chance of developing type 2 diabetes later in life,” says Dr. Durnwald. “That’s why it’s important for a woman who develops gestational diabetes to have access to a team of obstetricians, specialists in maternal fetal medicine and diabetes, and nutritionists who can help manage her care during pregnancy and after.”

“Our goal is to educate women about diabetes in pregnancy and make recommendations that will improve their health and the health of their baby,” says Dr. Durnwald.

Expanding Diabetes Management Locations

For women outside of Philadelphia, having access to Penn Medicine specialists for diabetes management during pregnancy is easier than ever. Dr. Durnwald is now offering the same services as in our Philadelphia locations at Chester County Hospital.

She emphasizes that women who come to the Penn Maternal Fetal Medicine practice at Chester County Hospital can feel confident they are getting the same level of service and access to care as women who visit the Perinatal Diabetes Program in Philadelphia.

“We have a great relationship with specialists here and throughout the Penn Medicine health system,” she adds. “Patients in the Chester County area don’t necessarily need to come into the city to receive the same quality of care.”

Find out more about maternity services at Penn.

Thursday, July 30, 2015

When Should Pelvic Floor Issues Send You to the Doctor?

Some women deal with their pelvic organ prolapse or urinary incontinence on their own and don’t let their symptoms interfere with their lives. Others are mortified by them.

Dr. Uduak Andy
“What I always tell my patients with prolapse and incontinence is that none of those things will kill you, but they can significantly impact your quality of life,” says Uduak Andy, MD, a urogynecologist at Penn Medicine.

The decision to seek treatment is up to the patient, Dr. Andy explains. “It depends on how much it bothers the woman.”

That said, some women live in a state of denial about how much their pelvic floor disorders change their lives.

There comes a time when seeking treatment is in your best interest. Here are five clues it’s time to see a doctor for your pelvic floor issues.

1. When you start to experience depression and self confidence issues

“Incontinence is associated with depression, isolation, and a worsened quality of life,” says Dr. Andy.

Depression caused by pelvic floor disorders can create a self-perpetuating cycle: You avoid social situations and other activities because you’re depressed, but that avoidance only worsens the depression.

2. When you stop doing activities you used to enjoy

“If a woman has to worry about something in between her legs, she’s probably not going out as much or doing as many things as she wants to,” Dr. Andy explains.

“If she has to wear a diaper every time she leaves the house, she may not engage in things like sports.”

Many women don’t realize just how much they miss these activities until they start doing them again after treatment. Dr. Andy has seen firsthand how treatment for pelvic floor disorders helped women return to their normal routines.

3. When you start avoiding sex

“Both incontinence and prolapse can interfere with people’s sex lives,” says Dr. Andy.

“A lot of women who have prolapse are very apprehensive about sex. They don’t feel sexy. They wonder, ‘Is he going to notice? What’s going to happen?’” These are common insecurities expressed by women with this condition.

But, as Dr. Andy explains, “If prolapse is getting in the way of your having sex, then we absolutely need to take care of it.”

The same goes for incontinence, she says. “Some women with incontinence are leaking urine while they’re having sex and they’re absolutely petrified. That’s not what we want.”

4. When you need to wear a pad

“If you’re spending money on pads for your incontinence, you really should be seeing somebody for it,” Dr. Andy says.

This can be a bit subjective, however. “You’ll have a woman who’s changing her pad four times a day who’s not bothered, and a woman who has a panty liner and is losing her mind about it,” she explains.

The decision to seek treatment goes back to the quality of life issue.

5. When you start changing your social life

According to Dr. Andy, “A women who leaks anytime she coughs or laughs is probably not laughing. She’s probably not going out with her friends.”

“One thing that decreases quality of life is that as we get older, we isolate ourselves,” she explains. “The last thing we want is for an older woman not to engage in things because she’s worried about prolapse or incontinence. This should not be a reason for a woman to stay at home.”

This is why treatment is so important.

“If we can treat her condition and she can feel more confident and comfortable when she goes out, then I think that’s a huge success.”

Thursday, July 23, 2015

Hair Loss – Not Just a Problem for Men

Women can experience significant hair loss and baldness.

“Hair loss in women may be caused by either over or under production of androgen (male) hormones in the body,” says George Cotsarelis, MD, chair of the department of dermatology at Penn Medicine. “So as women age and produce less estrogen, they may notice that their hair is getting thinner.”

A change in hormone levels at the time of menopause is just one of the causes of hair loss in women. For women not approaching menopause, there could be multiple reasons that need to be considered.

Dr. George Cotsarelis
“If you’re concerned about hair loss, it’s important to work with a physician who will complete a thorough exam and tests to identify possible causes,” says Dr. Cotsarelis. “Thyroid disorders, medications, stress, illness, diet or even anesthesia can trigger hair loss.”

Dr. Cotsarelis also says an iron deficiency can affect a woman’s hair.


“Women who have had a dramatic weight loss, or aren’t getting enough iron through their diet may experience hair loss.”

Hair loss is also not uncommon in women with Polycystic Ovary Syndrome (PCOS). PCOS is a complex condition in which women experience infrequent menstruation, weight gain, acne, hair loss or excess hair growth. On ultrasound examination the ovaries have multiple small cysts. Most women complain of excess hair growth on the face, arms, chest and back, but a subset of women will experience hair loss. It's associated with high levels of testosterone.

“Women with PCOS are at risk for other related life-long conditions including diabetes, high cholesterol, hypertension and, in some cases, fertility problems,” says Anuja Dokras, MD, PhD, director of the Penn Polycystic Ovary Syndrome Center. “Hair loss or excess hair growth may be one of the first signs in a young woman.”

What Can You Do?

Dr. Anuja Dokras
“The first step is identifying the underlying reason a woman is losing her hair,” says Dr. Cotsarelis. “For women who have normal iron and hormone levels, but are still experiencing female pattern baldness, a product that contains minoxidil can help regrow hair.”

When treated by a team of physicians and specialists trained in PCOS management, women can regain control of their hair growth and loss.

“Treatment for PCOS-related symptoms includes hormonal and non-hormonal medications, nutritional counseling and weight loss,” says Dr. Dokras.

The Penn PCOS Center assists women in managing their PCOS symptoms and related health conditions. Penn physicians take an individualized approach to care. They understand that no two cases of PCOS are exactly alike, and work closely with each patient to determine the best treatment plan.

Led by Dr. Dokras, the Penn PCOS Center works with Penn dermatologists to offer patients a multidisciplinary approach to treatment. Patients have access to a variety of services including hormonal treatment, fertility treatment, weight management, nutrition services and laser hair removal to manage the excessive hair growth associated with PCOS.

Thursday, July 16, 2015

Top Five Myths About Urinary Incontinence in Women

Dr. Uduak Andy
Urinary incontinence—the fancy clinical term for those inconvenient leaks that women sometimes experience—is far more common than most people would expect.

Even though there are plenty of treatment options available for this condition, a lot of people buy into widespread myths about urinary incontinence in women.

Uduak Andy, MD, a urogynecologist at Penn Medicine, is all too familiar with these myths. She’s also ready to help spread the truth.

So here are the top five myths about urinary incontinence in women—busted.

1. Incontinence Is a Normal Part of Aging

Perhaps the most popular myth about urinary incontinence is that it’s inevitable—that as women age, their bodies are bound to lose the ability to hold their urine.

“One of the big risk factors for incontinence is advancing age, but it’s not normal,” Dr. Andy says.

Unfortunately, she adds, “Incontinence is one of the leading reasons why women will get put in nursing homes.”

2. There’s Nothing You Can Do About Incontinence, So Just Wear a Pad

Too often, women assume that aren’t any treatment options available for urinary incontinence. And they’re very, very wrong.

“Not knowing that there are options for treating it is probably one of the big misconceptions and reasons why women don’t go to their doctors,” says Dr. Andy. Aside from the embarrassment, that is.

But wearing a pad is not a solution. It’s a bandaid that doesn’t address the underlying condition.

3. You’ll Have to Have Surgery to Fix Your Incontinence

On the other end of the spectrum, some women assume that a super invasive surgery is the only way to deal with the problem.

Many women don’t know that there are non-surgical treatment options for urinary incontinence. These treatments tend to fall under the umbrella of behavioral therapy. They include:
  • Pelvic muscle training: Kegel exercises can help build muscle control and prevent leakage.
  • Bladder training: Gradually expand the length of time between bathroom trips.
  • Relaxation exercises: Taking slow, deep breaths can help calm the urge to urinate until you can get to a bathroom.
  • Dietary modifications: Decreasing caffeine intake, for instance, can reduce the risk of leakage.
  • Medication: Some medications can help with bladder muscle control.

4. Your Doctor Can’t Help You with Incontinence

Some women may want to seek treatment for their urinary incontinence, but don’t know where to turn.

“They’re not clear on who to see—should they see their primary care physician? A gynecologist? Women sometimes don’t know that there’s a specialist called a urogynecologist,” Dr. Andy says.

A urogynecologist is a doctor who specializes in both urology and gynecology.

“I like being a urogynecologist because it’s really a field where you help women live better. You get to improve their quality of life,” explains Dr. Andy.

The reason many women don’t know about this unique specialty could be because urogynecology is a relatively new field. Doctors only began receiving board certification in this specialty in 2013, according to the American Urogynecologic Society.

5. Running for the Bathroom Is a Good Idea

“A lot of women with urge incontinence will just beeline for the bathroom,” Dr. Andy says. “You’re not going to make it. You’re not going to be able to run your way to the bathroom.”

Instead, she says, “When you have that really bad urge, stop, take a deep breath, do a really strong Kegel to contract your pelvic floor muscles. The contraction will break a bladder spasm. Then, you can walk to the bathroom.”

Thursday, July 9, 2015

No Periods – Should You Be Alarmed?

Menstrual bleeding is a normal monthly event for most women, so should you be concerned if you or your daughter stops bleeding or has not started having regular periods?

Athletic Amenorrhea

Kate Temme, MD, specializes in sports medicine and women’s health, including treatment of the female athlete triad. According to her, the female athlete triad is composed of three interrelated conditions that include:
  • Energy availability (nutritional intake)
  • Menstrual function
  • Bone mineral density
The triad occurs along a spectrum from optimal health to disease. At the extreme, the triad is defined by low energy availability (with or without an eating disorder), amenorrhea and osteoporosis. Girls and women can have one, two or all three components. Low energy availability is the core component of the triad, and affects bone health by decreasing new bone formation, and increasing bone resorption due to a lack of estrogen. Without adequate nutrition, adolescent girls miss out on critical bone health – a price they may pay throughout their whole life.

Dr. Kate Temme
“The vast majority of bone density is built in the years surrounding the onset of menstruation,” says Dr. Temme. “Without estrogen, a girl cannot build the critical bone mass she needs throughout her lifetime. This can result in low bone density, fractures and osteoporosis.”

Dr. Temme sees girls who have multiple stress fractures due to repetitive movements. While training errors may be at fault, frequent stress fractures are often associated with poor bone health.

“Gymnasts, ballet dancers and runners – any athlete who participates in a ‘lean physique’ sport - can be at greater risk, but the triad can affect girls and women across a wide range of sports and activity levels” she says. 

According to the American Society for Reproductive Medicine and the American College of Sports Medicine, girls who have not yet menstruated by the time they are 15 have a condition called primary amenorrhea. Women who have previously had a period and stop menstruating for three or more consecutive months have secondary amenorrhea. 

Primary Amenorrhea

“Primary amenorrhea can result from genetic, anatomic or endocrine causes. In young athletes, primary amenorrhea may occur when a girl does not eat enough to support the amount of energy she is expending in her sport,” says Dr. Temme. “In extreme cases, this may be a result of an eating disorder, but often times, it is inadvertent – she is simply not getting enough nutrition to sustain the exercise her body is performing as well as her body’s other physiologic functions.”

This imbalance of energy intake versus energy expenditure affects the body’s endocrine system, including reproductive function and estrogen production.

“It’s the body’s way of saving energy for all the exercise a girl is doing,” she says. “Certain biologic systems shut down, affecting metabolism, skeletal and reproductive health.”

Secondary Amenorrhea

Dr. Monica Mainigi
In some cases, secondary amenorrhea can be associated with low estrogen levels and can lead to osteopenia, which is the precursor for osteoporosis, osteoporosis and bone fractures. It also decreases a woman’s chance of becoming pregnant.

“When a woman’s body doesn’t have enough estrogen, she does not ovulate.” says Monica Mainigi, MD, assistant professor of obstetrics and gynecology at the Hospital of the University of Pennsylvania, “This is the body’s way of saying there is not enough energy to support a pregnancy.”

Dr. Mainigi specializes in infertility and reproductive endocrinology. She explains that some women who exercise excessively or restrict their caloric intake can experience secondary amenorrhea and infertility. One of the first steps is a comprehensive evaluation by a gynecologist to identify the cause of amenorrhea so that a personalized treatment strategy can be developed.

Treating the Female Athlete Triad

“Treating girls and women who have the Female Athlete Triad is complex and requires women to be plugged in to the right resources,” says Dr. Mainigi. At Penn, nutritionists, counselors, orthopaedic specialists and endocrinologists work together to provide coordinated care for these athletes.

“Simply telling a woman to eat more or train less is not the answer,” says Dr. Mainigi. “Her personal identity may be wrapped up in appearance, athletics and performance, and she can lose sight of what is healthy and what is not.”

Dr. Temme adds that there are positives when it comes to treatment. 

"The good news is that when discovered early, and treated comprehensively, a lot of the damage can be prevented.”

Friday, June 26, 2015

What on Earth Is Urogynecology?

Picture this: You’re out with your friends and someone says something so hilarious that you all burst out laughing. But your good mood plummets to embarrassment: You’ve started to leak urine. You dash to the nearest restroom, hoping you’ll make it in time.

Over the next few months, you’re plagued by more embarrassing leaks and close calls. Finally, you mention it to your primary care physician. She recommends you see a urogynecologist.

A what...? You heard right—urogynecologist.

No, it’s not a European gynecologist. Urogynecology is a hybrid specialty: Urology plus gynecology.

“I see a lot of women who are postpartum—just had babies. I see women who are in or approaching menopause. I see women who are postmenopausal.  I also see women at other times in their life who are simply bothered by their symptoms,” explains Pamela Levin, MD, assistant professor of Clinical Obstetrics and Gynecology.

Here's what you should know about the specialty.

What exactly does a urogynecologist do?

Urogynecologists help women who have pelvic floor conditions. They handle everything from evaluation and diagnosis to treatment and management.

“The beauty of urogynecology is that it is a collaboration between you and your doctor. It’s all aimed at meeting your goals,” says Dr. Levin. “The primary focus is on quality of life.”

Treatment for pelvic floor conditions include:
  • Behavioral therapy—relaxation techniques, muscle training, dietary changes can help manage symptoms
  • Pessaries—after receiving doctor instruction on proper use, this device that fits into the vagina to support the bladder, uterus, etc. can be removed for cleaning and reinserted
  • Medications—depending on the condition, this may be an option for treatment  
  • Surgery—options vary from minimally invasive and laparoscopic procedures to reconstructive surgery, depending on the condition

What are some common pelvic floor conditions that urogynecologists treat?

Urinary Incontinence

Urinary incontinence is the clinical term for urine leakage. The American Urogynecologic Society (AUGS) found that it's twice as common in women than in men. Risk factors include:
  • Vaginal childbirth
  • Genetics
  • Diuretic medications
  • Chronic constipation
  • Obesity
  • Smoking

Overactive Bladder

People with overactive bladder have urine leakage as well as a frequent, intense urges to urinate.

Some women have an obvious underlying medical condition—usually a neurological or inflammatory illness—that causes overactive bladder. But for most women, the cause is unknown.

Pelvic Organ Prolapse

Pelvic organ prolapse occurs when the pelvic organs—like the uterus or bladder—drop because of weakened vaginal muscles, says the AUGS.

Risk factors for pelvic organ prolapse include:
  • Vaginal childbirth
  • Genetics
  • Smoking
  • Pelvic floor injuries
  • Chronic constipation
  • Chronic coughing
  • Obesity
Obese women are 40 to 75 percent more likely to have pelvic organ prolapse.

Is urogynecology a new field of medicine?

Yes and no. The health issues that urogynecologists deal with are not new.

But the American Board of Medical Specialties (ABMS)—the organization that oversees certification standards—added urogynecology as a subspecialty in 2011, according to AUGS.

Urogynecology is also known as Female Pelvic Medicine and Reconstructive Surgery. Doctors began receiving board certification for it in 2013.

What should you look for in a urogynecologist?

Your primary care physician or gynecologist can refer you to a urogynecologist if you're dealing with pelvic floor issues.

If you’re looking at prospective doctors on your own, keep in mind a few key factors: Experience and certification are important. But, so is the doctor’s personality and how comfortable you feel with him or her.

“You have to make sure you feel like this person is someone you can share intimate details of your life with," says Dr. Levin "Someone that you feel comfortable with, that you trust and that you know is listening to you."

Do you want to learn more about urogynecology services? Ready to see a specialist about your pelvic floor issues? Sign up for an appointment with a Penn urogynecologist.

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