University of Pennsylvania Health System

Penn Health for Women Newsletter

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.

Friday, March 13, 2015

Penn Fertility Care Celebrates 50 Years: Pioneers in IVF, Reproductive Services and Preservation

This year, Penn Fertility Care celebrates its 50th anniversary. Penn Fertility Care was the first fertility practice in the Greater Philadelphia area and established the fourth in vitro fertilization (IVF) program in the country. Propelled by expert visionaries and compassionate care, it has helped couples create and grow their families for decades.

Dr. Coutifaris
“When the Penn Fertility Care practice was first created, Penn had a vision to develop a practice that included three cornerstones that are still relevant today. They include: innovation and research of technologies to help couples conceive, education and training of the next generation of fertility specialists, and excellence in providing patient care,” says Christos Coutifaris, MD, PhD, chief of Reproductive Endocrinology and Infertility.

To commemorate the anniversary, we thought we'd give you a look at our past breakthroughs in reproductive medicine and patient care, our current focuses in the field of fertility, and our vision for the future.

The Beginning

Dr. Mastroianni
In 1964, Luigi Mastroianni Jr., MD, joined Penn Medicine as the chair of the department of Obstetrics and Gynecology. He, together with his long-time colleague, Celso Ramon Garcia, MD, were committed to establishing a world-class academic program that would develop and provide state-of-the-art care for infertile couples.

They recognized that it was critical to have a robust research program focused on reproductive biology and a clinical program focusing on human reproduction. To accomplish this, they established the division of reproductive biology, which eventually evolved into the Center for Research on Reproduction and Women's Health, one of the best research programs in women’s health.

“The tools were very limited in the 60s,” says Clarisa Gracia, MD, MSCE, director of Fertility Preservation at Penn. “There were a few medications to induce ovulation, but treatments didn't address male factor infertility or blocked Fallopian tubes, then treated solely with surgical procedures pioneered here at Penn.”

“Patient care has evolved over the past five decades. In the 1950s and 1960s, IVF had not been applied to clinical practice. Today, it's the preferred and most common infertility treatment used when the Fallopian tubes are severely damaged or absent and for unexplained or male factor infertility. In fact, due to its high success rate, IVF is being used more frequently in recent years as a first line of therapy for practically all causes of infertility,” says Dr. Coutifaris.

Dr. Mastroianni’s vision and leadership are acknowledged by many to have shaped obstetrics and gynecology into an academic and clinical specialty. Beyond his scientific expertise and his skill in training physician-scientists, Dr. Mastroianni was an eloquent advocate for reproductive biology and women’s reproductive rights.

Penn Fertility Care Today

Dr. Gracia
To this day, Penn Fertility Care continues to be among the top National Institutes of Health (NIH)-funded programs in the nation, providing a range of comprehensive reproductive and infertility services for both men and women.

“In the past, because IVF was still so new, we were very focused on its success,” says Dr. Gracia. “Now that IVF success rates have improved, our expectations have grown. We continually strive for excellence and try to make patients happier and feel good about the process.”

At Penn Fertility Care, we provide consultation and evaluations, diagnostic imaging and testing, medical and surgical treatment options, and IVF. We also offer the following specialty programs:
  • Penn Polycystic Ovary Syndrome (PCOS) Center: Under the leadership of Anuja Dokras, this program takes a multi-disciplinary approach to treating women with PCOS. It provides treatment options to address their menstrual problems, fertility concerns, weight management, emotional and psychological issues and cardiovascular health.
  • Fertility Preservation Program: Directed by Dr. Gracia, Penn Fertility Care pioneered approaches for the care of patients facing fertility threatening cancer therapies. The Fertility Prevention Program offers a variety of options for both females and males to preserve embryos, eggs, sperm or ovarian tissue. 
  • Male Fertility Program: Puneet Masson, MD, director of Male Fertility at Penn, established a program that provides evaluation, testing, consultations and specialized treatment options for men with fertility concerns. Penn Fertility Care is the only clinic with a full-time reproductive urologist on site to care for couples with male factor infertility. 
“Penn Fertility Care brings together a well-rounded, diverse group of experienced fertility specialists, nurses and dedicated staff into one practice” says Dr. Coutifaris. “Our physicians are all leaders in their field with national and international reputations, and are dedicated to our specialty programs for both women and men trying to conceive.”
The Penn Fertility Care Team

The Future of Fertility Care at Penn

Our clinicians and researchers are constantly working towards improving success rates for IVF and using more sophisticated approaches to achieve better outcomes.

As the only program in the country that has received continuous funding from the NIH for clinical research, we believe we'll remain on the forefront of reproductive medicine. We're able to offer clinical trials to fertility patients and give patients access to the latest treatment options before they are widely available elsewhere in the region. 

Working with the Abramson Cancer Center and Children’s Hospital of Philadelphia, it's become routine for us to bank eggs or ovarian tissue for women who are undergoing cancer therapy. 

“There have been so many advances in cryopreservation for women’s eggs,” says Dr. Gracia. “Because we can offer this service with confidence to women, they can focus on their cancer care.”

Genetic testing of embryos is also getting more sophisticated.

“We can biopsy embryos prior to transferring the embryo after IVF and test the embryo for a number of genetic conditions,” says Dr. Dokras, director of the Preimplantation Genetic Diagnosis Program. “This level of care and diagnosis can help improve success rates, decrease the chance of pregnancy loss or avoid other genetic problems."

Looking at how much has been accomplished in the past 50 years, we're excited to see what's next for us. One thing we know for sure: We'll continue coming up with new options for people to build the family that they dream of.

“Penn continues to propel innovation, education and patient care to new levels,” says Dr. Coutifaris. “We are proud of the accomplishments that Penn Fertility Care has made over the years, but also look forward to what is ahead for the program in the years to come.”

Monday, May 12, 2014

PCOS and Sleep Apnea: When Snoring Shouldn't (or Can't) Be Ignored

Polycystic ovary syndrome (PCOS) is a complex condition, or group of physical symptoms, in which women experience infrequent menstruation, weight gain, acne, abnormal hair growth and fertility problems.

“Women with PCOS are at risk for other, related life-long conditions and symptoms including diabetes, high cholesterol, hypertension,” says Anuja Dokras, MD, PhD, director of the Penn Polycystic Ovary Syndrome Center. “They are also at risk for sleep apnea.”

Sleep apnea is a respiratory disorder in which a person experiences pauses in breathing. Pauses can last from a few seconds to a minute, and can occur multiple times throughout the night. “Sleep apnea presents itself as snoring, pauses in breathing followed by a gasp for breath and frequent, disturbed sleep,” says Dr. Dokras. “A partner or spouse may tell the person with sleep apnea this is occurring, or in some cases, the person with sleep apnea wakes themselves up during the night.” Snoring itself isn’t serious, but if a person is experiencing snoring with sleep apnea, the situation can have serious complications.

“For women with PCOS, sleep apnea can exacerbate other PCOS symptoms such as tiredness, difficulty losing weight, hypertension and insulin resistance,” says Dr. Dokras. “Of course, many women report feeling tired, but some also say they feel depressed and experience unexplained moodiness.”

Diagnosing Sleep Apnea

Allan Pack, MD, PhD, chief of the division of sleep medicine and director of the Center for Sleep and Respiratory Neurobiology at Penn says sleep apnea often goes undiagnosed.

“There are two different ways we can diagnose sleep apnea,” he explains. “A sleep study in a sleep lab that resembles a hotel room requires patients be hooked up to wires throughout the night. An electroencephalogram, or EEG, monitors brain activity throughout the night to determine how well an individual is sleeping, while patients are watched using respiratory monitors to see if there are pauses in their breathing as they sleep”. Dr. Pack explains “at-home” sleep studies are also an option for some patients.

“For patients without a lot of other health conditions, an ‘at-home’ sleep study can monitor sleep, and pauses in breathing,” he says. “The only difference is that an EEG study is not done in the home.”

Treatments for Women with PCOS and Sleep Apnea

Treatment for PCOS includes medication, nutritional counseling and weight loss. “Weight loss can help improve sleep apnea, but treatment for sleep apnea itself can have a marked improvement on a woman’s life,” says Dr. Dokras.

Dr. Pack says most patients can use a continuous positive airway pressure machine, or CPAP machine, to help regulate breathing throughout the night.

“A CPAP machine uses a mask with pressurized air to force the airways in the mouth and neck to remain open while the person is lying down and asleep,” says Dr. Pack. “A CPAP machine is very effective. Patients who use it report having more energy throughout the day, and less drowsiness.”

There is also a small amount of evidence that suggests use of a CPAP machine can help other metabolic functions in women with PCOS such as insulin resistance, high blood pressure and high cholesterol. For those who cannot tolerate wearing a CPAP mask throughout the night, an oral device that pulls the jaw forward may be an option for treatment.

For those who cannot tolerate wearing a CPAP mask throughout the night, an oral device that pulls the jaw forward may be an option for treatment.

"We are learning more and more that restful, healthy sleep is important for every other body function," says Dr. Dokras. "That's why it's so important women with PCOS talk to their physician about their sleep, and if they are experiencing any symptoms of sleep apnea."

Wednesday, April 23, 2014

What Women Need to Know About Endometrial Cancer

Endometrial cancer is the most common gynecologic cancer in the United States. A statistic like this can be daunting and a bit frightening, but the good news is according to gynecologic oncologist Emily Ko, MD, MSCR, assistant professor of obstetrics and gynecology at Penn Medicine, women diagnosed at an early stage generally have good outcomes.

“Knowing the symptoms of endometrial cancer is extremely important,” says Dr. Ko. “Irregular bleeding is typically the first symptom. At that point, a woman should see a physician for an exam, and all of the appropriate tests needed to make a diagnosis.” Endometrial cancer is a cancer that develops in the lining of the uterus called the endometrium. There are two types of endometrial cancer. Type 1 endometrial cancer tends to be associated with diabetes, obesity and metabolic syndrome, a cluster of conditions that includes high blood pressure, high blood sugar levels and high cholesterol.

“Together with cancer treatment, it’s important for women with this type of endometrial cancer to work on other areas of their health such as weight management, exercise and diet in order to have better control of the associated issues like diabetes and high blood pressure that can affect their overall health,” says Dr. Ko. She adds that there are even some clinical trials examining the use of metformin, widely used in the treatment of diabetes, to treat pre-cancerous cells in the uterus.

Type 2 endometrial cancer tends to be biologically different and is less related to metabolic syndrome, says Dr. Ko. “This type of endometrial cancer has a different way of developing in the uterus,” she adds. “We tend to see this type of cancer more frequently in African-American women.”

Who is at Risk for Endometrial Cancer?

While there are currently no screening recommendations for endometrial cancer, it’s important women speak with their physicians about their personal risk. Endometrial cancer is typically diagnosed in women over the age of 45. Other risk factors for endometrial cancer may include:
  • Obesity
  • Diabetes
  • Family history of endometrial cancer
  • Early onset of menstruation
  • Polycystic ovary syndrome (PCOS)
  • Hormones – excessive estrogen through hormone replacement therapy or obesity
  • Tamoxifen after menopause

Gynecologic Oncologists at Penn – Part of Your Entire Team

Key to successful outcomes is early detection and coordination of your care. “As surgeons, we perform complex surgery, but we also provide chemotherapy and collaborate closely with radiation oncologists at Penn,” says Dr. Ko.

“For women with endometrial cancer, we perform minimally invasive surgery via robotic-assisted surgery or laparoscopy,” she says. She also explains that in some cases, medical management with hormones or medications, or radiation alone may be used in place of surgery – especially for women who want to preserve their uterus.

For women who are still interested in having children, Penn gynecologic oncologists work closely with reproductive medicine and fertility specialists at Penn Fertility Care, so women undergoing treatment for cancer have options for child-bearing.

“Aside from comprehensive cancer care at the Abramson Cancer Center, we offer women exercise interventions, nutritional counseling and we have access to related services like diabetes and cardiovascular care,” says Dr. Ko. “Because we all work together, it’s easy to follow patients, and share information so we know the whole picture of health.”

And, Dr. Ko adds, advances in endometrial cancer research continue. “Technology and research have allowed us to get more sophisticated in the way we view cancer so we can treat it with more personalized approaches,” she says. “Tumor biology, targeted therapy, genetics and prevention are all adding more information so we can continue to enhance the standard of care.”

Learn more about Penn's Gynecologic Cancer Team and find out what's right for you.
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